# U ni te d S ta te s Co ur t of A pp ea ls

For the Eig hth Circu it

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No. 1 2- 40 47

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Sean Nich ol s

ll ll ll ll ll ll ll ll ll ll l Pla in ti

ff - App el le e

v.

Uni care Life a nd Heal th Ins ur an ce Co m pa ny

ll ll ll ll ll ll ll ll ll ll l Defe nd

an t

Acx io m Co rp or at io n Life an d Acci de nt al Deat h an d Dis m em be rm en t In su ran ce Pl an

ll ll ll ll ll ll ll ll ll ll l Defe nd

an t - Ap pe ll an t

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No. 1 3- 10 33

__ __ __ __ __ __ __ __ __ __ __ __ __ _

Sean Nich ol s

ll ll ll ll ll ll ll ll ll ll l Pla in ti

ff - App el le e

v.

Uni care Life a nd Heal th Ins ur an ce Co m pa ny

ll ll ll ll ll ll ll ll ll ll l Defe nd

an t - Ap pe ll an t

Acx io m Co rp or at io n Life an d Acci de nt al Deat h an d Dis m em be rm en t In su ran ce Pl an

ll ll ll ll ll ll ll ll ll ll l Defe nd

an t__ __ __ __ __ __

App eal fro m

Uni te d S ta te s Di st ric t Co ur t

fo r th e Eas te rn Dis tri ct of Ark an sa s - Li tt le Ro ck

__ __ __ __ __ __

Su bm it te d: Sep te m

be r 25 , 20 13

Fil ed : J an ua ry

16 , 20 14

__ __ __ __ __ __

Befo re WOL LMAN, BEAM, an d S MITH, Ci rcu it Ju dg es

.

__ __ __ __ __ __

BEAM, Ci rcu it Ju dg e.

Uni Care Life an d Heal th In su ran ce Co m pa ny ("Un ic are" ) ap pe al s th e di st ric t

co ur t's gr an t of su m

m ary jud gm en t in fav or of Sean Nich ol s in th is Em pl oyee 1

Ret ire m en t In co m e Secu rit y Act (ERISA)

, 29 U.S.C. §§ 10 01 et se q. cas e. W e affi rm

.

I. BACKGRO UND

Nich ol s is th e s u r v i vi ng sp ou se of Dan a Nich ol s. Dan a was em pl oyed by

Acx io m Co rp or at io n, an d sh e was in su red un de r t h e A cx io m Co rp or at io n Life an d

Acci de nt al Deat h an d Dis m em be rm en t In su ran ce Pl a n (th e "p la n" ). The pl an is

fu nd ed by a po li cy un de rwri tt en by Uni Care

, an d Un iC are a ls o s erv es as t he cla im s

ad m in is tra to r.

On May 3, 20 10

, Dan a was fo un d face do w n i n be d, an d up on be in g

tra ns po rte d to a ne arb y ho sp it al

, sh e was pr on ou nc ed de ad

. The au to ps y rep o r t

The Ho n o r a bl e Su sa n W eb be r W rig ht

, Uni te d St at es Dis tri ct Ju dg e fo r th e 1

East ern Dis tri ct of Ark an sa s.

-2

-in di cat ed th at he r m an ne r of de at h (n at ur al

, acci de nt al

, et c.) "co ul d no t be

de te rm in ed ," an d h e r cau se of de at h was m ix ed dr ug in to xi cat io n. The au to ps y

re p o r te d th at "[t ]oxi co lo gy de te ct ed m ul ti pl e dr ug s in th e bl oo d to in cl ud e

ci ta lo pr am

/e sc it al op ram

, hydro co do ne

, ox y co do ne an d lo rat ad in e. The at ro pi ne

de t e c t e d i s th e res ul t of te rm in al m ed ic al at te nt io n. No al co ho l was de te ct ed ." An

in su ran ce reco rd do cu m en ti ng Dan a's pr es cri pt io n cl ai m s du r i ng th e la st twel ve

m on th s of he r li fe sh ow th e fo ll owi ng pr e sc rip ti on s an d fil l da te s: End oc et 30 -d ay

pr es cri pt io n l as t fi ll ed on Apri l 2 7, 2 01 0; Am bi en 30 -d ay

pre sc rip ti on las t fil le d o n

Apr il 3, 20 10 ; le vo th y ro xi ne

, 30 -d ay pr es cri pt io n la st fil le d on Apr il 3, 20 10 ;

ap ap /c od ei ne 2- da y pr es cri pt io n la st fil le d on Decem be r 29

, 20 09 ; di azep am 2- da y

pr es cri pt io n la st fil le d on Decem be r 29

, 20 09 ; an d se rtr al in e, 30 -d ay pr es cri pt io n la st

fil le d on Octo be r 12

, 20 09

. Em erg e n c y p e r s o nn el res po nd in g at th e sc en e al so

rep or te d a pr es cri pt io n bo tt le fo r hydro co do ne on th e ni gh t st an d wit h 12 pi ll s

m is si ng fro m it

. As we read th e ad m in is tra ti ve reco rd

, th ere is no in fo rm at io n ab ou t

whe n t hi s p res cri pt io n was fil le d. 2

Nich ol s fil ed a cl ai m fo r acci de nt al de at h be ne fit s un de r th e pl an

. By le tt er

da te d Feb ru ary 9, 20 11

, Uni Care de ni ed Nich ol s' cl ai m

, st at in g th at be cau se th e cau se

of de at h was li st ed as " co ul d n ot be de te rm in ed ," it ha d " no ch oi ce" bu t t o d en y th e

cl ai m

. Nich ol s fil ed a n a d mi ni st rat iv e ap pe al an d su pp le m en te d th e reco rd (wh ic h

pr ev io us ly co ns is te d on ly of th e au to ps y rep or t) w i t h med ic al an d pr es cri pt io n

reco rd s, as well as le tt ers fro m hi m se lf an d Dan a's pa ren ts

, reco un ti ng he r rece nt

m ed ic al pr ob le m s an d he r so ci al hi st or y

. Nich ol s reco un te d th at si nc e Dan a's Mar ch

20 10 car acci de nt

, sh e ha d di ffi cu lt y sl eep in g, an d was pr es cri be d Am bi en

. He no te d

th at whi le on Am

bi en

, Dan a ha d be en sl eep walk in g th ro ug ho ut th e ho us e an d wou ld

ev en eat so m et hi ng an d no t rem em be r it in th e m or ni ng

. D a n a ' s m ot he r reco un te d

The di st ric t co ur t no te d th at Dan a's Mar ch 20 10 car acci de nt ha d ex acer ba te d 2

he r ba ck pa in

, an d fu rth er ob se rv ed th at th e in su rer's li st of m ed ic a t i o n s i n th e

ad m in is tra ti ve reco rd wou ld no t in cl ud e pr es cri pt io ns fil le d wit ho ut a co rres po nd in g

m ed ic al in su ran ce cl ai m

.

-3

-th at Dan a was ha pp il y m arri ed wit h gr own ch il dr en ; th at Dan a's so n was ne wly

m arri ed ; an d Dan a's da u g h t e r w a s s et to be gi n nu rs in g sc ho ol

. Dan a's m ot he r al so

reco un te d th at Dan a was lo ok in g fo rward to a sc he du le d la p ba nd su rg ery to as si st he r

wit h w e i gh t lo ss an d eas e he r ba ck pa in fro m th e car acci de nt s an d th at sh e was

ge ne ral ly lo ok in g fo rward to th e fu tu re. The le tt er fro m Dan a's fat he r rei te rat ed

Nich ol s' st at em en ts ab ou t Dan a's sl eep walk in g be ha vi or whi l e o n Am bi en an d he r

ge ne ral go od ou tl oo k fo r th e fu tu re.

By le tt er dat ed Sep te m

be r 2, 20 11

, Uni Care de ni ed Nich ol s' ap pe al

, th is ti m e

st at in g two reas on s fo r th e ad ve rs e de ci si on : (1 ) th e m an ne r of de at h was li st ed on th e

de at h cert ifi cat e as "co ul d no t be de te rm in ed ," an d (2 ) th e pl an ex cl ud es be ne fit s fo r

de at h cau se d by in to xi cat io n. N ic ho ls fil ed th e in st an t act io n in di st ric t co ur t

pu rs ua nt to ERISA. Upo n Nich ol s' m ot io n fo r su m m ary jud gm en t, th e di st ric t co ur t,

ap pl y in g a d e n o vo st an da rd of rev ie w, fo un d th at Nich ol s was en ti tl ed to be ne fit s

be cau se th e cau se of Dan a's de at h was m or e li ke ly th an no t an acci de nt

. The di st ric t

co ur t reject ed Uni Car e ' s arg um en t th at it s an al y si s of whe th er Dan a's de at h was an

acci de nt sa ti sf

ie d th e st an da rd se t fo rth i n Wic km an v. Nor th wes te rn Nati on al

In su ran ce Co ., 90 8 F .2d 10 77 (1s t Ci r. 19 90 ).

Uni Care arg ue d to th e di st ric t co ur t th at un de r W ic km an

, Dan a's co ns um pt io n

of nu m ero us m ed ic at io ns was an in te nt io na l a c t fo r whi ch sh e wou ld ha ve

su bj e c t i v e l y ex pe ct ed de at h to be a hi gh ly li ke ly ou tc om e. In th is reg ard

, Uni Care

co nt en de d th at si nc e Dan a ha d be en co ns um in g pr es cri pt io n m ed ic at io ns fo r at le as t

a y ear, a reas on ab le in te rp ret at io n of th e ev id en ce was th at Dan a ha d es ta bl is he d a

to le ran ce t o th e m ed ic at io ns sh e ha d bee n con su m in g in co m bi na ti on for

y ears , and

th at sh e m

us t h av e ta ke n m or e th an th e pr es cri be d do sa ge s on th e da te of he r de at h.

The di st ric t co ur t reject ed th is arg um en t an d no te d th at Uni Care 's an al y si s was fla wed

be cau se it "p ro vi de s no in di cat io n th at Uni Care at te m pt ed to as cert ai n Dan a Nich ol s's

su bjec ti ve ex pe ct at io ns o r w h e t he r a reas on ab le pe rs on in he r po si ti on wou ld ha ve

vi ewed he r de at h a s h ig hl y li ke ly to o ccu r." J .A. at 3 2.

-4

-W it h reg ard to th e in to xi cat io n ex cl us io n, th e di st ric t co ur t co nc lu de d th at th e

ex cl us io n was no t in te nd ed to co ve r Dan a's si tu at io n. Bec au se th e pl an de fin es

"i nt ox ic at ed " as "l eg al ly in to xi cat ed as de te rm in ed by th e la ws of th e juri s d i c ti on

whe re th e acci de nt oc cu rred ," th e di st ric t co ur t fo un d th at a reas on ab le pe rs on in th e

po s i ti on of a pl an pa rti ci pa nt wou ld un de rs ta nd th at th e ex cl us io n fo r in to xi cat io n

was in te nd ed to ap pl y to de at h cau se d by co m m it ti ng act s, su ch as dr iv in g, whi le

in to xi cat ed

, n o t t o s i tu at io ns whe re th e im m ed ia te cau se of de at h is in ge st io n of a

le th al m ix tu re of p r e s c r i p ti on dr ug s. The di st ric t co ur t ci te d Sh eeh an v. Gua rd ia n

Life In su ran ce Co

., 37 2 F.3 d 96 2, 96 7 (8 th Ci r. 20 04 ) (fi nd in g th at ex cl us io n fo r lo ss

res ul ti ng fro m be in g un de r th e in flu en ce of a co nt ro ll ed su bs ta nc e was "i nt en de d to

ap pl y to de at h cau se d by, fo r ex am pl e, dr iv in g whi le in to xi cat ed

, no t to th e acci de nt al

in ge st io n o f a co nt ro ll ed su bs ta nc e") , in su pp or t o f it s co nc lu si on . J.A. at 3 3- 34

.

Uni Care ap pe al s an d arg ue s th at th e st an da rd of rev ie w sh ou ld be ab us e of

di sc ret io n; th at th e di st ric t co ur t im pe rm is si bl y sh ift ed t h e b u r d e n fro m Nich ol s

ha vi ng to pr ov e en ti tl em en t to be ne fit s to Uni Care ha v i ng to di sp ro ve Nich ol s'

en ti tl em en t; a n d t ha t th e di st ric t co ur t erro ne ou sl y co nc lu de d th at th e in to xi cat io n

ex cl us io n di d no t pr ecl ud e an a w a r d o f acci de nt al de at h be ne fit s. Uni Care al so

ch al le ng es th e $ 22 ,22 0 a tt or ne y fee awa rd ed to Nich ol s.

II

. DISCUSS IO N

A. Sta nda rd o f Rev ie w

ERISA pr ov id es th at an em pl oyee m ay br in g a ci vi l act io n to reco ve r be ne fit s

du e to hi m un de r th e te rm s of an em pl oyee welf

are be ne fit pl an

. 29 U.S.C. §

11 32 (a)( 1) (B). Alt h o u g h t he st at ut e do es no t sp eci fy th e sc op e of jud ic ia l rev ie w

ap pl ic ab le to ERISA cl ai m s, in Fi res to ne Tire & Ru bb er Co

. v. Bru ch

, 48 9 U.S. 10 1,

11 5 (1 98 9)

, th e Su pr em e Co ur t he ld th at a de ni al of be ne fit s ch al le ng ed un de r ERISA

is su bjec t to de no vo rev ie w un l e s s th e te rm s of th e be ne fit pl an gi ve th e pl an

-5

-ad m in is tra to r or fid uc ia ry di sc ret io na ry au th or it y to de te rm in e el ig ib il it y fo r be ne fit s

or to co ns tru e th e t e r ms o f th e pl an

. W he n a pl an co nf ers su ch di sc ret io na ry

au th or it y

, th e ad m in is tra to r's or fid uc ia ry 's de ci si on is gi ve n de fere nc e an d rev ie wed

un de r an ab us e-o f-d is cret io n st an da rd

. Met ro

. Life In s. Co

. v. Glen n, 55 4 U.S. 10 5,

11 1 (2 00 8)

. Howev er, w h e n a co nf li ct of in te res t ex is ts be cau se th e pl an

ad m in is tra to r is bo th th e d eci si on -m ak er and th e in su rer, " we ta ke th at co nf li ct in to

acco un t an d g iv e it so m e wei gh t i n t he ab us e-o f-d is cret io n cal cu la ti on ." Carr ow v

.

St an da rd Ins . Co., 6 64 F.3d 12 54 , 12 59 (8t h C ir. 2 01 2)

.

The di st ric t co ur t fo un d th at th e pl an di d no t co nf er di sc ret io na ry au th or it y on

Uni Care as th e pl an di d no t co nt ai n th e ne ces sa ry di sc ret io na ry la ng ua ge

. The di st ric t

co ur t fo cu se d on th e la ng ua ge in th e c l a im s pr ov is io ns

, sp eci fic al ly th e fo ll owi ng :

"[a ]ny be ne fit s du e un de r th is pl an sh al l be du e on ce we ha ve rece iv ed pr op er, writ te n

pr oo f of lo ss , t og et he r wit h su ch reas on ab ly n eces s a r y i n f or m at io n we m ay req ui re

to de te rm in e ou r ob li ga ti on ." W e ha ve pr ev io us ly fo un d th at si m il ar la ng ua ge di d no t

co nf er di sc ret io na ry au th or it y on th e ad m in is tra to r. See Ri tt en ho us e v. Uni te dHe al th

Gro up Lon g Term Dis ab il it y In s. Pl an

, 47 6 F.3 d 62 6, 62 9 (8 th Ci r. 20 07 ) (n ot in g th at

po li c y l a n g u a g e st at in g th at be ne fit s wou ld be pa id whe n "we de te rm in e th at pr oo f

. . . is sa ti sf

act or y " w a s am

bi gu ou s an d di d no t co nf er di sc ret io n on pl an

ad m in is tra to r).

Uni Care

, on th e o th er ha nd

, po in ts us to Ferr ari v. Teach ers In su ran ce an d

Ann ui ty Ass 'n, 27 8 F.3 d 80 1 (8 th C ir. 20 02 ). In Ferr ari

, th e cl ai m an t was in it ia ll y

award ed di sa bi li ty be ne fit s, an d in or de r to ke ep rece iv in g th em on a lo ng -te rm ba si s,

was req ui red to su bm it writ te n pr oo f of co nt in ue d to ta l di sa bi li ty. W e no te d th at th e

pl an la ng ua ge "t ha t th e em pl oyee m us t pr ov id e w r i t t e n pr oo f of co nt in ue d to ta l

di sa bi li ty at reas on ab le in te rv al s to be de te rm in ed by TIAA an d th at su ch pr oo f m us t

be sa ti sf act or y to TIAA" su ffi ci en tl y co nf erre d di sc ret io n on t h e a dm in is tra to r. Id

.

at 80 6. Uni Care arg ue s th at i t s pl an ha s th e sa m e la ng ua ge

, al be it in th e se ct io n

ad dr es si ng en ro ll men t in th e po li cy

, no t in th e se ct io n ad dr es si n g c l a i m s

-6

-ad m in is tra ti on

. Uni Care co nt en ds th at di sc ret io na ry la ng ua ge an y whe re in th e pl an

co nf ers up on it th e di sc ret io n ne ces sa ry to ob ta in an ab us e-o f-d is cret io n st an da rd of

re v i e w f o r de ni al of cl ai m s. Nich ol s, on th e ot he r ha nd

, co nt en ds th at th e

di sc re t i o n a r y la ng ua ge m us t ad dr es s cl ai m s ad m in is tra ti on or m us t gr an t ge ne ral

di sc ret io n to co ns tru e pl an te rm s in or de r fo r th e pl an to ob ta in an ab us e-o f-d is cret io n

st an da rd of r ev ie w.

W e ag ree wit h Nich ol s th at th e pl an do es no t gr an t Uni Care d i s c r e ti on to

de te rm in e el ig ib il it y fo r be ne fit s or to ge ne ral ly co n s t r u e t h e te rm s of th e pl an

.

Ferr ari do es no t be ar th e weig ht Uni Care pl aces on it be cau se th e la ng ua ge fro m th e

pl an in th at cas e g a v e th e ad m in is tra to r th e di sc ret io n to m ak e de ci si on s ab ou t

"co nt in ue d to ta l di sa bi li ty cl ai m s" –a nd th e vi ab il it y of a "co nt in ue d to ta l di sa bi li ty

cl ai m " was th e de ci si on be in g ch al le ng ed o n a p p eal

. Id

. at 80 5- 06

. In th e in st an t

cas e, th e de ci si on be in g ch al le ng ed on ap pe al ha s no th in g to do wit h Dan a's

en ro ll m en t in th e pl an

. The ch al le ng ed de ci si on is t h e ad m in is tra to r's de ni al of a

cl ai m fo r acci de nt al de at h be ne fit s. The pl an 's la ng ua ge in th e cl ai m s se ct io n, whi ch

is la ck in g di sc ret io n- gr an ti ng wor ds acco rd in g to ou r cas e la w, se e Ri tt en ho us e, 47 6

F.3 d a t 62 9, is th e m os t rel ev an t. Nor is th ere a ge ne ral gr an t of di sc ret io na ry

au th or it y to Uni Care to co ns tru e al l pl an te rm s. Acco rd in gl y

, we ho ld th at th e di st ric t

co ur t co rrec tl y

ap pl ie d a n a bu se -o f-d is cret io n s ta nd ard of r ev ie w. 3

Eve n if we were to ho ld th at th e pl an gr an te d Uni Care di sc ret io n, th e fin an ci al 3

co nf li ct of in te res t th at ex is ts in th is cas e wou ld be ta ke n i n to acco un t, so m ewh at

am el io rat in g th e ab us e-o f-d is cret io n st an da rd

. See Carr ow, 664 F. 3d at 1259 (h old ing

th at whe n a co nf

li ct of in te res t ex is ts be cau se th e pl an ad m in is tra to r is bo t h t h e

de ci si on -m ak er an d th e in su rer, "we ta ke th at co nf li ct in to acco un t and gi ve it so m e

weig ht in th e ab us e-o f-d is cret io n c al cu la ti on ").

-7

-B. Acci dent al Deat h Cla im

N ic ho ls arg ue s Uni Care erre d in de nyin g hi s cl ai m fo r acci de nt al de at h bene fi ts

wit h th e st at ed rat io na le th at th e au to ps y rep or t li st ed th e m an ne r of de at h as "co ul d

no t b e d et erm in ed ." Nic ho ls su bm it te d pro of of h is cla im

for acci de nt al be ne fit s i n

th e fo rm o f th e de at h cert ifi cat e, au to ps y rep or t, in su ran ce m ed ic al reco rd s,

pr es cri pt io ns reco rd s, an d ev id en ce rel ev an t to Dan a's st at e of m in d, he r rel at io ns hi ps

wit h fa m il y , and an up co m in g s ch ed ul ed su rg ery.

As no te d, in fro nt of th e di st ric t co ur t, Uni Care ad va nc ed th e W ic km an te st as

th e ve hi cl e fo r de te rm in in g whe th er Dan a's de at h was an acci de nt

, an d as se rte d th at

th e fact s of th is cas e, as pl aced in th e W ic km an ru br ic

, in di cat ed th at th e in ci de nt was

no t a n acci de nt

. Und er W ic km an

, an ev en t is an acci de nt if th e de ced en t di d no t

su bjec ti v e l y ex pe ct to su ffer "an in jury s im il ar in type or ki nd to th at su ffer ed " an d

th e su pp os it io ns un de rlyi n g t h a t ex pe ct at io n were reas on ab le

. 90 8 F.2 d at 10 88

.

"Th e de te rm in at io n of wha t su pp os it io ns are un reas on ab le sh ou ld be m ad e fro m th e

pe rs pe ct iv e of th e in su red

, al lo win g th e in su red a gr eat de al of la ti tu de an d ta ki ng in to

acco un t th e in su red 's pers on al ch arac te ris ti cs an d ex pe rie nc es ." Id

. If the ev id en ce

is in su ffi ci en t to de te rm in e th e de ced en t's su bjec ti ve ex pe ct at io n, th e qu es ti on is th en

w h e t h e r "a reas on ab le pe rs on

, wit h ba ck gr ou nd an d ch arac te ris ti cs si m il ar to th e

in su red

, wou ld ha ve vi ewed th e in jury as hi gh ly li ke ly to o c cu r as a res ul t of th e

in su red 's i nt en ti on al co nd uc t." Id.

Uni Care co nt en ds th at th ere is in su ffi ci en t su bjec ti ve ev id en c e o f D an a's

ex pe ct at io ns

, an d t he ob jecti ve ev id en ce su gg es ts th at Dan a's co ns um pt io n of

nu m ero us m ed ic at io ns was an in te nt io na l act fo r whi ch a r e a s o n a bl e pe rs on wou ld

ha ve ex pe ct ed de at h as th e ou tc om e. Uni Care su rm is es th at si nc e D a n a h a d be en

ta ki ng th is sa m e co m

bi na ti on of m ed ic at io ns fo r se ve ral m on th s, sh e be cam e to le ran t

to th at le ve l of m ed ic in e an d su bs eq ue nt ly to ok m or e th an th e pr es cri be d do sa ge on

th e ni gh t sh e di ed

. Uni Care a rg ue s th at

, ob jecti ve ly sp eak in g, Dan a wou ld ha ve

-8

-vi ewed de at h as hi gh ly li ke ly to oc cu r in su ch a si tu at io n. Thi s arg um en t is st rik in gl y

si m il ar to th e on e m ad e by th e pl an ad m in is tra to r/i ns ur er i n t h e r ecen t cas e of

McC le ll an d v. Life In su ran ce Co m pa n y o f N or th Am eri ca, 67 9 F.3 d 75 5 (8 th Ci r.

20 12 ).

In McC le ll an d, un de r th e de fere nt ia l ab us e-o f-d is cret io n st an da rd of rev ie w,

we he ld th at th e in su ran ce co m pa ny erro ne ou sl y de ni ed acci de nt al de at h be ne fit s to

th e wid ow of th e in su red de ced en t who di ed w h i l e dr iv in g a m ot or cy cl e at hi gh

sp eed s wit h an el ev at ed bl oo d al co ho l le ve l. As "ev id en ce" of th e de ceas ed 's st at e of

m in d, th e in su ran ce co m pa ny of fere d t h a t McC le ll an d ha d be en ed uc at ed on th e

da ng ers of dr in ki ng an d dr iv in g an d sh ou ld ha ve kn own th at de at h was hi gh ly li ke ly

to oc cu r in hi s ci rcu m st an ces

. We h el d th at th is reas on in g was an ab us e of th e

in su rer's di sc ret io n, an d a m is ap pl ic at io n o f t h e a gr eed -u po n st an da rd se t fo rth in

W ic km an

, be cau se be tt er an d m or e co nc ret e ev id en ce of Mc Cl el la nd' s subj ec tiv e state

of m in d on th e m or ni ng o f t he acci de nt (s ub m it te d in th e fo rm of affi da vi ts fro m

fam il y

, fri en ds an d wit ne ss es on th e da y of th e acci de nt ), was th at he ha d no in te nt io n

to di e an d cert ai nl y di d no t th in k de at h was li ke ly to oc cu r as he wen t on a so ci al m id

Sat ur da y m or ni ng m ot or cy cl e ri de . Id. at 76 0- 61

.

Lik e th e in su ran ce co m

p a n y i n McC le ll an d, Uni Care ig no res th e su bjec ti ve

ev id en ce s u b mi t t e d by Nich ol s, an d in st ead m ak es le ap s to ge t to th e "o bjec ti ve "

co nc lu si on it de si res

. The re was no ev id en ce in th e reco rd th at Dan a ha d de ve lo pe d

a to le ran ce to he r m ed ic at io ns or th at sh e to ok al l 12 of th e m is si ng hydro co do ne pi ll s

on th e n ig ht of h er d eat h. No ev id en ce s ug ge st s t ha t Dan a was su ic id al . Sim il ar t o

th e m ot or cy cl e dr iv er in McC le ll an d who ha d be en su cces sf ul ly weav in g in an d ou t

of tra ffi c at a hi gh rat e of sp eed fo r ov er si x m il es an d th eref or e di d no t ex pe ct to di e

th at da y

, Dan a ha d be en ta ki ng th is co m bi na ti on of pr es cri b ed m ed ic at io ns

, as

ad m it te d by Uni Care

, fo r so m e pe rio d of ti m e. The re is no ev id en ce wha ts oe ve r th at

Dan a in te nd ed to ki ll he rs el f or th ou gh t it li ke ly sh e wou ld di e on May 3, 20 10

. The

su bjec ti ve ev id en ce, in th e f o r m o f le tt ers an d st at em en ts fro m he r hu sb an d an d

-9

-pa ren ts

, su gg es ts ot he rwis e. To th e ex te nt th at he r su bjec ti ve m in d se t co ul d st il l be

vi ewed as un cert ai n

, t he ob jecti ve ev id en ce te nd ed to sh ow th at Dan a ha d be en

in ge st in g a co m

bi na ti on of pr es cri be d m ed ic at io n fo r so m e ti m e, an d un de r th es e

ci rcu m st an ces

, a reas on ab le pe rs on wit h Dan a's ch ara c t e r i s ti cs wou ld no t ha ve

vi ewed de at h as hi gh ly li ke ly to oc cu r. Nor is th ere a m ed ic al de te rm in at io n th at th e

de at h was "n ot acci de nt al " as al le ge d by Uni Care

. Dan a's de at h fal ls sq ua rel y wit hi n

th e m ean in g of acci de nt , a wor d no t o th erwi se de fin ed in th e p ol ic y , a nd as vi ewed

un de r th e W ic km an m an da te t o c o ns id er th e si tu at io n fro m th e "p ers pe ct iv e of th e

in su red

, al lo win g th e in su red a gr eat de al of la ti tu de a n d t ak in g in to acco un t th e

in su red 's pe rs on al ch arac te ris ti cs an d ex pe rie nc es ." 90 8 F.2 d at 10 88

. As th e di st ric t

co ur t ap tl y

st at ed , "[i ]n su m , all of t he ev id en ce i nd ic at es th at Dan a's de at h was th e

un ex pe ct ed res ul t of in ge st in g pr es cri be d m ed ic at io ns ." J. A

. at 33. Acco rd in gl y

, du e 4

to al l of th e fo reg oi ng

, we fin d th at th e di st r i c t co ur t co rrec tl y fo un d th at Uni Care

erre d i n d en y in g c ov erag e fo r acc id en ta l d eat h b en efi ts

.

Our co nc lu si on is bo ls te red by th e pr es u mp t io n ag ai ns t su ic id e th at th e 4

Elev en th Ci rcu it ha s reco gn iz ed in th e co nt ex t of an ERISA cas e, ho ld in g th at "[b ]oth

th e ne ga ti ve pr es um

pt io n ag ai ns t su ic id e an d th e affi rm at iv e pr es um p t i o n o f

acci de nt al de at h" ad va nc e ERISA's go al s of pr ot ect in g t h e i n t e res ts of pl an

be ne fic ia rie s an d un ifo rm it y in pl an ad m in is tra tio n. H or to n v. Rel ia nc e St an da rd Life

In s. Co

., 14 1 F.3 d 10 38

, 10 41 (1 1t h Ci r. 19 98 ). Th e H o rto n co ur t he ld th at th es e

go al s were fu

rt he re d by pr ov id in g "u ni fo rm ru le s to res ol ve co ve rag e qu es ti on s whe re

th e ev id en ce of ho w th e in su red di ed is in co nc lu si ve ." Id

. The co ur t al so no te d th at

a m ajor it y of st at es reco gn iz e t he pr es um pt io n ag ai ns t su ic id e, id

., an d Ark an sa s is

on e of th os e st at es

. See W oo d v. Vall ey Fo rg e Life In s. Co

., 47 8 F.3 d 94 1, 94 7 (8 th

Ci r. 20 07 ) (rec og ni zi ng th e Ark an sa s "st ro ng " pres um pt io n aga in st su ic id e). The re

wou ld be no th in g rem ark ab le ab ou t a p p l y in g su ch a pr es um pt io n in an un cert ai ncaus e-o f-d eat h ERISA cas e, as ERISA pl an ad m in is tra to rs are boun d to fo llo w fe de ra l

co m m on la w, as in fo rm ed by st at e co m m on la w. Sh ip le y v. Ark

. Bl ue Cro ss & Bl ue

Sh ie ld , 3 33 F.3 d 89 8, 90 2 (8 th Ci r. 20 03 ). Howev er, we ne ed no t ev e n r e l y o n t h e

pr es um pt io n be cau se as no te d ab ov e, Nich ol s ha s met h i s b u rd en to es ta bl is h

en ti tl em en t t o Dan a's acci de nt al de at h b en efi ts

.

-1 0-C. In to xi ca tio n Ex cl us io n

Uni Care 's fin al arg um en t is th at it can av oi d paying be ne fit s du e to th e pl an 's

in to xi cat io n e xc lu si on . The excl us io n st at es th at no be ne fit wil l be pai d for a de at h

th at res ul ts fro m b e i n g i nt ox ic at ed

. "In to xi cat ed " is de fin ed in th e pl an as "l eg al ly

in to xi cat ed as de te rm in ed by th e la ws o f th e juri sd ic ti on whe re th e acci de nt

oc cu rred ." Bec au se it is an ex cep ti on to co ve rag e, Uni Care ha s th e bu rd en of pr ov in g

th at th e ex cl us io n ap pl ie s. Farl ey v. Ben efi t Trus t Life In s. Co ., 9 79 F.2 d 65 3, 65 8

(8 th C ir. 19 92 ). W e ag ree wit h th e di st ric t co ur t th at Uni Care di d no t m eet th is

bu rd en

. Ark an sa s la w de fin es in to xi cat io n wit h refe ren ce on ly to th e pu bl ic of fen se s

of dr un k dr iv in g an d pu b l i c in to xi cat io n. Jo ne s Truc k Lin es

, In c. v. Lets ch

, 43 6

S.W .2d 28 2, 28 4 (Ark

. 19 69 ). Dan a's de at h in vo lv ed ne it he r. W e vi ew th e co m m on

an d or di na ry m ean in g of th e p ol ic y lan gu ag e as a reas on ab le pe rs on in th e po si ti on

of th e p la n p art ic ip an t wo ul d h av e u nd ers to od th e wor ds to m ean . Adam s v . Con t'l

Cas

. Co

., 36 4 F.3 d 95 2, 95 4 (8 th Ci r. 20 04 ). A reas on ab le p l a n pa rti ci pa nt wou ld

ha ve un de rs t o o d th at th e pl an 's in to xi cat io n ex cl us io n is in te nd ed to ap pl y to de at h

cau se d by co m

m it ti ng act s, su ch as dr iv in g, whi le in to xi cat ed ; no t to si tu at io ns whe re

th e im m ed ia te cau se of de at h is in ge st io n of a le th al m ix tu re of dr ug s th at ha ve be en

pr es cri be d fo r us e by th e de ced en t. See Sh e e h an

, 37 2 F.3 d at 96 7 (fi nd in g th at

ex cl us io n fo r lo ss res ul ti ng fro m be in g un de r th e in flu en ce of a co nt ro ll ed su bs ta nc e

was "i nt en de d to ap pl y to de at h cau se d by, fo r ex am pl e, dr iv in g whi le in to xi cat ed

, no t

to th e acci de nt al in ge st io n of a co nt ro ll ed su bs ta nc e")

. The di st ric t co ur t co rrec tl y

fo un d th at Uni Care ha d no t pr ov en th at th e ex cl u s i o n sh ou ld be us ed to de ny

co ve rag e.

D. Cos ts an d Fees

In a se pa rat e or de r, th e di st ric t co ur t award ed Nich ol s fil in g fees

, pr ejud gm en t

in te res t an d $2 2,2 20 in at to rn ey fees

. Uni Care arg ue s th is was an ab us e of th e di st ric t

co ur t's di sc ret io n. In de ci di ng whe th er to award fees in ERISA cas es

, we are gu id ed

-1 1-by th e fiv e fact or s set fo rth in Lawren ce v. W es te rh au s, 74 9 F.2d 49 4, 49 6 (8t h Cir.

19 84 ) (p er cu ria m ) ((1 ) de gr ee of ba d fai th ; (2 ) ab il i t y t o p ay ; (3 ) de te rren ce; (4 )

s i gn ifi can ce of th e le ga l qu es ti on ; an d (5 ) rel at iv e m eri ts of th e po si ti on s )

. Th e

di st ric t co ur t's de c is io n is rev ie wed fo r an ab us e of di sc ret io n. Id

. at 49 5. In

an al y zi ng th e fac to rs , th e d is tri ct co ur t fo un d th at a fee was warra nt ed , a nd we fi nd

th at th e di st ri c t c o u r t d i d no t ab us e it s di sc ret io n in so de ci di ng

. Fu rth er, th e fee

award ed was re as on ab le

.

II I. CONCLUSI ON

W e aff irm th e d is tri ct co ur t.

__ __ __ __ __ __ __ __ __ __ __ __ __ __ __

-1 2-