United States District Court, D. Minnesota
Yegge Tataryn, Esq. and Nolan, Thompson, Leighton &
Tataryn, PLC, counsel for plaintiff.
M. Sugden, Esq., Kadee Jo Anderson, Esq., and Stinson Leonard
Street LLP, counsel for defendant.
S. DOTY, JUDGE UNITED STATES DISTRICT COURT
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.
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.
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. ¶
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).
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.
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