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DiDomenico v. Employers Co-op. Industry Trust, 676 F.Supp. 903, 9 Employee Benefits Cas. 1476

Facts

Frederick J. DiDomenico, employed as a production supervisor at Wayne Chemical, was diagnosed with biliary cirrhosis of the liver and required a liver transplant. His primary physician, Dr. Kaplan, deemed the transplant necessary after DiDomenico's condition deteriorated. Despite being an acceptable candidate for the transplant, the Employers Cooperative Industry Trust denied coverage, claiming the procedure was 'experimental.' DiDomenico filed for a preliminary injunction to compel the trust to provide coverage for the surgery.

Frederick J. DiDomenico, employed as a production supervisor at Wayne Chemical, was diagnosed with biliary cirrhosis of the liver and required a liver transplant. His primary physician, Dr. Kaplan, deemed the transplant necessary after DiDomenico's condition deteriorated.

Issue

Whether the Employers Cooperative Industry Trust's denial of coverage for DiDomenico's liver transplant was justified under the terms of the group health plan.

Whether the Employers Cooperative Industry Trust's denial of coverage for DiDomenico's liver transplant was justified under the terms of the group health plan.

Rule

The court applied the principle that ambiguous terms in an insurance policy should be interpreted in favor of the insured, and that a preliminary injunction may be granted if the plaintiff shows irreparable harm and a likelihood of success on the merits.

The court applied the principle that ambiguous terms in an insurance policy should be interpreted in favor of the insured, and that a preliminary injunction may be granted if the plaintiff shows irreparable harm and a likelihood of success on the merits.

Analysis

The court analyzed the language of the health plan, noting its ambiguity regarding coverage for liver transplants. It highlighted that the plan stated organ transplants are covered, but also included a clause about experimental procedures. Given the medical testimony indicating that liver transplants are not experimental and the lack of evidence from the trust to support its denial, the court found that DiDomenico had a strong likelihood of success in his claim.

The court analyzed the language of the health plan, noting its ambiguity regarding coverage for liver transplants. It highlighted that the plan stated organ transplants are covered, but also included a clause about experimental procedures.

Conclusion

The court granted DiDomenico's request for a preliminary injunction, ordering the Employers Cooperative Industry Trust to provide coverage for his liver transplant and related medical services.

The court granted DiDomenico's request for a preliminary injunction, ordering the Employers Cooperative Industry Trust to provide coverage for his liver transplant and related medical services.

Who won?

Frederick J. DiDomenico prevailed in the case because the court found that he would suffer irreparable harm without the necessary medical treatment and that the trust's denial of coverage was likely arbitrary and capricious.

Frederick J. DiDomenico prevailed in the case because the court found that he would suffer irreparable harm without the necessary medical treatment and that the trust's denial of coverage was likely arbitrary and capricious.

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