Court Opinion

ID: 9557757
Source: CourtListenerOpinion
Date Created: 2023-08-21 16:56:54.904916+00
Date Added: 2024-06-11T09:06:34.542346
License: Public Domain

SMITH, Circuit Judge,
dissenting.
The majority correctly notes that the district court may have considered facts not set forth in the complaint, such as references to “an exposure of stasis, or facts regarding the unavoidability of the exposure to stasis, or any reference to the health of the other passengers.” However, accepting only the facts set forth in the complaint, we can decide, as a matter of law, whether an “accident” occurred within the meaning of the policy language. Because a remand is unnecessary, I respectfully dissent.
As the majority notes, the appellants’ complaint alleged that:
McAuley was enrolled in the Plan; that the Plan included two accidental loss of *789life policies; that those policies covered “accidents” including, but not limited to, “unavoidable exposure to elements arising from a covered hazard;” that McAu-ley took a lengthy flight; that “[t]he extensive and massive acute bilateral pulmonary thromboemboli suffered by McAuley was a result of embolisms, or blood clots, that formed in his leg(s) during the extended airplane flight;” and that the resulting death was accidental in that it was a sudden and unexpected occurrence that resulted from the extended flight.
The complaint also set forth the relevant policy language:
30. The Accident Policy provides the following regarding coverage:
We will pay the applicable Benefit Amount if an accident results in a Loss not otherwise excluded. The accident must result from a covered Hazard and occur during the policy period. The Loss must occur within one (1) year of the accident.
40. The Business Travel Policy provides the following regarding coverage:
We will pay the applicable Benefit Amount if an accident results in a Loss not otherwise excluded. The accident must result from a covered Hazard and occur during the policy period. The Loss must occur within one (1) year of the accident.
No other facts are necessary to resolve this case. Whether the blood clots that formed in McAuley’s legs during the flight were an “accident” within the terms of the policy is a question of law. The manner in which McAuley died is not in dispute. What is in dispute is whether that death is an “accident” under the law. According to the appellants, the district court erroneously rejected the application of the First Circuit’s Wickman test, Wickman v. Northwestern National Insurance Co., 908 F.2d 1077 (1 st Cir.1990), and relied on the “plain terms of the policy.” The appellants note that the policies provide no definition of “accident” and assert that the Wickman test has become federal common law under ERISA for determining whether a death as a result of the decedent’s voluntary conduct is an “accident.” The appellants assert that McAuley’s death was an “accident” under the Wickman test because McAuley did not subjectively believe that his conduct was highly likely to result in death and this belief was objectively reasonable.
In response, the appellees argue that the district court correctly ruled that an “accident” is an unexpected or unusual event or happening that is external to the insured. They contend that the appellants’ argument that the Accidental Death Policies did not require that McAuley’s death have been “caused by” an accident ignores the plain terms of the policies and relies on inapplicable case law.
Because we review de novo the district court’s decision to dismiss a complaint, Knieriem v. Group Health Plan, Inc., 434 F.3d 1058, 1060 (8th Cir.2006), and because “[t]he interpretation of an insurance policy and construction of the terms of an insurance contract are questions of law subject to de novo review on appeal,” Day v. Toman, 266 F.3d 831, 835 (8th Cir.2001), I would resolve this case on its merits and not remand the case to the district court.5

. I also note that the appellants never made a motion for reconsideration, after the district court granted the motion to dismiss, arguing that the district court erroneously converted the motion to dismiss into a motion for sum*790mary judgment. Furthermore, the appellants did not raise this argument on appeal. The only argument that the appellants raise with regard to the pleadings on appeal is the claim that the district court erroneously dismissed the claims with prejudice based upon the ap-pellees' post hoc rationales for denying coverage and without the administrative record before it. They argue that, under ERISA, the district court’s role is to review the administrator’s benefits decision; in doing so, the administrator’s post hoc rationales are not to be considered. Thus, they assert that the district court could not identify these post hoc rationales because it did not have the administrative record before it. Instead, it relied on the fact that it was reviewing the decision de novo and that these arguments were raised in response to their arguments. This argument is separate and distinct from an argument that the district court treated the motion to dismiss as a motion for summary judgment.