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Little v. PreferredOne Insurance Co.

United States District Court, D. Minnesota

June 25, 2019

Patrick Little, Plaintiff,
v.
PreferredOne Insurance Company, Defendant.

          Denise Yegge Tataryn, Esq. and Nolan, Thompson, Leighton & Tataryn, PLC, counsel for plaintiff.

          Ryan M. Sugden, Esq., Kadee Jo Anderson, Esq., and Stinson Leonard Street LLP, counsel for defendant.

          ORDER

          DAVID S. DOTY, JUDGE UNITED STATES DISTRICT COURT

         This matter is before the court upon the motion for a preliminary injunction by plaintiff Patrick Little. Based on a review of the file, record, and proceedings herein, and for the following reasons, the motion is denied.

         BACKGROUND

         I. The Parties

         This Employee Retirement Income Security Act (ERISA) dispute arises out of Defendant PreferredOne Insurance Company's (PIC) denial of coverage for plaintiff Patrick Little's liver transplant surgery.

         Little is a fifty-six year old Minnesota resident. Compl. ¶ 1. Little was employed by L&K Tree & Shrub (L&K), a landscaping business. Id. ¶ 2. L&K maintains an employee benefit plan providing long-term health care benefits (the Plan). Id. ¶ 3. PIC insures the Plan under a group insurance policy. Id. ¶ 4.

         II. The Plan

         PIC is both the Plan administrator and insurer. Id. ¶ 9. The Plan gives PIC “discretionary authority to determine eligibility for benefits and to interpret and construe terms, conditions, limitations, and exclusions.” Cox. Aff. Ex. A § V(a).

         Under the Plan, PIC covers eligible organ transplant procedures. Id. § X(L). PIC determines whether an organ transplant procedure is medically necessary. Id. PIC does not cover “investigative” organ transplant procedures. Id. The Plan defines “investigative” as any drug, device, or medical treatment that “reliable evidence does not permit conclusions regarding safety, effectiveness, or effect on health outcomes.” Id. § XXII.

         PIC considers the following evidence in determining whether an organ transplant procedure is investigative:

1. Whether there is a final approval from the appropriate government regulatory agency, if required. This includes whether a drug or device can be lawfully marketed for its proposed use by the FDA; or if the drug, device or medical treatment or procedure is under study or if further studies are needed to determine its maximum tolerated dose, toxicity, safety or efficacy as compared to standard means of treatment or diagnosis; and
2. Whether there are consensus opinions or recommendations in relevant scientific and medical literature, peer-reviewed journals, or reports of clinical trial committees and other technology assessment bodies....; and
3. Whether there are consensus opinions of national and local health care providers in the applicable specialty as determined by a sampling of providers, including whether there are protocols used by the treating facility or another facility, ...

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