Opinion ID: 5175677
Heading Depth: 2
Heading Rank: 2

Heading: Adverse Benefit Determination

Text: Even though the district court held that courts within the First Circuit are not obligated to apply the Eleventh Circuit's presumption against suicide, it nevertheless explained in dicta that even considering Horton's presumption, National Union's denial of benefits was not arbitrary, capricious, or an abuse of discretion given the substantial evidence indicating that Marzuq's death was intentional. On appeal, Alexandre contests this dicta, while National Union maintains that its decision to deny accidental death benefits to Alexandre was the correct one. Notably, Alexandre does not offer any argument that she can prevail under the Wickman framework, even though she recognizes that binding precedent likely requires us to adhere to Wickman instead of Horton. Applying the Wickman framework, we affirm. We review the district court's grant of summary judgment de novo, Wright, 402 F.3d at 73-74; however, because the AD&D Plan at issue stated that National Union has the right to interpret the provisions of th[e] Plan, and [that] its decisions are conclusive and binding, we must review National Union's adverse benefit determination under the aforementioned arbitrary, capricious, or abuse of discretion standard. Supra p. 11–12. On - 21 - appeal, Alexandre challenges neither the district court's conclusion that the AD&D Plan afforded National Union discretion nor the corresponding consequence that courts must employ the arbitrary, capricious, or abuse of discretion standard in reviewing National Union's adverse benefit determination. Because these issues are not before the court, we do not address them further. As such, although we look at the district court's decision with fresh eyes, under the arbitrary, capricious, or abuse of discretion standard, we will uphold [National Union's] denial of benefits if [its] decision was 'reasoned and supported by substantial evidence,' Stamp, 531 F.3d at 87 (quoting Wright, 402 F.3d at 74). Evidence is substantial if it is reasonably sufficient to support a conclusion, and the existence of contrary evidence does not, in itself, make the administrator's decision arbitrary. Gannon v. Metro. Life Ins. Co., 360 F.3d 211, 213 (1st Cir. 2004). While Wickman is not cited by name, the analysis in AIG's20 ERISA Appeal Determination submitted to Alexandre by letter on May 4, 2020 conforms with Wickman's subjective/objective test for assessing accidents. As set out above, supra p. 13, where the term accident is otherwise undefined in an AD&D Policy, to find 20Recall that AIG serves as the Claims Administrator for National Union. - 22 - that an insured's death is covered, the beneficiary must demonstrate that the insured [reasonably] did not expect an injury similar in type or kind to the one that occurred, Wightman, 453 F. Supp. 3d at 467 (emphasis added) (discussing Wickman, 908 F.2d at 1088 and citing McGillivray, 519 F. Supp. 2d at 163); where the insured's subjective expectations are unknowable, an objective analysis of the insured's expectations is required, Wickman, 908 F.2d at 1088. Consistent with this directive, AIG reasoned that Marzuq's volitional and purposeful conduct of sprinting out of the hotel room and hurtling himself over the 10th floor railing of a high-rise hotel is dangerous conduct and no reasonable person would believe that [doing as such] would not result in bodily harm or death, even if Marzuq didn't intend to kill himself. Thus, AIG -- and thereby, National Union -- concluded that Marzuq's death did not result from an accident on the basis of the kind of subjective/objective analysis required by Wickman. Next, we ask whether substantial evidence in the record supports AIG's application of the Wickman framework. Inexplicably, Alexandre's counsel does not challenge AIG's finding that Marzuq hurtl[ed] himself over the 10th floor railing. Although it appears that nothing more than speculation supports this claim -- as the evidence establishes only that Marzuq ran out of his hotel room and was then found one floor below the railing -- [w]e [do] not consider potentially applicable arguments that - 23 - are not squarely presented in a party's appellate brief, BaybankMiddlesex v. Ralar Distribs., Inc., 69 F.3d 1200, 1203 n.5 (1st Cir. 1995) (citing United States v. Zannino, 895 F.2d 1, 17 (1st Cir. 1990)); see also Sanchez v. United States, 740 F.3d 47, 48– 49, 54–55 (1st Cir. 2014) (affirm[ing] the district court's decision that it had no choice but to dismiss where counsel failed to timely lodge plaintiff's claims). On appeal, Alexandre's sole contention -- and thus, the only argument that we address -- is that substantial evidence does not support the denial of benefits to Alexandre because AIG relied on reports produced by state personnel who arrived at the hotel after Marzuq's death rather than on the sworn declaration produced by Mujihad in September 2019. We cannot conclude -- at least not on the basis argued by Alexandre -- that National Union's adverse benefit determination was arbitrary, capricious, or an abuse of discretion. In rendering its decision, AIG considered the Fulton County Medical Examiner's Investigative Summary -- which captured the accounts of two percipient witnesses, including an otherwise unaffiliated witness's statement that he heard Mujihad yelling no[,] no, keep still, don't do it immediately prior to Marzuq's fall -- as well as Marzuq's final Death Certificate listing his cause of death as a suicide, among other documents. While Alexandre questions whether opinions and reports produced by state - 24 - personnel who arrived on the scene after Marzuq's death should be considered evidence, we agree with the district court that these contemporaneous and impartial documents authored by . . . state official[s] in the exercise of [their] official duties are probative. Moreover, we agree with the district court that National Union reasonably engaged with Alexandre's contrary evidence -- namely, Mujihad's later sworn declaration -- and reasonably rejected [it] as less credible than the contemporaneous, neutral evidence from the state. [T]he existence of contrary evidence does not, in itself, make the administrator's decision arbitrary. Gannon, 360 F.3d at 213. As such, we cannot -- on the basis raised by Alexandre -- conclude that National Union's determination that Marzuq's death was excluded from coverage because it was not accidental was arbitrary, capricious, or an abuse of discretion.21,22 21National Union also maintains that Alexandre's claim is further precluded from coverage by the AD&D Plan's intentional selfinflicted injury exclusion. Because Alexandre has not argued grounds sufficient to disturb National Union's conclusion that Marzuq's death was excluded from coverage because it was not accidental, we need not reach this additional contention. 22In her reply brief as well as in a Federal Rule of Appellate Procedure 28(j) letter, Alexandre submitted the cases Krantz v. John Hancock Mutual Life Insurance Co., 141 N.E.2d 719 (Mass. 1957) and Bohaker v. Travelers' Insurance Co., 102 N.E. 342 (Mass. 1913), to argue for the first time that Massachusetts also employs a presumption against suicide. As an initial matter, [b]lack-letter law holds that, in the absence of exceptional circumstances, arguments presented for - 25 - the first time in an appellant's reply brief are deemed waived. Álamo-Hornedo v. Puig, 745 F.3d 578, 582 (1st Cir. 2014). The same is true for Rule 28(j) letters. See, e.g., Rosa-Rivera v. Dorado Health, Inc., 787 F.3d 614, 617 (1st Cir. 2015) (Not only is it improper to advance new arguments in a 28(j) letter, but it is far too late in the game. (internal citation omitted)). As Alexandre does not advance any exceptional circumstances to justify the delay, we find her argument waived. But waiver aside, Alexandre's argument is also incomplete because each of her submitted cases predates ERISA. As such, even if Massachusetts state law has embraced a presumption against suicide -- a point on which we take no position at this time -- Alexandre has not argued either (1) that any such presumption regulates insurance so as to fall within ERISA's Savings Clause, see UNUM Life Ins. Co. of Am. v. Ward, 526 U.S. 358, 367–68 (1999); or (2) that we have incorporated that presumption into the First Circuit's federal common law on ERISA, see Sampson, 863 F.2d at 109–10 (rejecting the argument that the substantive law of Massachusetts -- rather than the body of federal common law that has grown up around ERISA -- should govern the interpretation of the . . . policy at issue). In fact, Alexandre appears to concede both of these points, as her reply brief states: Had Ms. Alexandre, without the involvement of her employer, purchased an accidental death benefits insurance policy on her husband's life from [National Union], she would have gone into battle with [National Union] armed with the presumption against her husband's suicide. However, because her employer had procured the [National Union] accidental death benefits policy, . . . Ms. Alexandre went into battle with [National Union] unarmed with the presumption against her husband's suicide. (emphasis in original). In essence, Alexandre is saying that if this were not an ERISA case, she would get the benefit of the presumption against suicide under Massachusetts state law; but because this is an ERISA case -- and thus ERISA's preemption provisions apply -- she does not get the benefit of such a statelaw presumption. While we take no view on whether Alexandre is correct that federal common law, not state law, applies in this circumstance, we conclude that Alexandre's statement is, at the very least, a concession that we should apply federal common law, not state law, to her case. - 26 -