Court Opinion

ID: 9498167
Source: CourtListenerOpinion
Date Created: 2023-08-05 17:09:53.633875+00
Date Added: 2024-06-11T17:58:39.625992
License: Public Domain

BRIGHT, Circuit Judge,
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 *1007that Schanus’s claim should be paid. King ex rel. Schamis v. Hartford Life & Accident Ins. Co., 357 F.3d 840 (8th Cir.2004), vacated by order granting reh’g en banc.
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., 908 F.2d 1077, 1088 (1st. Cir.1990).
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.5 On remand, the plan administrator can do just that.
II.
According to the plan administrator’s definition of “accident,” an injury is not an accident if it was reasonably foreseeable.6 The dissenting opinion discusses the reasonableness of this definition — an issue that the opinion for the Court does not and *1008need not reach. In its partial- discussion, the dissenting opinion does not consider the startling implications of this definition. I wish to contribute here only a few initial observations.
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, 47 F.3d at 1456. On the other hand, a slim chance of an injury — mere foreseeability — is enough to say one “could expect” to suffer an injury. If the common law definition, developed through many cases in several courts, is reasonable, one would not expect a reasonable discretionary definition by a plan administrator to be separated by so vast a chasm from the common law definition.
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 908 F.2d at 1088.
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 *1009participants).7 See Lutheran Med. Ctr. v. Contractors Health Plan, 25 F.3d 616, 621 (8th Cir.1994); Brumm v. Bert Bell NFL Ret. Plan, 995 F.2d 1433, 1439-40 (8th Cir.1993). Such a definition also runs afoul of the first Finley factor:. It is not consistent with the goals of an accident insurance plan to deny coverage for all accidents other than those in which the victim was passive or which did result from the victim’s own actions but were so bizarre as to be unforeseeable.
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, 908 F.2d at 1088.

. 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., 908 F.2d 1077 (1st Cir.1990), and subsequent cases. The federal common law definition of "accident” is! An injury that the victim reasonably expected to escape or (where the victim's subjective expectations cannot be determined) an' injury that a reasonable person with background and characteristics similar to those of the victim would not have considered "highly likely.” See id., at 1088-89. An unexpected injury is an accident unless it would be objectively unreasonable for the victim to expect to escape the injury. See id. See also Todd v. AIG Life Ins. Co., 47 F.3d 1448, 1456 (5th Cir.1995) (Justice Byron White, ret.) (decedent's death was an accident because decedent’s expectation of survival was objectively reasonáble; expectation is objectively reasonable if death was not "substantially certain”); Critchlow v. First UNUM Life Ins. Co. of Am., 378 F.3d 246, 264 (2nd Cir.2004); Padfield v. AIG Life Ins. Co., 290 F.3d 1121, 1126-27 (9th Cir.2002); Santaella v. Metro. Life Ins. Co., 123 F.3d 456, 463 (7th Cir.1997).
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., 140 F.3d 1104 (7th Cir.1998) applied a standard for "reasonableness” review that required only that the plan administrator’s decision be rational, or make “a rational connection” between "the issue to be decided, the evidence in the case, the text under consideration, and the conclusion reached.” See id. at 1108-09. The Cozzie court merely noted that the plan administrator had taken a position that had also been taken by certain district courts, and that was enough for the court to conclude that the administrator’s decision was not irrational or "downright unreasonable.” See id. at 1109— 11. This relaxed sort of reasonableness review is not available under Finley.
In Cates v. Metropolitan Life Ins. Co., 149 F.3d 1182 (Mem.); 1998 WL 385897 (6th Cir.1998), an unpublished opinion not binding within the Sixth Circuit, the court applied a similar rational-decision review for reasonableness that is at odds with Finley. See id. at 1998 WL 385897, 2-3.
Our reasonableness review, announced in Finley, would not permit the decisions and dicta stated in these cases and relied on by Hartford.