Guardian Flight, LLC v. Godfread, 359 F. Supp. 3d 744

Guardian Flight (successor to Valley Med Flight) is a federally regulated air ambulance provider that offers emergent transports and a low-cost membership/subscription program that effectively prepays patient responsibility for out-of-network balance billing.
North Dakota enacted SB 2231 (N.D.C.C. §§ 26.1-47-08 and 26.1-47-09) in 2017: § 26.1-47-08 bans air ambulance subscription agreements; § 26.1-47-09(3) deems insurer payments for out-of-network air ambulance services (when calculated per subsection (1)) a full and final payment, prohibiting balance billing.
Guardian Flight sued for a declaratory judgment that both provisions are preempted by the Airline Deregulation Act (ADA), arguing they regulate air carrier prices/services.
State defendants defended the statutes as insurance regulation and argued the McCarran-Ferguson Act (MFA) reverse-preempts federal law where the state law regulates the business of insurance.
The court evaluated ADA preemption doctrine (Morales/Wolens/Ginsberg), applied the Pireno three-part test (as developed in McCarran-Ferguson jurisprudence) to assess whether the state laws regulate the business of insurance, and resolved cross-motions for judgment on the pleadings.

Issue	Plaintiff's Argument	Defendant's Argument	Held
Whether N.D.C.C. § 26.1-47-09(3) is preempted by the ADA	§ 26.1-47-09(3) directly regulates air carrier reimbursement and thus is preempted	It merely regulates insurer–insured relationship (insurance), so not preempted	Court: Preempted by ADA; enjoined enforcement of § 26.1-47-09(3)
Whether N.D.C.C. § 26.1-47-08 (subscription ban) is preempted by the ADA	Ban on subscriptions affects prices/services and is preempted	Statute regulates insurance; MFA saves it from ADA preemption	Court: ADA would preempt it absent MFA; subscription ban is assessed under MFA
Whether the Payment Provision (§ 26.1-47-09(3)) is saved by the McCarran-Ferguson Act	MFA protects state insurance regulation from federal preemption	MFA applies because provision is in insurance title and affects insurer–insured settlements	Court: MFA does not apply; the provision does not regulate the business of insurance and thus is not saved from ADA preemption
Whether the Subscription Provision (§ 26.1-47-08) is saved by the McCarran-Ferguson Act	Subscription agreements are not insurance; MFA should not save the ban	Subscriptions shift and spread risk and are therefore insurance; MFA saves the statute	Court: Subscriptions are a form of insurance; MFA applies and saves § 26.1-47-08 from ADA preemption

Morales v. Trans World Airlines, Inc., 504 U.S. 374 (1992) (ADA preemption broadly bars state laws "relating to" airline rates, routes, or services)
Am. Airlines, Inc. v. Wolens, 513 U.S. 219 (1995) (distinguishes state-law contract claims from state-imposed regulation; ADA preempts state-law consumer-protection regulation of airline practices)
Northwest, Inc. v. Ginsberg, 572 U.S. 273 (2014) (ADA preempts state common-law obligations that have the effect of regulating airline rates/services)
Union Labor Life Ins. Co. v. Pireno, 458 U.S. 119 (1982) (three-factor test for whether a law/practice regulates the "business of insurance")
U.S. Dep't of Treasury v. Fabe, 508 U.S. 491 (1993) (McCarran-Ferguson Act protects state laws enacted to regulate the business of insurance)
Humana Inc. v. Forsyth, 525 U.S. 299 (1999) (explains MFA reverse-preemption framework and its limits)
Watson v. Air Methods Corp., 870 F.3d 812 (8th Cir. 2017) (ADA preemption applies to air ambulances; no presumption against preemption)
Bailey v. Rocky Mountain Holdings, LLC, 889 F.3d 1259 (11th Cir. 2018) (applied Pireno factors and held MFA did not save a balance-billing law from ADA preemption)