Lead Opinion
This appeal involves the review of a decision by Hartford Life and Accident Insurance Company (“Hartford”) to deny a claim for benefits under an employee benefit plan governed by the Employee Retirement Income and Security Act (“ERISA”), 29 U.S.C. §§ 1001-1461. We reverse the decision of the district court granting summary judgment in favor of Hartford, and remand the case to the district court with directions that it be returned to the administrator for further consideration.
I.
Hartford issued a group insurance policy to Prairie Island Indian Community d/b/a Treasure Island Resort and Casino in Minnesota. As part of its employee benefit plan, Treasure Island provided its employees with life insurance benefits and accidental death benefits under the Hartford policy. Martin Schanus, an employee of Treasure Island, died in a motorcycle
Schanus was killed after the motorcycle he was operating’veered off a road and struck a fence. Schanus was ejected from the motorcycle and suffered fatal head injuries. Blood tests taken after the accident showed that Schanus was legally intoxicated at the time of the crash (with a blood-alcohol level of 0.19), and his death certificate listed “acute alcohol intoxication” as a significant condition contributing to death.
Hartford denied a claim for an accidental death benefit, which would have doubled the life insurance benefit paid to Amber Lynn, on the ground that Schanus’s death was not the result of an “accidental bodily injury” within the meaning of the policy. Alternatively, Hartford asserted that the claim fell within a policy exclusion for losses caused by an “intentionally self-inflicted injury, suicide, or suicide attempt, whether sane or insane.” King then brought an action in Minnesota state district court, alleging that Hartford’s denial of the accidental death benefit was “arbitrary, capricious, and not a fair or logical reading of the policy, language.” Hartford removed the action to the United States District Court for the District of Minnesota because the claim arises under ERISA. See Metro. Life Ins. Co. v. Taylor,
In the district court, despite the general rule that a challenge to the decision of a benefits administrator under ERISA should be decided based on the evidence presented to the administrator, see, e.g., Short v. Central States, Southeast and Southwest Areas Pension Fund,
Hartford defended its decision that Schanus’s death did not result from an “áccidental bodily injury” by invoking the definition of “accident” set forth in Wick-man v. Northwestern National Insurance Co.,
On appeal, a panel of this court reversed the grant of summary judgment in-favor of Hartford and remanded the case for further proceedings. King v. Hartford Life and Accident Ins. Co.,
Having considered the matter en banc, we now reverse the grant of summary judgment in favor of Hartford, but we do so on a narrower ground than that articulated by the panel. For the reasons detailed below, we conclude that Hartford’s litigating position concerning the proper interpretation of “accidental bodily injury” is fundamentally inconsistent with its stated basis for denying the claim in 2001 during the administrative process. Under these circumstances, we hold that the administrator’s decision cannot be sustained, and the appropriate remedy is to remand the case to the district court, with directions to return the case to the administrator for application of the standard that Hartford now says should govern the claim.
II.
Several basic principles govern our ■ review of challenges to the decision of an plan administrator to deny a claim for benefits under a plan governed by ERISA. Congress enacted the statute with “expectations that a federal common law of rights and obligations under ERISA-regulated plans would develop.” Pilot Life v. Dedeaux,
In Firestone Tire and Rtibber Co. v. Bruch,
Where a plan gives the administrator discretionary power to construe uncertain terms or to make eligibility determinations, however, the landscape is much
Review for abuse of discretion also ensures that an administrator’s decision is supported by substantial evidence, that is, “such relevant evidence as a reasonable mind might accept as adequate to •support a conclusion.” Donaho v. FMC Corp.,
III.
A.
The benefit plan at issue in this case gives discretion to the administrator. A general provision of the group life insurance policy, in explaining who interprets terns and conditions in the policy, states that “[w]e have full discretion and authority to determine eligibility for benefits and to construe and interpret all terms and provisions of the Group Insurance Policy.” (Appellant’s App. at 58) (hereinafter “App.”). The administrator’s decisions, therefore, are subject to review for abuse of discretion under the Bruch framework. Our court, of course, reviews de novo the district court’s decision to grant summary judgment.
In describing the accidental death benefit sought by Amber Lynn Schanus, the policy explains that:
The Hartford will pay [the accidental death benefit] if [the participant] suffer[s] accidental bodily .injury while [his] insurance is in force and:
(1) a Loss results directly from such injury, independent of all other causes; and
(2) such a Loss occurs within 90 days after the date- of the accident causing the injury.
(App. at 56) (emphasis- added). The plan does not define the term “accidental.” It then provides a list of exclusions for accidental death benefits, including that “[n]o benefit will be paid for a loss caused or contributed to by ... (6) any intentionally self-inflicted injury, suicide, or suicide attempt, whether sane dr insane.” (App. at 57).
After Martin Schanus’s death, King presented proof of death and the necessary claim forms to Hartford. On December 26, 2000, Hartford awarded a death benefit of $42,916.04 to Amber Lynn, but denied her claim for an accidental death benefit. Hartford’s initial denial letter stated that:
The information reviewed including the toxicology findings demonstrates that by driving while intoxicated, Mr. Schanus voluntarily exposed himself to an unnecessary danger which resulted in a fatal self inflicted injury. The Black’s Law Dictionary, Sixth Edition, West Publishing Company, 1990, defines Accidental as:
“Happening by chance, or unexpectedly; taking place not according to usual course of things; casual; fortuitous.”these conditions that a serious bodily injury would occur and that he voluntarily caused these conditions to exist, we have also concluded that Mr. Scha-nus’ death was caused or contributed to by a self-inflicted injury. Since his death was caused or contributed to by an injury specifically excluded from coverage, no Group Accidental Death benefits are payable.
Since it could be expected that if Mr. Schanus operated his vehicle under
According to - the plan, a beneficiary whose claim is denied initially may “appeal to the Insurance Company for a full and fair review.” (App.67). Hartford then will respond with “a written decision” that “will include specific reasons for the decision and specific references to the plan provision on which the decision is based.” (Id.) King appealed Hartford’s initial denial of an accidental death benefit in a letter dated February 21, 2001, arguing that Hartford’s denial was “unreasonable and not supported by the evidence.” (App. at, 90).
On June 14, 2001, Hartford responded with a decision letter denying King’s appeal and concluding that Sehanus’s death “was not an accident.” (App. at 91). In this written decision, Hartford explained that its letter dated December 26, 2000, (i.e., the initial denial letter) “lists the evidence contained in [Schanus’s] claim file,” and informed King that “[o]ur decision to uphold the denial of his claim for benefits is based upon that evidence and your letter dated 2/21/01.” (Id.)
In explaining its rationale for concluding that Schanus did not suffer “accidental bodily injury” that would trigger the accidental death benefit, Hartford wrote that “a reasonable person would have known that death or serious injury was a reasonably foreseeable result of driving while intoxicated.” (App. at 92). The decision further opined that “[a] death is not accidental when it is a foreseeable result of the insured’s voluntary act of becoming intoxicated,” and concluded that Schanus’s death “was not am accident.” (Id.)
Hartford’s decision cited, as “case law supporting this defense,” the opinion in Weisenhorn v. Transamerica Occidental Life Insurannce Co.,
B.
As explained above, where a benefit plan ■gives the administrator discretion to interpret uncertain terms in the plan, we typically begin our analysis by considering whether the administrator’s interpretation of the terms is “reasonable.” In its final decision on Amber Lynn’s claim, Hartford said that Martin Schanus did not suffer “accidental bodily injury,” ■ triggering the accidental. death benefit, because “a reasonable person would have known that
This inquiry would present a debatable question. Some courts have accepted as reasonable an interpretation that excludes “reasonably foreseeable” injuries from the scope of “accidental” injuries, e.g., Cozzie v. Metro. Life Ins. Co.,
We find it unnecessary and inappropriate to reach the issue in this case, because Hartford has not defended its denial of Amber Lynn’s claim for an accidental death benefit on the ground that Martin Schanus’s death was “reasonably foreseeable.” Rather, Hartford consistently has maintained in litigation that the proper definition of “accidental” in its policy is that set forth in the First Circuit’s decision in Wickman, which held that there is no accident if “a reasonable person, with background' and characteristics similar to the insured, would have viewed the injury as highly likely to occur as a result of the insured’s intentional conduct.”
We disagree with Hartford’s interpretation of the administrative decision. The decision on Amber Lynn’s appeal clearly applied a “reasonably foreseeable” standard. The decision letter cited two court decisions as “case law supporting” its rationale; it did not cite Wickman, and neither cited case applied the Wickman rationale. The initial denial letter, which Hartford suggests we should consider as further explanation of its rationale, does not state that the administrator applied the Wickman rationale and- a standard of “substantial probability” or “highly likely to occur” in denying the claim. ’ The initial denial, invoking Black’s Law Dictionary, merely concluded that Schanus’s death “could be expected,” which begs the question whether “expected” means “reasonably foreseeable” or “highly likely.” Hartford acknowledges that the Wickman court itself thought the term “unexpected” left “some ambiguity with respect to the ‘level of expectation ... necessary for an act to constitute'an accident,’” (Br. of Appellee at 15-16 (quoting Wickman,
We thus conclude that this case falls in the category where an administrator offers a post hoc rationale during litigation to justify a decision reached on different grounds during the administrative process. Even assuming it is reasonable to interpret the term “accidental” to exclude “reasonably foreseeable” injuries, Hartford does not defend the administrator’s decision on that basis. We will not uphold Hartford’s decision on a ground that is fundamentally inconsistent with its emphatic position that Wickman sets forth the proper interpretation of the term “acciden
Whether a reasonable person would have viewed Schanus’s injuries and death as “highly likely to occur,” Wickman,
C.
Hartford argues alternatively that we should affirm on a ground not relied upon by the district court, namely, that Martin Schanus’s injuries and death are ineligible for coverage under a specific policy exclusion. It invokes an exclusion providing that “[n]o benefit will be paid for a loss caused or contributed to by ... (6) any intentionally self-inflicted injury, suicide, or attempted suicide, whether sane or insane.” (App. at 57). Hartford admits that Schanus did not intend to injure himself by driving his motorcycle on the night of his death, but claims that Schanus’s alcohol intoxication was itself an “intentionally self-inflicted injury” that “contributed to” his injuries and death.
We reject this alternative argument because it is based on an unreasonable interpretation of the plan, and because it represents another effort to uphold the administrator’s decision with a post hoc rationale not expressed when benefits were denied. The most natural reading of the exclusion for injuries contributed to by “intentionally self-inflicted injury, suicide, or attempted suicide” does not include injuries that were unintended by the participant, but which were contributed to by alcohol intoxication. The Seventh Circuit seemed to think this self-evident when it explained in a case involving death by drunk driving that the plan at issue “does not specifically exclude from coverage the conduct at issue but does exclude other conduct — notably suicide, attempted suicide and purposefully self-inflicted injury.” Cozzie,
But even if Hartford’s reading of “intentionally self-inflicted injury” might be a reasonable interpretation of the language standing alone, cf. Nelson v. Sun Life Assurance Co. of Canada,
In any event, Hartford’s current position concerning the exclusion for “intentionally self-inflicted injury” is another post hoc rationale that differs from the stated basis for denying benefits. The decision on Amber Lynn’s appeal mentioned the self-inflicted injury exclusion almost as an afterthought, and did not provide any reasoning. ‘ (App. at 92). The initial denial letter, which Hartford says we should consider to understand its reasoning, explained that “[t]he information reviewed including the toxicology findings demonstrates that by driving while intoxicated, Mr. Schanus voluntarily exposed himself to an unnecessary danger ivhich resulted in a fatal self inflicted injury.” (App.86) (emphasis added). This rationale is inconsistent with Hartford’s current position that alcohol intoxication was the “intentionally self-inflicted injury.” Scha-nus’s alcohol intoxication was not a fatal self-inflicted injury; it is evident that when Hartford denied the claim, it was referring to Schanus’s head injury as the “self-inflicted injury,” because the head injury — ■ not the drinking — was “fatal.” Accordingly, we reject Hartford’s argument that we should affirm the district court’s grant of summary judgment on the alternative ground that Schanus’s alcohol intoxication was an “intentionally self-inflicted injury” that contributed to his death. ■
D.
The question remains how to resolve this appeal. We think the posture of this case is comparable to those in which the administrator of an ERISA-regulated plan denies á claim for benefits based on an unreasonable interpretation of terms in the plan. ' Here,’ by asserting that the Wickman test of “highly likely to occur,” rather than a “reasonably foreseeable” standard, should' govern whether, Amber Lynn is entitled' to “accidental death benefits” under the plan,' Hartford effectively concedes that it applied the wrong definition of “accidental” in denying the claim.
Under these circumstances, we believe the proper remedy is to return the case to the administrator for reevaluation of the claim under what Hartford.says is the correct standard. The statute affords -the courts a range of remedial powers under ERISA, 29 U.S.C. § 1132(a), and returning the case to a plan administrator for further consideration is often appropriate. E.g., Shelton v.. ContiGroup Companies, Inc.,
* * - * * * *
For the foregoing reasons, we reverse the judgment of the district court granting summary judgment in favor of Hartford, and remand the case with instructions to return the claim to the administrator for reevaluation of Amber Lynn’s claim ■ for accidental benefits under the Wickman standard that Hartford asserts should be applied.
Notes
Lay, Bright, Wollman, Murphy, Bye, Melloy, Smith, and Benton, Circuit Judges, join this opinion in its entirety. Riley, Circuit Judge, joins Parts II, III.A, and III.C of this opinion.
. Hartford did object to two exhibits proffered by King, but did not complain about the introduction of statistical evidence concerning the frequency of'injuries and deaths from drunk driving. See Reply Mem. in Supp. of Def.’s Mot. for Summ. J. (R. Doc. 14 at 2).
. The other exclusions are (1) sickness, (2) disease, (3) any medical treatment for sickness or disease, (4) any infection, except a pus-forming infection of an accidental cut or wound; (5) war or any act of war, whether war is declared or not, and (6) taking drugs, sedatives, narcotics, barbiturates, amphetamines or hallucinogens unless prescribed for or administered to you by a licensed physician.
. The dissent insists that the Wickman court did not adopt a specific definition of accidental injury that calls for an evaluation whether a reasonable person would have viewed the injury as highly likely to occur, and that Hartford did not endorse such a definition in this litigation. Post at 1011. We think the dissent's reading is impossible to square with Hartford's quotation of Wickman 's statement
Nor do we agree that the Wickman court’s analysis is "devoid of any discussion about whether a reasonable person in Mr. Wick-man’s shoes would have viewed death as 'substantially' or ‘highly’ likely to occur.” 'Post at 1011. The heart of the First Circuit's analysis noted the magistrate judge’s conclusion that Wickman should have known that death was "substantially likely to occur,” observed that " 'substantially likely to occur’ is ail equivalent, if not tougher, standard to 'highly likely to occur,' ” and thus concluded that the magistrate "applied an acceptable legal standard.” Id. at 1089. Hartford itself defined the "second prong of the Wickman test” to mean "whether a reasonable person would view the injury as 'highly likely to occur,' " and then urged this court to reject what Hartford characterized as a "strained interpretation” of “highly likely to occur” adopted in West v. Aetna Life Ins. Co.,
. The dissent urges that even when a plan administrator abandons in litigation its stated basis for denying benefits, the court should • nonetheless consider whether the abandoned ' rationale provides a sufficient basis to reject the beneficiary's claim. Post at 1012. We think the better course in our adversarial system is for the court to limit its consideration to grounds actually advanced before the court. If Hartford does not wish to defend the interpretation that an injury is not "accidental’' simply because it is "reasonably foreseeable,” then it is not our place to press that position for the insurer. We suspect, moreover, that the claimant in this case will feel less "sandbagged,” post at 1012, if she has an opportunity for consideration of her claim at the administrative level under the standard that Hartford now says should apply, than if her claim is rejected by-this court on a basis not even urged by Hartford in its briefs on appeal.
Of course, if a plan administrator attempts to gain a tactical advantage by proffering a new plan interpretation for the first time in litigation, then we are "free to ignore” it, Marolt,
Concurrence Opinion
with -whom LAY and BYE, Circuit Judges, join, concurring.
I join in Judge Colloton’s excellent opinion in this case. I write separately to comment on the remand. However, the dissenting opinion discusses an issue that Judge Colloton’s opinion for the Court does not reach- — the reasonableness of the plan administrator’s definition of “accident.” While discussion of this issue is unnecessary, see maj. op. at 1001 -1002, I write separately also to contribute some observations to the dissenting opinion’s partial discussion of that issue.
I.
I write separately, first, to explain why Hartford, a nationally known and highly-regarded insurer, should be given an opportunity to correct its previous faulty administrative decision denying the claim of Amber Lynn Schanus, a minor child, for accidental death benefits in the sum of $42,000 plus interest resulting from the death of her father, an employee-insured under the Hartford policy. In the panel opinion, Judge Murphy and Judge Lay joined me in an outright reversal, ruling
As Judge Colloton’s opinion observes, the record before the plan administrator did not contain the statistical evidence presented in the district court relating to the frequency of injuries and deaths from drunk driving. Maj. op. at 997. That evidence shows that drunk driving deaths constitute less than one percent of the number of people arrested for drunk driving. Id. at 844.
Apart from Hartford’s litigation position, Hartford is obligated to be fair and reasonable to itself and to claimants in ruling whether a policy should be paid. With the review, the plan administrator will have all the facts and can apply the standard that in litigation it has acknowledged to be correct — Whether a reasonable person, with background and characteristics similar to the insured, would have viewed Schanus’s injuries and death as highly likely to occur as a result of Schanus’s conduct. See Wickman v. N.W. Nat’l Ins. Co.,
I am quite sure that Hartford has spent considerably more to defend its denial .of Schanus’s claim than it would have cost to pay the claim itself. It is time now to reasonably and properly conclude Scha-nus’s claim on all the facts and the correct law.
II.
According to the plan administrator’s definition of “accident,” an injury is not an accident if it was reasonably foreseeable.
Anytime we review a plan administrator’s definition of a term, we review more than a denial of claims in a single insurance case — a case, for instance, involving a drunk driver. We are reviewing a definition that the plan administrator would, be free — if we affirmed it — to apply in all cases, even those involving, for instance, sober drivers.
The gulf between the common law definition and the plan administrator’s definition here is telling. The two definitions are at opposite poles. The common law definition asks whether the victim could reasonably have expected to escape the injury. See n. 1, supra. The plan administrator’s definition here asks whether the victim could reasonably have expected to suffer the injury. As Justice White noted, one can reasonably expect to escape injury so long as the injury is not “substantially certain.” See Todd,
Let us briefly examine the possible results of the plan administrator’s definition, which could exclude from “accident” coverage all deaths or injuries that were reasonably foreseeable. When a woman stands on a shaky stool to reach for a bottle of baby formula on the top shelf of the cupboard, it is reasonably foreseeable that she will fall and, in crashing to the kitchen counter and then to the floor, break her neck. Under the plan administrator’s definition, the woman’s injury is not an accident. When. a lineman - working atop an electricity pole relies; on his partner to have cut the power, instead of checking it himself, it is reasonably foreseeable that he will be electrocuted. Under the plan administrator’s definition, the lineman’s injury would be ruled a non-accident. When a man speeds his pregnant wife to the hospital, breaking the speed limit, it is reasonably foreseeable that he will crash the car and injure the passengers. Applying a reasonably-foreseeable standard, the plan administrator could rule the injuries not accidental.
As the Wickman court noted, people buy accident insurance to protect ■ themselves against their own negligence — that is, voluntary but imprudent conduct that may with reasonable foreseeability result in injuries or even death. See
By excluding from accident coverage any injury that was reasonably foreseeable, the plan administrator’s decision would seem to make nonsense of the concept of an “accident.” It would seem to reduce “accident insurance” to insurance only for strange, unforeseeable injuries (e.g., choking to death on a piece of meat) or for injuries in which the victim was passive rather than active (being struck by lightning or being run down-by a reckless driver while crossing the street). Such a construction of the terms of an insurance plan would turn the insurance policy into a trap for the unwary. It would deceive employees — attracting them to a job with 'the promise of benefits that turn' out, when they are claimed, to be illusory. Such interpretations of plan language by a plan administrator constitute an abuse of discretion — under the third Finley factor, namely, that 'a decision may not violate the substantive or procedural requirements of ERISA (by, for instance, misleading plan
One might think that the plan administrator would not apply the “reasonably foreseeable” standard in cases such as those I have listed, but would apply it only in drunk driving cases or in autoerotic self-asphyxiation cases (the sorts of cases Hartford focuses on in its briefs). But our law is clear that we cannot allow a definition on the basis that a plan administrator will apply it in some cases but not others, at his/her pleasure. Such inconsistent application itself constitutes an abuse of discretion (the fourth Finley factor). If we permit a definition in one case, we must expect it to be applied consistently, in all cases.
Again, the opinion for the Court does not, and need not, reach the issue of whether the plan administrator’s reasoning was reasonable or was an abuse of discretion. See maj. op., supra, at 1001-1002.
. Because Hartford has adopted the Wickman definition of "accident,” the administrator must consider the background and characteristics of the decedent. See Wickman,
. The key phrases in Hartford's denial letters were that Schanus's injuries "could [have been] expected” or were "[not] unexpected” or were “foreseeable” or "reasonably foreseeable.” The "reasonably foreseeable” language came in Hartford’s second denial letter, amplifying and justifying the standard it used to define "accident.”
As Judge Colloton's opinion for the Court notes, in litigation Hartford has argued that the plan administrator used the federal common law definition of "accident,” developed in Wickman v. Northwestern Nat’l Ins. Co.,
In litigation, Hartford did not deny that the plan administrator defined "accident” to exclude reasonably foreseeable injuries. Hartford simply argued that "highly likely” and "reasonably foreseeable” are the same thing. Obviously they are not. The highly-likely standard not only creates a far more inclusive definition of "accident,” but also requires more care and consideration in assessing likelihoods. The reasonably-foreseeable standard, by contrast, not only could define.away most accidents resulting from the victim's imprudence or negligence, but also provides an easy way for an insurance company to deny just claims relating to accidents.
. Hartford cites one published case and one unpublished case in which courts permitted a plan administrator's use of a "reasonably foreseeable” standard in defining "accident.” These cases from other circuits apply a different and less searching reasonableness review than we apply under Finley.
The Seventh Circuit in Cozzie v. Metropolitan Life Ins. Co.,
In Cates v. Metropolitan Life Ins. Co.,
Our reasonableness review, announced in Finley, would not permit the decisions and dicta stated in these cases and relied on by Hartford.
Dissenting Opinion
with whom LOKEN, Chief Judge, and MORRIS SHEPPARD ARNOLD and RILEY, Circuit Judges, join, dissenting.
Because I conclude that the district court did not err in granting summary judgment in favor of Hartford, I respectfully dissent.
As I analyze it, this case presents one relatively straightforward issue: Whether the Hartford plan administrator abused its discretion when it denied Amber Lynn Schanus’s claim for accidental-death benefits on the basis that her father, Martin Schanus, did not die from an “accidental bodily injury” under the terms of the Hartford insurance policy when he crashed his.motprcyele while driving with a blood-alcohol level of 0.19 g/dl-nearly twice the legal limit.
Our prior decisions provide a workable framework for reviewing decisions of ERISA plan administrators for abuse of discretion. I see no reason to deviate from those decisions in this case. Using our well-established framework, I would conclude that the Hartford plan administrator did not abuse its discretion in deny
In my view, the Court has confused the issue in this case with its conclusion that, “by asserting that the Wickman test of ‘highly likely to occur,’ rather than a ‘reasonably foreseeable’ standard, should govern whether Amber Lynn is entitled to ‘accidental death benefits’ under the plan, Hartford effectively concedes that it applied the wrong definition of ‘accidental’ in denying the claim.” First, the Court misreads the test set forth in Wickman v. Northwestern National Insurance Co.,
The facts of Wickman are simple and few. Paul Wickman was last seen standing on the outside of the guardrail of a highway bridge and holding on to the guardrail with only his right hand. He fell to his death from the bridge to railroad tracks forty or fifty feet below. His widow, Mrs. Wickman, submitted a claim for benefits under an ERISA-governed, accidental-death insurance policy sponsored by her husband’s employer. Noting that the policy defined accident as “an unexpected, external, violent and sudden event,” the plan administrator denied Mrs. Wickman’s claim.
As a result, Mrs. Wickman brought a suit for benefits under ERISA. Acknowledging that there is no right to a jury trial in an action for benefits under ERISA, the parties consented to a trial before a magistrate judge. The magistrate judge performed a de novo review of the facts
According to the Court’s opinion in the present case, “the Wickman test” is a definition of accident that excludes injuries that a reasonable person would have viewed as highly likely to occur. See supra at 997. To consider this to be “the Wickman test” misreads the First Circuit’s task in Wickman. The focus of Wickman was not to formulate a generally applicable definition of accident; the term was already defined in the insurance policy, and the court even noted that the “[c]ase law is fairly consistent in defining an accident, using equally ambiguous terms .... ” Wickman,
Faced with the task of resolving this issue, the First Circuit sought to give “substance to a concept which is largely intuitive.” Id. at 1087. The Wickman court rejected the parties’ invitation to analyze the issue in terms of “what level of expectation is necessary for an act to constitute an accident; whether an intentional act proximately resulting in injury or only the 'ultimate injury itself must be accidental.” Id. at 1085-86. Instead, the Wick-man court concluded that the proper starting point in determining whether an injury constitutes an accident under the terms of an insurance policy should be the “reasonable expectations of the insured when the policy was purchased.” Id. at 1088. Noting that “[generally, insureds purchase accident insurance for the very purpose of obtaining protection from their own miscalculations and misjudgments,” the First Circuit proffered a test to use in analyzing accident claims that aims to “prevent unrealistic expectations from undermining the purpose of accident insurance.” Id.
The proffered test has two prongs. First, “[i]f the fact-finder determines that the insured did not expect an injury similar in type or kind to that suffered, the fact-finder must then examine whether the suppositions which underlay that expectation were reasonable.” Id. at 1088. Next, if the fact-finder finds the evidence insufficient to accurately determine the insured’s subjective expectations, “the fact-finder should then engage in an objective analysis of the insured’s expectations.” Id. The Wickman court stated that in conducting such an analysis, “one must ask whether a reasonable person, with background and characteristics similar to the insured, would have viewed the injury as highly likely to occur as. a result of the insured’s intentional conduct.” Id. “An objective analysis ... serves as a good proxy for actual expectation.” Id.
In my view, the Wickman test is an analysis that gives “substance” to a fact-finder’s application of the definition of accident by focusing on the reasonable expectations of the insured. Although the Wickman court used the phrase “highly likely to occur,” when viewed in the context of the entire- opinion, it is apparent that the court’s emphasis was not on the degree of the insured’s expectations but on the reasonableness of the insured’s expectations.
The Wickman court’s focus on reasonableness is evident from its holding. The court upheld the magistrate judge’s decision denying Mrs. Wickman’s accidental-death claim, concluding that “the magistrate appropriately engaged in an objective analysis.” Id. at 1089. The court reasoned that the magistrate judge’s conclusion that Mr. Wickman should have known that death or injury was substantially likely to occur “equates with a. determination ... that a reasonable person in [Mr. Wick-man’s] shoes would have expected the result, and that any other expectation would be unreasonable.” Id. (emphasis added). Furthermore, the First Circuit’s own'application of the objective analysis to Mrs. Wickman’s claim is devoid of any discussion about whether a reasonable person in Mr.'Wickman’s shoes would have viewed -death as “substantially” or “highly” likely to occur. Id.' Rather, the Wickman court simply explained, “Objectively, he reasonably should have expected serious injury when he climbed over the guardrail and suspended himself high above the railroad tracks below by hanging 'on to the guardrail with only one hand.” Id.
As I read Wickman, the First Circuit did not adopt a specific definition of accident. Hartford has recognized this subtlety. Before -both the district court and this Court, Hartford has relied on the.analyt
Based on .the foregoing, I must respectfully disagree with the Court that Hartford has defended its denial of Amber Lynn’s claim by invoking a Wickman-like “highly likely to occur” definition of “accidental.” Therefore, I would proceed by reviewing the Hartford plan administrator’s claim denial for an abuse of discretion, using the analytical framework provided by the case law of this Circuit. However, at this point I think it is necessary to explain that even if I agreed with the Court that Hartford “effectively concede[d]” the plan administrator used the wrong definition of “accidental” in denying Amber Lynn’s claim, I would disagree that the proper course of action in such a situation is to return the claim to the plan administrator for reevaluation using “the Wickman standard that Hartford asserts should be applied” and considering evidence that was not before the plan administrator in the first instance. See supra at 1005-1006.
I believe the Court would be obliged to “ignore ERISA plan interpretations that did not actually furnish the basis for a plan administrator’s benefits decision,” Marolt v. Alliant Techsystems, Inc.,
Moreover, the Court’s decision potentially allows an ERISA defendant to usurp the reviewing court’s role in determining whether and how a plan administrator may have abused its discretion in denying a claim for benefits. The rule adopted by the Court-“when an administrator abandons in litigation its original basis for denying benefits, the better course generally is to return the case to the administrator”makes it possible for an ERISA defendant fearing defeat in litigation to return the proceedings to the plan administrator for another bite at the apple simply by abandoning its administrative position and advancing a new interpretation or reason during litigation.
The other cases cited by the Court are distinguishable from the present case because they involve situations where remand was necessary because the plan administrator either did not 'give reasons for its decision or had not yet interpreted the plan; thus, it was the plan administrator’s role to develop the administrative record and decide the claim in the first instance, not the court’s. See, e.g., Shelton v. ContiGroup Cos., Inc.,
Because I do not think Hartford advanced a Wickman-like “highly likely to occur” definition of “accidental,” and because I would ignore any post hoc rationales even if I agreed with the Court that Hartford advanced a different definition during ■ litigation, I now turn to what I believe is the only issue in this case: Whether the Hartford plan administrator abused its discretion in denying Amber Lynn’s claim.
As the Court explains, because the Hartford policy gives ■ the plan administrator the discretionary authority to decide eligibility questions or to construe the terms of the policy, the administrator’s denial of Amber Lynn’s claim is reviewed for an abuse of discretion. Firestone,
In this Circuit, two tests are relevant in analyzing whether the Hartford plan administrator’s denial of Amber Lynn’s claim was reasonable. First, in determining whether the plan administrator’s interpretation of the term “accidental” was reasonable, the five-factor test set forth in Finley v. Special Agents Mutual Benefit Ass’n, Inc.,
Given the deferential standard of review governing this case and applying the two relevant tests, I cannot- say that the Hartford plan administrator reached an unreasonable decision. Consequently, I would affirm the decision of the district court.
The Hartford plan administrator’s interpretation of the word “accidental” was reasonable under the Finley fíve-factor test.
Next, the Hartford plan administrator’s interpretation of the word “accidental” to
Third, relying on the Seventh Circuit’s decision Cozzie v. Metropolitan Life Insurance Co.,
The purpose of this plan is to provide the families ... with insurance against the- tragedy of unexpected death by providing additional benefits for those who experience such a loss and all its consequent tremors. Whenever a plan fiduciary determines that benefits are not owed under particular circumstances, it does, from the perspective of the claimants in that case, frustrate the purpose of providing assistance. However, as with all insurance arrangements, the plan fiduciary or administrator must ensure that payments are reserved for those who truly fall within the terms of the policy. Otherwise, the financial 'health of the -pooled assets is jeopardized and the cost of providing recovery for future applicants owed assistance is escalated.. We cannot say, therefore, that MetLife’s determination that the purposes of the plan are best served by acknowledging a qualitative difference between the ingestion of a huge quantity of alcohol and other tragedies of human life which do not involve such a significant assumption of a known risk by the insured is incompatible with the goals of the plan.
Id: See also Finley,
Next, the Hartford plan administrator’s interpretation of- “accidental” does hot render any language in the policy meaningless or internally inconsistent. Appellant argues, that the interpretation of “accidental” to mean “unexpected”-or “unforeseen” renders meaningless the policy’s “express exclusion” of death by suicide, attempted suicide or intentionally self-inflicted injury,
Lastly, the Hartford plan administrator’s interpretation of “accidental” does not conflict with the substantive or procedural requirements of the ERISA statute. Nowhere in ERISA is a plan required to use a specific definition of “accident.” It may be true that a body of common law has developed regarding the definition of “accident” in an ERISA employee benefit plan; courts have had to devise and apply their own interpretations of the term “accident” when conducting de novo review of a plan administrator’s decision where the plan did not give the administrator the discretionary authority to interpret the terms of the plan. See, e.g., Santaella v. Metro. Life Ins. Co.,
Having concluded that the Hartford plan administrator’s interpretation of “accidental” to mean “unexpected” or “unforeseen” is reasonable under the Finley five-factor test, I now turn to the issue of whether the plan administrator reasonably applied its interpretation to the facts of Amber Lynn’s claim. I conclude that it did.
The plan administrator gave a “reasoned explanation, based on -the evidence,” for denying Amber Lynn’s claim. See Donaho,
Appellant argues that Mr. Schanus’s “expectation of reaching home ... was not patently unreasonable. since most people who drive after drinking (even with a 0.19 BAC) are not injured or killed on the highway.” Brief of Appellant at 41. For example, she explains that evidence she submitted to the district court “demonstrates that the number of people who died as a result of drunk driving is'less than 1% of all individuals who are arrested for driving under the influence of alcohol.” Brief of Appellant at 35.
In- sum, I would conclude that the Hartford plan administrator did not abuse its discretion. The administrator reasonably interpreted and applied the terms of the policy to the facts of Amber Lynn’s claim for accidental-death benefits. Given the deferential standard of review, the administrator’s decision to deny benefits must not be disturbed even if a different reasonable decision could have been made. Therefore, I would affirm the judgment of the district court.
. As the Court explains in its opinion, in Firestone Tire and Rubber Co. v. Bruch,
. While a remand to the plan administrator in this case could work to the benefit of this claimant, the Court's holding today may well
With regard to the Court's proviso that remand need not occur if an ERISA defendant changes its litigation position in an attempt to gain a tactical advantage, see supra at 1006 n. 4, I do not share the Court's confidence that a reviewing court will necessarily be able to divine the intent behind a litigation strategy that drifts away from the plan administrator's original position. Apparently, the Court has decided that Hartford is gaming no tactical advantage in this case because Hartford has moved away from "its original, narrower interpretation” of accidental injury. See id. However, on remand, the Hartford plan administrator may not interpret or apply "Wick-man 's more generous interpretation of accidental injury," id., as generously as the Court expects. Regardless of the outcome on remand, the fact remains that "ERISA's purpose of streamlining and shortening the time-frame for disposing of claims,” see Schadler,
. The five factors to be considered are:' (1) whether the Hartford plan administrator's interpretation is consistent with the goals of the policy; (2) whether the interpretation renders any language in the policy meaningless or internally inconsistent; (3) whether the interpretation conflicts with the substantive or procedural requirements of the ERISA statute; (4) whether the Hartford plan administrator has interpreted the word "accidental" consistently; and (5) whether the interpretation is contrary to the clear language of the policy. See Finley,
. The Hartford insurance policy provided that Hartford will pay an accidental-death benefit if the employee participant's death results directly from an "accidental bodily injury.” However, the policy did not define "accidental.” As a result, the plan administrator consulted Black’s Law Dictionary which defined “accidental” as: “Happening by chance, or unexpectedly; taking place not according to the usual course of things; casual; fortuitous." In its initial claim denial letter dated December 26, 2000, the plan administrator denied Amber Lynn’s claim, reasoning: “Given [Mr. Schanus’s] blood alcohol level, his bodily injury can in no way be considered unexpected, happening -by chance or fortuitous. On the contrary, it could be expected that if he drove his vehicle in such a reckless manner and in an intoxicated condition, serious bodily injury could result." Amber Lynn appealed the denial, and on June 14, 2001, the plan administrator upheld the denial, explaining: “[A] reasonable -person would have known that death or serious injury was a reasonably foreseeable result of driving while intoxicated.”
. In an employee benefit plan, an exclusion is a benefit that meets the rule of coverage under the plan (e.g., meets the definition of ''accident”), but nonetheless is not covered under the terms of the plan..
. The policy provides:
What types of injuries are excluded from coverage?
No benefit will be paid for a loss caused or contributed to by:
(1) sickness; or
(2) disease; or (3) any medical treatment for items (1) or (2); or
(4) any infection, except a pus-forming infection of an accidental cut or wound; or
(5) war or any act of war, whether war is declared or not; or
(6) any intentionally self-inflicted injury, suicide, or suicide attempt, whether sane or insane; or
(7) taking drugs, sedatives, narcotics, barbiturates, amphetamines or hallucinogens unless prescribed for or administered to you by a licensed physician.
. It is interesting to note that the same evidence submitted by Appellant also indicates that "[t]here were 16,653 alcohol-related fatalities in 2000-40 percent of the total traffic fatalities for the year.... The 16,653 fatalities in alcohol-related crashes during 2000 represent an average of one alcohol-related fatality every 32 minutes.”
. See also Nelson v. Sun Life Assurance Co. of Canada,