Pryzbowski v. U.S. Healthcare, Inc.
| Decision Date | 08 September 1999 |
| Docket Number | No. Civ.A. 97-3097(MTB).,Civ.A. 97-3097(MTB). |
| Citation | 64 F.Supp.2d 361 |
| Parties | Linda PRYZBOWSKI, Plaintiff, v. U.S. HEALTHCARE, INC., Medemerge, P.A., et al., Defendants. |
| Court | U.S. District Court — District of New Jersey |
Jerrold D. Goldstein, North Plainfield, New Jersey, for plaintiff.
Edward S. Wardell, Nancy C. Fletcher, Kelley, Wardell & Craig, Haddonfield, New Jersey, for defendant U.S. Healthcare, Inc.
Joseph R. Lang, Lenox, Socey, Wilgus, Formidoni & Casey, Lawrenceville, New Jersey, for defendants Medemerge, P.A., John Pilla, M.D., Kent Ellis, M.D. and Carol Sgamburelli, M.D.
This matter comes before the court upon the motion for summary judgment of defendants Medemerge, P.A. ("Medemerge") and John Pilla, M.D. ("Dr.Pilla"), Kent Ellis, M.D. ("Dr.Ellis"), and Carol Sgambelluri, M.D. ("Dr.Sgambelluri")1 (collectively as "the doctor defendants").2 This court having reviewed the submissions of the parties without oral argument pursuant to Fed.R.Civ.P. 78, and for the reasons discussed below, defendants' motion for summary judgment will be granted.
On November 10, 1993, plaintiff sought treatment at Medemerge, her primary care center, after experiencing increasing back pain for several days. See Lang Cert.,3 Exh. A-1. A CT Scan of plaintiff's lower back was performed on November 29, 1993, revealing: a neurostimulator, implanted during a previous surgery; disc degeneration; and a "large extra-dural defect ... compressing the thecal sac" consistent with disc herniation. See Exh. B.
Plaintiff was evaluated on December 3, 1993 by Dr. Alan J. Sarokhan ("Dr.Sarokhan") based on a referral from Dr. Ellis of Medemerge. See Exh. C. Dr. Sarokhan noted in his report that plaintiff's was "an extremely complicated case" that "really falls outside of my range of expertise and probably out of the range of expertise of most of the surgeons in this area." Id. at 2. He observed that plaintiff has "had five prior back surgeries, [and] has a lot of scarring in an implanted nerve stimulator." Id. Furthermore, Dr. Sarokhan noted that plaintiff "certainly needs a neurosurgical evaluation and needs one promptly" and stated that Dr. Pilla, also of Medemerge, with whom he had been in contact, "was kind enough to arrange it." Id.
Plaintiff was subsequently evaluated on December 9, 1993, upon referral, by neuro-surgeon Dr. Aiden J. Doyle ("Dr.Doyle"). See id., Exh. D. Dr. Doyle's report, which noted plaintiff's "multiple lumbar disc surgeries" and the insertion of an "epidural transducer" in her back, concluded that Id. The surgeon who implanted the device in question was Dr. Giancarlo Barolat ("Dr.Barolat") of Thomas Jefferson University Hospital ("TJUH"). See Exh. E.
Because Dr. Barolat was an "out of network" physician,4 on December 15, 1993, Medemerge sought — and received — approval from U.S. Healthcare for the referral. See Exh. A-2. On January 19, 1994, Dr. Barolat evaluated plaintiff and concluded that she was in "excruciating pain" and had a "definite lesion ... that has to be removed." Exh. E. He stated that:
the following things would be required for us to take care of this lady:
1. Surgical intervention by me with a re-do laminectomy and removal of large disc herniation.
2. Spinal instrumentation and fusion by a separate orthopaedic surgeon.
3. Pulmonary clearance by Dr. Cohen who is our pulmonary specialist who would also be following her during the hospital stay in case of problems.
4. Consultation with the Pain Service for pre and postop pain management.
5. Possible psychological assessment and follow-up during the hospital stay to cope with her emotional status.
Exh. E at 2. Dr. Barolat elaborated on the complexities of the potential surgery, the "very large doses of narcotics" plaintiff was taking, and stated, in conclusion:
If we go ahead with the surgical intervention I would certainly want to see her again prior to the surgery in order to discuss more thoroughly the surgical procedure and the risks. I would probably also want to try to reduce her medications to a minimum prior to the surgery in order to avoid habituation and avoid the fact that she might require incredibly large doses of narcotics in order to give her any kind of pain relief.
Id. Medemerge claims that it received Dr. Barolat's report on February 10, 1994. See Def.Br.Supp. at 2.
On March 19, 1994, Medemerge sent another request to U.S. Healthcare seeking approval for Dr. Barolat to perform plaintiff's back surgery.5 See Exh. A-3. Subsequently Anita McGinley ("McGinley"), an employee of Medemerge,6 faxed Ann Koenig, of U.S. Healthcare,7 some documentation and wrote the following on the fax cover sheet:
3/14/94 — Per Ann Koenig — Linda must be seen by par pulmonologist, mental health and & pain management teams thru us [Medemerge] before surgery. 1) Dr. Levin — Pain Management 2) Community Mental Health 3) Pulm. Dr. Sarraf.
Exh. A-4 (emphasis in original).
Defendants allege that "over the next few months, approval was sought from U.S. Healthcare for coverage for the surgery recommended by Dr. Barolat."8 Def.Br.Supp. at 2. Defendants further allege that plaintiff had the consultations requested by Dr. Barolat.9 See id. Apparently, however, Dr. Barolat insisted that those consultations be with TJUH physicians — who themselves were not participating in the Medemerge plan—before he would perform the surgery.10 See Def. Br.Supp. at 2.
Defendants claim, and plaintiff does not dispute, that eventually U.S. Healthcare agreed to allow plaintiff to consult with TJUH physicians, and she did so. Approval from U.S. Healthcare for the surgery was received on June 30, 199411 (Exh. H., 11/23/98 Peeno Ltr. at 2); Dr. Barolat performed the surgery on July 7, 1994. See Exh. G.
Plaintiff claims that, due to the delay in receiving the necessary approval for her back surgery, she has suffered various injuries. See Exh. J., Am.Compl. Furthermore, she alleges that it was the negligence of Medemerge and the doctor defendants that caused this delay. See id., Counts Six,12 Eight and Ten. Defendants13 now move for summary judgment on those counts.
Summary judgment may be granted when "there is no genuine issue as to any material fact and ... the moving party is entitled to a judgment as a matter of law." Fed.R.Civ.P. 56(c). When ruling on a motion for summary judgment all facts and reasonable inferences drawn from the evidence are viewed in the light most favorable to the non-moving party. See Matsushita Elec. Indus. Co., Ltd. v. Zenith Radio Corp., 475 U.S. 574, 587, 106 S.Ct. 1348, 89 L.Ed.2d 538 (1986). The moving party has the initial burden of pointing out the absence of a genuine issue as to any material fact, but summary judgment is only granted against a party who fails to demonstrate "the existence of an element essential to that party's case, and on which that party will bear the burden of proof at trial." Celotex Corp. v. Catrett, 477 U.S. 317, 322, 106 S.Ct. 2548, 91 L.Ed.2d 265 (1986).
Defendants essentially offer two arguments in support of their motion: one, that plaintiff's claims are preempted by ERISA § 514(a), 29 U.S.C. § 1144(a) (hereinafter "§ 514(a)"); and, two, that plaintiff fails to state a claim for negligence upon which relief can be granted. This court will address both arguments in turn.14
Defendants argue that although plaintiff's claims against them are not completely preempted15 by ERISA, those claims are, nonetheless, preempted because they "relate to" an ERISA plan. See § 514(a).16 "Relate to" preemption has traditionally been interpreted broadly in keeping with Congress's intent to regulate employee benefit plans. See Pilot Life Ins. Co. v. Dedeaux, 481 U.S. 41, 45-46, 107 S.Ct. 1549, 95 L.Ed.2d 39 (1987). Thus, in the past, a state law that had "a connection with or reference to" an ERISA plan was subject to ERISA preemption. Shaw v. Delta Air Lines, 463 U.S. 85, 96-97, 103 S.Ct. 2890, 77 L.Ed.2d 490 (1983). Indeed, even if the law had an indirect effect on an ERISA plan, it was deemed preempted. See Ingersoll-Rand Co. v. McClendon, 498 U.S. 133, 139, 111 S.Ct. 478, 112 L.Ed.2d 474 (1990).
Concerned, however, that the breadth of the preemption test was seemingly without limit, the Supreme Court narrowed the scope of "relate to" preemption. See De Buono v. NYSA-ILA Med. and Clinical Serv. Fund, 520 U.S. 806, 813-14, 117 S.Ct. 1747, 138 L.Ed.2d 21 (1997); New York State Conference of Blue Cross & Blue Shield Plans v. Travelers Ins. Co., 514 U.S. 645, 655, 115 S.Ct. 1671, 131 L.Ed.2d 695 (1995) () (citation omitted). Now, instead of simply looking for a remote connection to an ERISA plan, courts must "go beyond the unhelpful text and the frustrating difficulty of defining its key term ... and look instead to the objectives of the ERISA statute as a guide to the scope of the state law that Congress understood would survive." Bast v. Prudential Ins. Co. of America, 150 F.3d 1003, 1007 (9th Cir.1998) (quoting Travelers, 514 U.S. at 656, 115 S.Ct. 1671).
Here, plaintiff claims that defendants' negligence — a violation of state law — in failing to obtain prompt approval for her out-of-network surgery caused her injury.17 Defendants argue that, although dressed in state law clothing, plaintiff's negligence claims "relate to" an ERISA plan, as it was the plan that required that the outside specialist be approved — the requirement that caused the delay.18 See Def.Br.S...
To continue reading
Request your trial
-
Pryzbowksi v. U.S. Healthcare Inc.
...on the ground that those claims were expressly preempted by § 514(a) of ERISA, 29 U.S.C. § 1144(a). See Pryzbowski v. U.S. Healthcare, Inc., 64 F. Supp. 2d 361 (D.N.J. 1999). Our review of the District Court's orders granting dismissal and summary judgment based on ERISA preemption is plena......