Opinion ID: 2649685
Heading Depth: 2
Heading Rank: 2

Heading: Accidental Death Claim

Text: Nichols argues UniCare erred in denying his claim for accidental death benefits with the stated rationale that the autopsy report listed the manner of death as could not be determined. Nichols submitted proof of his claim for accidental benefits in the form of the death certificate, autopsy report, insurance medical records, prescriptions records, and evidence relevant to Dana's state of mind, her relationships with family, and an upcoming scheduled surgery. As noted, in front of the district court, UniCare advanced the Wickman test as the vehicle for determining whether Dana's death was an accident, and asserted that the facts of this case, as placed in the Wickman rubric, indicated that the incident was not an accident. Under Wickman, an event is an accident if the decedent did not subjectively expect to suffer an injury similar in type or kind to that suffered and the suppositions underlying that expectation were reasonable. 908 F.2d at 1088. The determination of what suppositions are unreasonable should be made from the perspective of the insured, allowing the insured a great deal of latitude and taking into account the insured's personal characteristics and experiences. Id. If the evidence is insufficient to determine the decedent's subjective expectation, the question is then 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. UniCare contends that there is insufficient subjective evidence of Dana's expectations, and the objective evidence suggests that Dana's consumption of numerous medications was an intentional act for which a reasonable person would have expected death as the outcome. UniCare surmises that since Dana had been taking this same combination of medications for several months, she became tolerant to that level of medicine and subsequently took more than the prescribed dosage on the night she died. UniCare argues that, objectively speaking, Dana would have -8- viewed death as highly likely to occur in such a situation. This argument is strikingly similar to the one made by the plan administrator/insurer in the recent case of McClelland v. Life Insurance Company of North America, 679 F.3d 755 (8th Cir. 2012). In McClelland, under the deferential abuse-of-discretion standard of review, we held that the insurance company erroneously denied accidental death benefits to the widow of the insured decedent who died while driving a motorcycle at high speeds with an elevated blood alcohol level. As evidence of the deceased's state of mind, the insurance company offered that McClelland had been educated on the dangers of drinking and driving and should have known that death was highly likely to occur in his circumstances. We held that this reasoning was an abuse of the insurer's discretion, and a misapplication of the agreed-upon standard set forth in Wickman, because better and more concrete evidence of McClelland's subjective state of mind on the morning of the accident (submitted in the form of affidavits from family, friends and witnesses on the day of the accident), was that he had no intention to die and certainly did not think death was likely to occur as he went on a social midSaturday morning motorcycle ride. Id. at 760-61. Like the insurance company in McClelland, UniCare ignores the subjective evidence submitted by Nichols, and instead makes leaps to get to the objective conclusion it desires. There was no evidence in the record that Dana had developed a tolerance to her medications or that she took all 12 of the missing hydrocodone pills on the night of her death. No evidence suggests that Dana was suicidal. Similar to the motorcycle driver in McClelland who had been successfully weaving in and out of traffic at a high rate of speed for over six miles and therefore did not expect to die that day, Dana had been taking this combination of prescribed medications, as admitted by UniCare, for some period of time. There is no evidence whatsoever that Dana intended to kill herself or thought it likely she would die on May 3, 2010. The subjective evidence, in the form of letters and statements from her husband and -9- parents, suggests otherwise. To the extent that her subjective mind set could still be viewed as uncertain, the objective evidence tended to show that Dana had been ingesting a combination of prescribed medication for some time, and under these circumstances, a reasonable person with Dana's characteristics would not have viewed death as highly likely to occur. Nor is there a medical determination that the death was not accidental as alleged by UniCare. Dana's death falls squarely within the meaning of accident, a word not otherwise defined in the policy, and as viewed under the Wickman mandate to consider the situation from the perspective of the insured, allowing the insured a great deal of latitude and taking into account the insured's personal characteristics and experiences. 908 F.2d at 1088. As the district court aptly stated, [i]n sum, all of the evidence indicates that Dana's death was the unexpected result of ingesting prescribed medications.4 J.A. at 33. Accordingly, due to all of the foregoing, we find that the district court correctly found that UniCare erred in denying coverage for accidental death benefits. 4 Our conclusion is bolstered by the presumption against suicide that the Eleventh Circuit has recognized in the context of an ERISA case, holding that [b]oth the negative presumption against suicide and the affirmative presumption of accidental death advance ERISA's goals of protecting the interests of plan beneficiaries and uniformity in plan administration. Horton v. Reliance Standard Life Ins. Co., 141 F.3d 1038, 1041 (11th Cir. 1998). The Horton court held that these goals were furthered by providing uniform rules to resolve coverage questions where the evidence of how the insured died is inconclusive. Id. The court also noted that a majority of states recognize the presumption against suicide, id., and Arkansas is one of those states. See Wood v. Valley Forge Life Ins. Co., 478 F.3d 941, 947 (8th Cir. 2007) (recognizing the Arkansas strong presumption against suicide). There would be nothing remarkable about applying such a presumption in an uncertaincause-of-death ERISA case, as ERISA plan administrators are bound to follow federal common law, as informed by state common law. Shipley v. Ark. Blue Cross & Blue Shield, 333 F.3d 898, 902 (8th Cir. 2003). However, we need not even rely on the presumption because as noted above, Nichols has met his burden to establish entitlement to Dana's accidental death benefits. -10-