United States Court of Appeals
For the First Circuit
No. 07-1061
KAREN STAMP,
Plaintiff, Appellant,
v.
METROPOLITAN LIFE INSURANCE COMPANY;
ADMINISTRATOR-BENEFITS, EXXONMOBIL BENEFIT PLAN;
EXXONMOBIL CORPORATION; EXXONMOBIL BENEFIT PLAN;
LIFE INSURANCE PROTECTION PLAN OF MOBIL OIL CORPORATION;
and LIFE INSURANCE PLAN OF MOBIL OIL CORPORATION,
Defendants, Appellees.
APPEAL FROM THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF RHODE ISLAND
[Hon. Ronald R. Lagueux, U.S. District Judge]
Before
Torruella, Lipez, and Howard,
Circuit Judges.
Fred L. Mason, Jr., with whom Mason Associates P.C. was on
brief, for appellant.
Ian Linker, with whom Brooks R. Magratten, Catherine A.
Shaghalian, and Vetter & White were on brief, for appellee
Metropolitan Life Insurance Company.
Neal J. McNamara, with whom Nixon Peabody LLP was on brief,
for appellees.
June 30, 2008
LIPEZ, Circuit Judge. This case requires us to determine
whether the plan administrator of an employee benefits plan
governed by the Employees Retirement Income Security Act ("ERISA"),
29 U.S.C. §§ 1001-1461, may reasonably conclude that the insured,
who was killed in a one-car collision with a tree while driving
with a blood alcohol content ("BAC") of three times the legal
limit, did not die as a result of an "accident" for purposes of his
Accidental Death and Dismemberment ("AD&D") life insurance
policies. After careful review of the developing federal common
law under ERISA, we uphold the plan administrator's determination
that, in this case, the insured was so highly intoxicated that his
death was not an "accident." In so doing, we affirm the judgment
of the district court.
I.
The facts are undisputed. On August 2, 2002, Steven
Stamp attended a meeting for employees of appellee Exxon Mobil
Chemical Company ("Mobil") at a resort in Westbrook, Connecticut.
The meeting consisted of presentations in the morning, a boat
cruise in the afternoon, and dinner that evening. Mr. Stamp spoke
with his wife, appellant Karen Stamp, at 5:20 p.m. and confirmed
that after dinner he planned to drive to his parents' home near
Providence, Rhode Island, where she and their young daughter would
join him to celebrate his brother's 40th birthday the next day.
Mrs. Stamp attests that he did not sound impaired during the phone
-2-
call, that he "sounded in good spirits," and that he had enjoyed
the meeting and cruise. Mr. Stamp consumed several alcoholic
beverages during the boat cruise and at dinner, but his co-workers
reported that he did not appear to be impaired or unsteady when he
left the resort between 8:30 and 9:00 that evening.
At 9:20 p.m., while en route to the Providence area, Mr.
Stamp placed a cell phone call to his friend Joe Kingsley, hoping
to visit him on his way through Rhode Island. Kingsley declined,
explaining that he needed to go to bed early. Kingsley described
Mr. Stamp's mood as positive and upbeat and reported that he did
not sound intoxicated.
The drive from Westbrook to Mr. Stamp's parents' house
should have taken about an hour and a half. Cell phone billing
records of calls placed through directory assistance at 9:51 p.m.
and 9:58 p.m. indicate that Mr. Stamp was already in the Providence
area at that time, but Mr. Stamp evidently did not go directly to
his parents' house. MetLife and Mobil posit that he must have
stopped somewhere and consumed additional alcohol instead. As
further evidence of this stop, MetLife notes that Mr. Stamp's hand
had a stamp on it that read "copy." In MetLife's view, this fact
indicates that Mr. Stamp went to a bar where his hand was stamped
at the door.
Just after midnight, Mr. Stamp died when his car went off
the road in Johnston, Rhode Island and struck a tree. At the time
-3-
of his death, his BAC was .265%, more than three times the legal
limit in Rhode Island.1 The police report described the road
conditions at the time of the collision as dry, the traffic as
light, and there were no other adverse driving conditions.2 The
autopsy report concluded that the cause of death was "[m]ultiple
injuries due to blunt force trauma," and noted "acute ethanol
intoxication" as another significant finding. The report
classified the manner of death as "accidental."
Mrs. Stamp, the beneficiary of her husband's life
insurance policies, submitted a claim for benefits. Appellee
Metropolitan Life Insurance Company ("MetLife"), acting as claim
fiduciary, paid her claim for Basic Life Insurance benefits, but
denied her claims for benefits from her husband's Basic and
Voluntary AD&D policies. MetLife left undetermined Mrs. Stamp's
claim for benefits under an additional Occupational AD&D policy.
Mrs. Stamp submitted a timely appeal to Mobil, which, in
its capacity as plan administrator, had "full and exclusive
authority to make final determinations as to all issues concerning
plan administration," including "discretionary and final authority
to determine coverage and eligibility for benefits . . . [and] to
1
Rhode Island criminalizes driving with a BAC of .08% or higher.
R.I. Gen. Laws § 31-27-2. Increased penalties apply when the
driver's BAC is greater than .15%. Id. § 31-27-2(d)(1)(ii).
2
The police report used the term "accident scene," but it did not
make any determination as to the cause of the crash.
-4-
interpret and explain the terms of the Life Insurance Program."
Mobil denied Mrs. Stamp's appeal of the Basic and Voluntary AD&D
benefit decisions, and rejected her claim for Occupational AD&D
benefits.
The ERISA plan at issue provides that Basic and Voluntary
AD&D benefits will be paid if the insured is "physically injured as
a result of an accident and die[s] within 90 days as a result of
that injury or accident." Occupational AD&D benefits will be paid
if the insured's death occurs "within one year as a result of an
injury caused by an occupational accident 'while at work.'" Mobil
concluded that Mr. Stamp's death was not the result of an
"accident," and therefore was not covered by his AD&D policies.3
The denial letter explained:
In your appeal submission you argue that the
weight of legal authority compels me to find
that the collision in this case was an
"accident" within the meaning of the plan.
Counsel has reviewed these and other cases and
advises that the weight of authority under
applicable Federal law would not compel such a
finding.
3
Mobil further determined that: (1) Mr. Stamp's death was caused
by an "intentionally self-inflicted injury," and thereby excluded
from coverage by the terms of the Basic and Voluntary AD&D
policies; (2) Mr. Stamp was committing a "serious crime" when the
collision occurred, excluding coverage under the terms of the
Voluntary and Occupational AD&D policies; and (3) the collision did
not occur "while at work" for the purposes of the Occupational AD&D
policy. Because we conclude that Mobil did not act arbitrarily in
denying benefits based on its application of the term "accident,"
we do not reach these other grounds for the denial.
-5-
In as much as I am not bound by law, I look to
the purpose of the plan. I believe that the
purpose of the plan is to protect participants
from risks that are outside of their control.
The risks flowing from driving while
intoxicated are completely within the control
of the participant. While it is true that
certain behavior that increases risk (such as
skiing or horseback riding) would not result
in loss of coverage, [driving while
intoxicated] can be distinguished because it
unreasonably increases the risk associated
with a normally safe activity by interfering
with an individual's ability to perceive and
respond to risk. To impose the costs of such
unreasonable risk-taking on the plan would
result in an unanticipated cost.
Mobil further explained that "[t]he fact that the coroner's report
and the police report use the term 'accident' does not govern the
proper interpretation under the plan."
Mrs. Stamp filed suit in district court, asserting claims
for breach of contract and breach of fiduciary responsibility. The
district court held that Mrs. Stamp's common law claims are
preempted by ERISA and treated her suit as an ERISA enforcement
action pursuant to 29 U.S.C. § 1132(a)(1)(B). Mrs. Stamp has not
appealed that determination. On cross-motions for summary
judgment, the district court reviewed Mobil's denial of benefits
under an "arbitrary and capricious" standard and concluded that the
"determination that Mr. Stamp's death was not accidental is
reasonable and supported by substantial evidence in the record."
The district court entered judgment in favor of MetLife and Mobil.
Mrs. Stamp filed this timely appeal.
-6-
II.
We review the district court's grant of summary judgment
de novo. Wright v. R. R. Donnelley & Sons Co. Group Benefits Plan,
402 F.3d 67, 73-74 (1st Cir. 2005). Where, as here, the ERISA plan
grants the plan administrator discretionary authority to make
benefit determinations, we must uphold the administrator's
determination unless it was "arbitrary, capricious, or an abuse of
discretion." Id. at 74 (quoting Doyle v. Paul Revere Life Ins.
Co., 144 F.3d 181, 183 (1st Cir. 1998)); cf. Firestone Tire &
Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989). Under this
standard, we will uphold the denial of benefits if the plan
administrator's decision was "'reasoned and supported by
substantial evidence.'" Id. (quoting Gannon v. Metro. Life Ins.
Co., 360 F.3d 211, 213 (1st Cir. 2004)). "Evidence is substantial
if it is reasonably sufficient to support a conclusion . . . ."
Gannon, 360 F.3d at 213.
Mrs. Stamp argued before the district court that this
deferential standard of review was inappropriate because Mobil's
contract with MetLife is "experience-rated," linking Mobil's
premium costs to the number and size of claims presented. She
asserted that this link represented a "structural conflict of
interest" that would mandate a less deferential standard of review.
However, Mrs. Stamp has abandoned this argument on appeal. In her
brief, she merely cites the legal proposition that a conflict of
-7-
interest may reduce the degree of deference we owe the plan
administrator; she does not argue that a conflict actually exists
in this case. Thus, this argument is waived.4 See United States
v. Zannino, 895 F.2d 1, 17 (1st Cir. 1990) ("[I]ssues adverted to
in a perfunctory manner, unaccompanied by some effort at developed
argumentation, are deemed waived."). Consequently, we review the
denial of benefits under the "arbitrary and capricious" standard.
III.
Mr. Stamp's AD&D policies stated that MetLife would pay
accidental death benefits if Mr. Stamp died as a result of an
"accident." The term "accident" is not defined in the plan
documents. The plan administrator had the task of applying this
term to the circumstances surrounding Mr. Stamp's death.
In reviewing the administrator's denial of benefits, we
are guided by the principles of the federal common law of ERISA.
Pilot Life Ins. Co. v. Dedeaux, 481 U.S. 41, 56-57 (1987)
(concluding that Congress intended for a federal common law to
develop in the ERISA context); Wickman v. Northwestern Nat'l Ins.
Co., 908 F.2d 1077, 1084 (1st Cir. 1990). In particular, we rely
on Wickman, a case in which we added to the ERISA common law by
4
Moreover, in MetLife v. Glenn, No. 06-923 (June 19, 2008), the
Supreme Court determined that a "conflict of interest" exists when
a single entity both funds the plan and evaluates the claims. Slip
op. at 5, 8. Mrs. Stamp did not assert this form of conflict;
here, MetLife funded the plan while Mobil made final benefit
determinations.
-8-
formulating an approach for interpreting the ambiguous term
"accident" in AD&D insurance policies. 908 F.2d at 1087-88.
We began with the principle that "the reasonable
expectations of the insured when the policy was purchased is the
proper starting point for a determination of whether an injury was
accidental under its terms." Id. at 1088. But we noted that this
was only a starting point. The operative inquiry into the
insured's "expectations" in Wickman actually concerned the
insured's state of mind at the time of the incident that caused his
death, not at the time the policy was purchased. See id. at 1089
("If he actually expected the result, even if he did not
specifically intend it, then his actual expectations make his death
not accidental."). We see no necessary inconsistency between these
two formulations of the relevant time frame. The conclusion that
the insured expected, or reasonably should have expected, that
death would result from the particular conduct at issue is
tantamount to the conclusion that no reasonable person, when buying
an insurance policy, could expect that AD&D benefits would be paid
out when his death results from that sort of conduct. In any case,
aside from the reference to the expectations at the time of
purchase as a "starting point," the analysis in Wickman makes no
further reference to those expectations and is instead concerned
solely with the insured's expectations related to the intentional
conduct that caused his death. We adopt that approach as well.
-9-
The Wickman analysis thus began with an inquiry into the
expectations of the insured at the time of the incident that caused
his death. However, this subjective inquiry was not determinative.
We held that even if "the fact-finder determines that the insured
did not expect an injury similar in type or kind to that suffered,
the fact-finder must then examine whether the suppositions which
underlay that expectation were reasonable." Id. at 1088. We
further observed that "'the subjective state of mind of the insured
cannot be generally known.'" Id. at 1087-88 (quoting Hoffman v.
Life Ins. Co., 669 P.2d 410, 419 (Utah 1983)). Thus, in the usual
case, where the fact-finder will find "the evidence insufficient to
accurately determine the insured's subjective expectation," the
fact-finder "should then engage in an objective analysis of the
insured's expectations." Id. at 1088. We framed this objective
analysis as an inquiry into "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. This reasonable person
analysis, "when the background and characteristics of the insured
are taken into account, serves as a good proxy for actual
expectation." Id.
We then applied this framework to the particular facts in
Wickman, where the insured died after falling from a railroad
bridge, having intentionally climbed over the guardrail on the side
-10-
of the bridge. Although there was some evidence that the insured
intended to kill himself, we determined that his actual
expectations could not be ascertained. Id. at 1088. Therefore, we
applied the objective prong of the Wickman analysis and concluded
that "[o]bjectively, he reasonably should have expected serious
injury when he climbed over the guardrail and suspended himself
high above the railroad tracks below by hanging on to the guardrail
with only one hand." Id. at 1089. Consequently, we upheld the
determination that his death was nonaccidental.5
Our reasoning in Wickman has been widely accepted by our
sister circuits.6 See Eckelberry v. Reliastar Life Ins. Co., 469
F.3d 340, 343-45 (4th Cir. 2006). Applying Wickman, federal courts
5
In Wickman, we interpreted the term "accident" de novo,
affording no deference to the plan administrator. Although the
case was decided about a year after the Supreme Court's statement
in Firestone, 489 U.S. at 115, that a deferential standard of
review should be applied where the benefit plan grants the
administrator discretion to make benefit determinations, Wickman
contains no discussion of the applicable standard of review. We
can only surmise that discussion of Firestone was unnecessary
because the policy at issue in Wickman did not contain the critical
discretionary language that would have altered the standard of
review.
6
Some of these courts have struggled with whether a "reasonable
foreseeability" test, which arguably is a less favorable test for
the insured than the "highly likely" phrase in Wickman itself, may
be used by a plan administrator without running afoul of Wickman.
See Lennon v. Metro. Life Ins. Co., 504 F.3d 617, 625 (6th Cir.
2007) (Boggs, C.J., concurring). Although MetLife used the phrase
"reasonably foreseeable" in its initial benefit denial, Mobil did
not invoke that standard. We review the decision of the plan
administrator, Mobil. As such, we have no occasion to comment on
the acceptability of using "reasonable foreseeability" as a
shorthand for Wickman.
-11-
have, "with near universal accord," upheld plan administrators'
determinations that "alcohol-related injuries and deaths are not
'accidental' under insurance contracts governed by ERISA." Id. at
344; see also Lennon v. Metro. Life Ins. Co., 504 F.3d 617, 622-23
(6th Cir. 2007); Cozzie v. Metro. Life Ins. Co., 140 F.3d 1104,
1110 (7th Cir. 1998); Weatherall v. Reliastar Life Ins. Co., 398 F.
Supp. 2d 918, 924 (W.D. Wis. 2005); Mullaney v. Aetna U.S.
Healthcare, 103 F. Supp. 2d 486, 494 (D.R.I. 2000); Walker v.
Metro. Life Ins. Co., 24 F. Supp. 2d 775, 782 (E.D. Mich. 1997);
Schultz v. Metro. Life Ins. Co., 994 F. Supp. 1419, 1422 (M.D. Fla.
1997); Nelson v. Sun Life Assurance Co., 962 F. Supp. 1010, 1012
(W.D. Mich. 1997); Miller v. Auto-Alliance Int'l, Inc., 953 F.
Supp. 172, 176-77 (E.D. Mich. 1997); Cates v. Metro. Life Ins. Co.,
14 F. Supp. 2d 1024, 1027 (E.D. Tenn. 1996), aff'd, 149 F.3d 1182
(6th Cir. 1998) (unpublished). But see West v. Aetna Life Ins.
Co., 171 F. Supp. 2d 856, 904 (N.D. Iowa 2001). Thus, the plan
administrator was correct to conclude, in denying Mrs. Stamp's
benefit claims, that "the weight of authority under applicable
Federal law would not compel" a finding that Mr. Stamp's collision
was accidental.7
7
Mrs. Stamp cites two federal cases, King v. Hartford Life & Acc.
Ins. Co., 357 F.3d 840 (8th Cir. 2004), and West v. Aetna Life Ins.
Co., 171 F. Supp. 2d 856 (N.D. Iowa 2001), for the proposition that
drunk driving deaths must be held to be "accidental" under the
Wickman analysis. However, the Eighth Circuit vacated the King
opinion to which she refers. King v. Hartford Life & Acc. Ins.
Co., 414 F.3d 994 (8th Cir. 2005) (en banc). Upon rehearing, the
-12-
In applying the Wickman analysis to drunk-driving deaths,
courts have stated that "'the hazards of drinking and driving are
widely known and widely publicized'" and reasoned that, as a
result, "the insured should have known that driving while
intoxicated was highly likely to result in death or bodily harm."
Eckelberry, 469 F.3d at 345 (quoting Nelson, 962 F. Supp. at 1012).
As the Supreme Court recently observed, albeit in a different
context, "[d]runk driving is an extremely dangerous crime." Begay
v. United States, 128 S. Ct. 1581, 1584 (2008). It is common
knowledge that the danger grows even more extreme as the driver's
level of intoxication increases. Nat'l Hwy. Traffic Safety Admin.,
U.S. Dep't of Transp., Setting Limits, Saving Lives: The Case for
.08 BAC Laws, DOT HS 809 241, revised Apr. 2001. Accordingly,
any drunk driver who takes to the road should
know he runs a risk of injuring another person
[or himself]. The extent of the risk will of
course vary from case to case, depending on
how intoxicated the driver is, how far he
drives, how fast he drives, and how many other
en banc court declined to reach the issue of whether the insured's
claim was, as a matter of law, an accident under the Wickman test
because the plan administrator had not explicitly applied Wickman
in explaining its benefit denial. King, 414 F.3d at 1003-04.
Instead, the court remanded the case to the plan administrator with
directions to apply the Wickman test because the administrator had
"abandon[ed] in litigation its original basis for denying
benefits." Id. at 1005-06. The Eighth Circuit's disposition of
King calls into question the continued vitality of West, which was
decided by a district court in that circuit. See McElyea v. AIG
Life Ins. Co., 326 F. Supp. 2d 960, 967 n.4 (E.D. Ark. 2004)
(noting that the King panel had endorsed the West opinion but that
the panel opinion had been vacated by the en banc court).
-13-
drivers and pedestrians are sharing the road
with him.
Lennon, 504 F.3d at 621 (quoting United States v. Rutherford, 54
F.3d 370, 376 (7th Cir. 1995)). Following this logic, courts have
emphasized the decedent's level of intoxication when determining
that a plan administrator's denial of benefits was reasonable.
See, e.g., id. at 623 (BAC of more than three times the legal
limit); Eckelberry, 469 F.3d at 345 (BAC of one and a half times
the legal limit); Cozzie, 140 F.3d at 1106 (BAC of more than two
times the legal limit). We endorse this approach.8 The Wickman
analysis does not require a categorical determination that all
alcohol-related deaths are per se accidental or nonaccidental.
Rather, it leads us to consider the circumstances of the fatal
event in question.9
In this case, the plan administrator had substantial
evidence that Mr. Stamp was severely intoxicated when he died. The
toxicology report indicated that Mr. Stamp's BAC at the time of his
8
The dissent asserts that we have "[d]eferentially follow[ed]
in the footsteps of other circuits that have examined this
question." Dissent at 24. That is not the case. We have simply
noted the trend among federal courts. However, we have, as Wright
and Firestone require, deferred to the decision of the plan
administrator.
9
The dissent appears to suggest that we are categorically
concluding that all alcohol-related deaths could be considered
nonaccidental. That is not so. On the contrary, we have been
careful to explain that the proper approach is fact-specific and
that the decedent's degree of intoxication is particularly
probative.
-14-
death was in the range of .231% to .265%. MetLife's medical
department had advised that this level of intoxication "would cause
delirium intoxication. In a sporadic drinker it would cause
lethargy, stupor, combativeness, incoherency & vomiting. In a
chronic drinker, there would be [illegible] emotional changes and
mood changes."10 An internal Mobil memorandum, prepared during the
review of Mrs. Stamp's claim, further elaborated:
Various on-line sources indicate that Mr.
Stamp's ability to control his vehicle would
have been significantly impaired. For
example, the National Highway Transportation
Safety Administration states that all drivers,
even experienced drivers, show impairment at a
BAC of 0.08 – one-third the level reported for
Mr. Stamp. The "Police Handbook" published by
the Oklahoma University Police has the
following descriptions of the effects of
various BACs:
0.20 Feeling dazed/confused or
otherwise disoriented. May need
help to stand/walk. Blackouts are
likely.
0.25 All mental, physical and
sensory functions impaired.
Our own medical department has confirmed that
the assessments by MetLife and these internet
sources are reasonable, and that serious
impairment would be expected.
In its letter denying Mrs. Stamp's claims, Mobil noted
that "[t]here is no evidence to suggest that another vehicle or
object, mechanical failure, or adverse weather or road collisions
contributed to the collision," and concluded that "Mr. Stamp's BAC
10
We note that there is no evidence in the record to suggest that
Mr. Stamp was anything more than a sporadic drinker.
-15-
was at least a substantial contributing cause of the collision."
In light of this well-developed record of the severe impairment
that would be expected from Mr. Stamp's level of intoxication and
the administrator's reasonable inference that his drunk-driving was
a "substantial contributing cause" of the crash, we cannot say that
it was arbitrary and capricious for the administrator to determine
that Mr. Stamp's death was not "as a result of an accident." In
Wickman terms, it is not arbitrary and capricious to conclude that
a reasonable person would view death or serious injury as a highly
likely outcome of driving while so drunk that one may need help to
stand or walk and is likely to black out.11
IV.
Mrs. Stamp makes four arguments to support her claim that
Wickman compels us to reach a contrary determination. First, she
11
Mobil did not invoke the particular terms of Wickman in the
denial letter it sent to Mrs. Stamp. Instead, it stated more
generally that "the weight of authority under applicable Federal
law would not compel" a finding that Mr. Stamp's death was an
accident. The benefit denial is then explained in terms of the
plan administrator's interpretation of the purposes of the plan.
This conclusion is not arbitrary and capricious because of its
failure to recite the Wickman formula. See Cozzie, 140 F.3d at
1110 ("We cannot say . . . that [the administrator's] determination
that the purposes of the plan are best served by acknowledging a
qualitative difference between the ingestion of a huge quantity of
alcohol and other tragedies of human life which do not involve such
a significant assumption of a known risk by the insured is
incompatible with the goals of the plan."). The decision reached
by the plan administrator is compatible with Wickman, even if the
administrator did not explain his decision in Wickman terms.
Moreover, Mrs. Stamp has not asserted that the plan administrator
made a legal error by failing to recite the Wickman formula in its
denial letter.
-16-
marshals evidence from phone calls earlier in the evening to make
the case that her husband did not sound impaired, was "in good
spirits," and was looking forward to a family event the next day.
She concludes that this evidence indicates "clearly" that Mr. Stamp
"had no subjective expectation of death or injury." We disagree.
The conversations she cites shed little light on Mr. Stamp's state
of mind many hours later after he had consumed more alcohol.
Moreover, Mr. Stamp's actual subjective expectation that he would
arrive safely at his parents' house, even if it were clearly
established in the record, is not dispositive. In Wickman, we
explicitly rejected the contention that "unless [the insured]
actually expected to die, essentially that he specifically intended
to commit suicide, his death must be considered an accident."12 908
F.2d at 1087. Instead, the critical determination under Wickman
lies in an objective analysis of what the insured reasonably should
have expected when he decided to drive while highly intoxicated.
Second, Mrs. Stamp contends that the statistical evidence
she presented to the district court "establishes that it cannot be
reasonably concluded by either common sense or legal analysis that
12
The dissent frames the issue as "whether [Mr. Stamp] intended
to kill himself by becoming intoxicated and driving while in this
condition." Dissent at 26. While this is the appropriate inquiry
under the policy exclusion for intentional self-inflicted injury,
it is not the appropriate inquiry when considering the term
"accident." Indeed, the theory that all deaths are accidental
unless the decedent subjectively intended to die was explicitly
rejected in Wickman. 908 F.2d at 1087.
-17-
death resulting from driving under the influence of alcohol is
. . . 'highly likely.'" Her statistics, gleaned from a comparison
of the number of drunk driving arrests and the number of alcohol
related driving fatalities, show that "the statistical probability
of a fatal accident resulting while driving under the influence of
alcohol is 1.19%." However, as the district court properly noted,
such statistics are "meaningless in this context." They simply do
not take into account the degree of intoxication of the driver in
question. As we noted earlier, the risk of being involved in a
fatal crash rises as blood alcohol levels rise. Accordingly,
statistics that do not differentiate between various levels of
intoxication are inapposite. See Lennon, 504 F.3d at 623
("[D]rivers with blood-alcohol levels above the legal limit as a
group are far more likely to arrive home safely than drivers who
are extremely drunk.").
Moreover, the focus of our objective analysis in Wickman
was not on the statistical probability that death would occur from
the decedent's actions. Instead, we were concerned chiefly with
what a reasonable person would perceive to be the likely outcome of
the intentional conduct. Wickman, 908 F.2d at 1089. Russian
roulette provides an archetypal example of this critical
distinction. From a statistical standpoint, the likelihood of
dying from a single round of Russian roulette is 16% – one in six.
Such a death is not "highly likely" if that phrase is taken to mean
-18-
"more likely than not" or "substantially certain." In fact, those
who play Russian roulette have a decent chance, statistically
speaking, of not being injured. Lennon, 504 F.3d at 623.
Nonetheless, such a death "would not be publicly regarded as an
accident" because the mortal risk associated with playing Russian
roulette is patently obvious to any reasonable person. Wickman,
908 F.2d at 1087. Similarly, even if Mrs. Stamp had adduced
evidence that those who drive while extremely drunk have a better
than even chance of arriving home safely, that evidence would not
have been dispositive. Statistical analysis is simply not at the
core of the Wickman analysis.13 Instead, as the Sixth Circuit has
explained, Wickman's framework reflects that "at some point the
high likelihood of risk and the extensive degree of harm risked,
weighed against the lack of social utility of the activity, become
not marginally but so overwhelmingly disproportionate that the
resultant injury may be outside a definition of 'accidental' that
is not unreasonably narrow." Lennon, 504 F.3d at 623. It was not
arbitrary for the plan administrator here to conclude that Mr.
13
In its discussion of the relevance of statistics, the dissent
analogizes to the high rate of lung cancer arising from smoking and
states that "it would be highly unusual . . . to conclude that
anyone who smokes is engaging in a suicidal act and is thus
excludable from coverage under the policy." Dissent at 29. We
agree that smoking is probably not a "suicidal act," but it is
equally true that a smoker's death from lung cancer is not
"accidental" within the meaning of an AD&D policy. As we are
concerned here with the definition of "accident" and not the
definition of "suicide," the dissent's analogy is inapt.
-19-
Stamp's decision to drive while grossly intoxicated qualifies as
overwhelmingly and disproportionately risky conduct.
Third, Mrs. Stamp challenges the conclusion that her
husband's death was causally related to his intoxication. She
speculates that the accident could have been caused by an attempt
to avoid a collision with another vehicle or with an animal.
Because we are concerned with the definition of "accident" as a
threshold of eligibility for benefits, the burden of proof is on
Mrs. Stamp to show the existence of coverage. See 17A Lee Russ &
Thomas F. Segalla, Couch on Insurance § 254:16 (3d ed. 2007); see
also Mario v. P&C Food Markets, Inc., 313 F.3d 758,765 (2d Cir.
2002) (asserting, in an ERISA case, that "the insured has the
burden of proving that a benefit is covered, while the insurer has
the burden of proving that an exclusion applies"); Jenkins v.
Montgomery Indus., Inc., 77 F.3d 740, 743 (4th Cir. 1996) (same);
Blair v. Metropolitan Life Ins. Co., 974 F.2d 1219, 1221 (10th Cir.
1992) (same). Mrs. Stamp's speculation regarding alternative
causes for the collision falls far short of the evidence needed to
carry her burden. As a result, the plan administrator's finding of
fact as to causation is not "arbitrary and capricious."
Fourth, Mrs. Stamp invokes the contra proferentem
doctrine, which holds that the policy terms must be strictly
construed against the insurer and in favor of the insured.
-20-
However, this doctrine is only applied when courts undertake de
novo review of plan interpretations:
When the administrators of a plan have
discretionary authority to construe the plan,
they have the discretion to determine the
intended meaning of the plan's terms. In
making a deferential review of such
determinations, courts have no occasion to
employ the rule of contra proferentem.
Deferential review does not involve a
construction of the terms of the plan; it
involves a more abstract inquiry – the
construction of someone else's construction.
Morton v. Smith, 91 F.3d 867, 871 n.1 (7th Cir. 1996); see also
Winters v. Costco Wholesale Corp., 49 F.3d 550, 554 (9th Cir.
1995). We are engaged in that "more abstract inquiry" here, and
thus the doctrine is inapplicable to our review.
V.
Under the "arbitrary and capricious" standard, "we need
not decide what is the best reading of the words in the insurance
policy," Lennon, 504 F.3d at 624, nor how we would have applied
those words de novo. Instead, we are called upon only to decide
whether the plan administrator's denial of benefits was "'reasoned
and supported by substantial evidence.'" Wright, 402 F.3d at 74
(quoting Gannon v. Metro. Life Ins. Co., 360 F.3d 211, 213 (1st
Cir. 2004)). As we have set forth above, the administrator's
determination that Mr. Stamp's death was nonaccidental is
compatible with Wickman. Objectively, he reasonably should have
expected death or serious injury when he drove with a BAC of more
-21-
than three times the legal limit. That conclusion does not lessen
the tragedy of Mr. Stamp's death. It simply means that the plan
administrator's denial of benefits was not arbitrary and
capricious, and the judgment below is affirmed.
So ordered.
- Dissenting Opinion Follows -
-22-
TORRUELLA, Circuit Judge (Dissenting). Mrs. Stamp's
ability to recover most of the insurance benefits at issue hinges
on whether her husband's death was an accident within the meaning
of the MetLife policies. It is clear to me that Mr. Stamp's death
while driving under the influence of alcohol was the result of an
accident. As the Supreme Court recently noted, "DUI . . . involves
'accidental or negligent conduct.'" Begay v. United States, 128 S.
Ct. 1581, 1587 (2008) (quoting Leocal v. Ashcroft, 543 U.S. 1, 11
(2004)) (emphasis added). In Wickman v. Northwestern Nat'l Ins.,
908 F.3d 1077, 1084 (1st Cir. 1990), we announced a standard for
determining whether a death was "accidental" within the meaning of
an ERISA-qualified policy. Noting that terms like "accident"
"should be judged from the viewpoint of the insured," we
promulgated a three-prong test because "actual expectation is often
difficult, if not impossible to determine." Id. (1) "[The]
reasonable expectations of the insured when the policy was
purchased is the proper starting point for a determination of
whether an injury was accidental under its terms." Id. at 1088.
(2) "If the fact-finder determines that the insured did not expect
an injury similar in type or kind to that suffered, the fact-finder
must then examine whether the suppositions which underlay that
expectation were reasonable." Id. (3) "Finally, if the fact-
finder, in attempting to ascertain the insured's actual
expectation, finds the evidence insufficient to accurately
-23-
determine the insured's subjective expectation, the fact-finder
should then engage in an objective analysis of the insured's
expectations." Id.
The present case marks our first opportunity to apply the
Wickman analysis to a factual scenario that involves a policy-
holder who died with a heightened Blood Alcohol Content ("BAC")
level in a one-car collision. Deferentially following the
footsteps of other circuits that have examined this question,14 the
majority concludes that Mr. Stamp's death was not accidental. I
cannot disagree more vehemently with that outcome.
I do not feel compelled to follow these prior opinions
because I believe that in reaching this outcome, those cases
misapplied the third prong of Wickman, an error duplicated by the
majority, which also focuses too heavily on a "reasonably
foreseeable" analysis. See slip op. at 10. In Wickman, we said
that "[i]n [our] analysis, [we are required to] ask 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." 908 F.3d at
1088 (emphasis added).
14
See Lennon v. Metro. Life Ins. Co., 504 F.3d 617 (6th Cir.
2007); Eckelberry v. Reliaster Life Ins. Co., 469 F.3d 340 (4th
Cir. 2006); King v. Hartford Life & Accident Ins. Co., 414 F.3d 994
(8th Cir. 2005) (en banc); Buce v. Allianz Life Ins. Co., 247 F.3d
1133 (11th Cir. 2001); Cozzie v. Metro. Life Ins. Co., 140 F.3d
1104 (7th Cir. 1998).
-24-
I believe that those circuits that have examined
insurance policy exclusions similar to the ones at issue here,
using a "highly likely" or "substantially certain" standard, are
the ones that have reached the correct answer to the question. See
Padfield v. AIG Life Ins. Co. of Am., 290 F.3d 1121 (9th Cir.
2002); Santaella v. Metro. Life Ins. Co., 123 F.3d 456 (7th Cir.
1997) Todd v. AIG Life Ins. Co., 47 F.3d 1448 (5th Cir. 1995).
Those circuits applied Wickman in a proper fashion by engaging in
the following analysis:
[F]or death under an accidental death policy
to be deemed an accident, it must be
determined (1) that the deceased had a
subjective expectation of survival, and (2)
that such expectation was objectively
reasonable, which it is if death is not
substantially certain to result from the
insured's conduct.
Santaella, 1243 F.3d at 463 (quoting Todd, 47 F.3d at 1456)
(emphasis added).
The administrator, which was affirmed by the majority,
created out of whole cloth an exclusion ex post facto denying
coverage where the decedent's BAC is above legal limits when death
occurs. Rather than attempting to insert an exclusion by
inference, what should be done in those cases in which the parties
have not agreed to such a provision beforehand, is to have a clause
specifically establishing such an exclusion. See Marcus Wilbers,
Note, Alcohol-Related Car 'Accidents'? The Eighth Circuit Moves
Toward Policy Change in ERISA Litigation, 71 Mo. L. Rev. 471, 491
-25-
(2006) ("To eliminate any uncertainty, plan administrators should
include an alcohol-related exclusion in all accidental death
insurance plans.").
The policies at issue here do not include a definition
for "accident." In Wickman, we said that "[c]ase law is fairly
consistent in defining an accident, using equally ambiguous terms
such as undesigned, unintentional, and unexpected." Wickman, 908
F.2d at 1087; Santaella, 123 F.3d at 464 ("Interpreting the policy
terms in an ordinary and popular sense, in the way that a person of
average intelligence and experience would, we treat the term
'accidental' as it is commonly defined, as 'unexpected or
unintentional.'" (footnote and citations omitted)).15 Applying
Wickman, Mr. Stamp's death can be termed nothing other than an
unfortunate accident. The question is not, as the majority frames
it, whether Mr. Stamp was severely intoxicated. See slip op. at
14. The question is whether he intended to kill himself by
becoming intoxicated and driving while in this condition. There is
absolutely no evidence that Mr. Stamp had any such intention.
I. Wickman Analysis
The first prong of the Wickman analysis requires us to
look at the reasonable expectation of the insured when the policy
was purchased. Wickman, 908 F.2d at 1088. As we said in Wickman,
15
Both the police and the autopsy reports indicated that the
manner of death was "accidental." This is not a mere coincidence.
-26-
"[g]enerally, insureds purchase accident insurance for the very
purpose of obtaining protection from their own miscalculations and
misjudgments." Id. Accepting that Mr. Stamp had a BAC above the
legal limit and that he was in a one-car collision with no other
evidence of why he veered off the road and hit a tree, it is fair
to say that, at most, Mr. Stamp miscalculated and misjudged his
ability to drive that fateful evening. He purchased insurance in
order to protect himself and his family against such unforeseen
accidents.
There is no evidence that Mr. Stamp's actions were the
result of anything but misjudgments, not intentional actions.
According to Joe Kingsley, he and Mr. Stamp discussed life
insurance at some point prior to August 2. Mr. Stamp told Kingsley
that he wanted to make sure that his wife and daughter would be
"taken care of if anything happened" to him, adding that he had
taken out significant life insurance for their benefit. On the
night of his death, all evidence indicates that if Mr. Stamp would
have continued along the route to his parents' house, he would have
reached his destination. There is no indication that he attempted
or intended to kill himself. There is no evidence that Mr. Stamp
was distraught or that he was experiencing any personal problems.
A few hours before the accident, he had positive, upbeat
conversations with his wife, co-workers, and friend. His decision
to drive was unlike the game of Russian roulette the majority
-27-
discusses because the point of that game is to see if you are lucky
enough to live, see slip op. at 18, or that as in Wickman, he was
doing something which objectively looked like suicide.
The second prong of the Wickman analysis instructs us to
examine the reasonableness of the insured's expectations. See id.
"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. (internal citations
omitted). Much more often than not, driving while under the
influence has a non-fatal outcome. Cf. Todd, 47 F.3d at 1457 ("the
risk of death from autoerotic practice is 'not of such a nature
that [the decedent] knew or should have known that it probably
would result in death. Death was not a normal expected result of
the behavior.'" (citation omitted)(emphasis added)). In 2002, the
year Mr. Stamp died, only forty-one percent of people who died in
automobile-related collisions did so in collisions that involved a
driver with a BAC above the legal limit. See U.S. Dep't of
Transp., Traffic Safety Facts 2004 32 (2004). Almost sixty percent
of the people who died that year did so from car accidents
involving a driver with a BAC of zero. See id. Given this, it can
be said that "a reasonable person would not view death as 'highly
likely' to result from driving drunk.'" Michael E. Gardner, Note,
Accidental Death Insurance Coverage of Drunk Drivers, 69 Mo. L.
-28-
Rev. 235, 246 (2004). Instead, "[i]t is not highly likely for an
impaired driver to die in an alcohol-related wreck, and those
deaths are therefore accidents." Id. at 472. Smoking cigarettes
is responsible for eighty-seven percent of lung cancer deaths, see
Am. Cancer Soc'y, Cancer Facts & Figures 2008 48 (2008), and nearly
twenty percent of smokers die from heart disease, see Am. Heart
Ass'n, Cigarette Smoking and Cardiovascular Diseases, (June 16,
2008). Yet it would be highly unusual where the administrator, or
this Court, to conclude that anyone who smokes is engaging in a
suicidal act and is thus excludable from coverage under this
policy.
In any objective analysis, we must "ask 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." Wickman, 908
F.2d at 1088 (internal citations omitted). In 2005, nearly 1.4
million drivers were arrested for driving under the influence of
alcohol or narcotics. See United States Dep't of Justice, Crime
Prevention in the United States 2005, Table 29. This number is
much higher, both empirically and as a percentage, than the number
of people who died as a result of driving under the influence.
Thus, "[w]hat common knowledge . . . actually tell[s] a person
driving while intoxicated is that he or she is far more likely to
be arrested for driving while intoxicated than to die or be injured
-29-
in an alcohol-related automobile crash, and far more likely to
arrive home than to be either arrested, injured, or killed." West
v. Aetna Life Ins. Co., 171 F. Supp. 2d. 856, 904 (N.D. Iowa
2001).
The likelihood of death is even less probable when we
take into account that the number of people arrested for drunk
driving is lower than one percent of the 159 million self-reported
cases of alcohol–impaired driving among adults in the United States
each year. See Kyran P. Quinlan et al., "Alcohol-Impaired Driving
Among U.S. Adults, 1993-2002," 28 Am. J. of Preventive Med., 346,
348-49 (2005). These statistics do not demonstrate that it is
highly likely that someone who is driving under the influence will
die.
Thus, Mr. Stamp "had a subjective expectation of survival
and . . . such an expectation was objectively reasonable because
death was not certain or even highly likely to result from [his]
conduct." Santaella, 123 F.3d at 464 (citing Todd, 47 F.3d at
1456). "Drunk driving is, to be sure, a foolish and reckless act.
However, when an insured dies as a consequence of his driving while
intoxicated, his death should still be considered accidental
because a reasonable person would not view death as a natural and
probable consequence of drunk driving." Gardner, supra at 253. It
cannot be said that Mr. Stamp expected or intended to kill himself.
See Santaella, 123 F.3d at 463 ("[T]he record simply would not
-30-
support a jury determination that a reasonable person in [the
decedent's] situation would have considered death either 'highly
likely to occur' . . . or 'substantially certain to result from the
insured's conduct.'" (citations omitted)). I believe that
appellees abused their discretion when they denied Mrs. Stamp's
claims because of a determination that Mr. Stamp's death was not an
accident. Mrs. Stamp's claims, however, were denied on other
grounds as well. We examine those grounds below.16
II. Intentionally Self-Inflicted Injury Exclusion
The inquiry for examining policy exclusions for
intentional self-destruction and intentionally self-inflicted
injury mirrors the analysis above. Given the facts, and knowing
that Mr. Stamp was on his way to his parents' house to meet his
family, it cannot be said that his death was the result of a self-
inflicted injury. In Wickman, the decedent drove onto a bridge,
got out of his car, and went to a part of the bridge that he only
would have gone to if he intended to kill himself. See Wickman,
908 F.2d at 1079-80. We found that his death was not the result of
an accident. See id. at 1089. "[A] reasonable person in Wickman's
shoes would have expected to die or be seriously injured as result
of [his actions]." Id. at 1088. That cannot be said here. There
is no evidence that he intentionally struck the tree which caused
16
The majority did not examine the other policies because they
also require the death to be a result of an accident. See slip op.
at 5 n.3.
-31-
his death. "[T]he record [does] not support a determination that
the insured 'did anything other than make a fatal mistake.'"
Padfield, 290 F.3d at 1121 (quoting Santaella, 123 F.3d at 465).
As with the term "accident," there is no definition in
the policy of "intentionally self-inflicted injury." In ERISA
cases, we use federal common law rules to "'interpret the terms of
the policy in an ordinary and popular sense, as would a person of
average intelligence and experience,' and 'construe all plan
ambiguities in favor of the insured.' Plan language may only be
deemed ambiguous where 'it is subject to more than one reasonable
interpretation.'" Santaella, 123 F.3d at 461 (quoting Life Ins.
Co. of N. Am. v. Von Valtier, 116 F.3d 279, 283 (7th Cir. 1997)).
A person of average intelligence and experience would not think
that someone who dies in a one-car collision, even with a BAC above
the legal limit, intentionally caused his own death.17 No doubt,
Mr. Stamp's decision to drive while intoxicated was risky, "but
voluntary risky acts resulting in injury are not necessarily acts
that result in 'intentionally self-inflicted injury.'" Padfield,
290 F.3d at 1129. Accordingly, I believe that Mrs. Stamp's claim
for Basic AD&D insurance benefits should not have been denied by
Appellees.
17
As previously noted, both the police and the autopsy reports
classified the manner of death as "accidental."
-32-
III. Crime Exclusion
Both the Voluntary and Occupational AD&D policies have
exclusions for decedents who die while "committing or attempting to
commit a felony or other serious crime." Appellees denied Mrs.
Stamp's claim because Mr. Stamp had a BAC level above the legal
limit while he was operating his vehicle.
I believe that the exclusion is inapplicable and find
that the Appellees abused their discretion when they found that Mr.
Stamp committed a serious crime. Mr. Stamp was operating his
vehicle in Rhode Island when he died, and under Rhode Island law it
is not a felony to operate a vehicle while under the influence of
alcohol; it is a misdemeanor. See Rhode Island Motor Vehicle
Offenses, § 31-27-2(a).18 By definition, a misdemeanor is not a
serious crime. See United Union of Roofers, Waterproofers, &
Allied Workers, Union No. 33 v. Meese, 823 F.2d 652, 656 (1st Cir.
1987) ("the 'misdemeanor' label typically applies to crimes that
are not very serious") (citation omitted). Accordingly, I would
find that the crime exclusion does not apply, and that Mrs. Stamp
is entitled to Voluntary AD&D benefits. This does not answer
18
The Rhode Island statute reads in relevant part:
(a) Whoever drives or otherwise operates any vehicle
in the state while under the influence of any
intoxicating liquor, drugs, toluene, or any controlled
substance as defined in chapter 28 of title 21, or any
combination of these, shall be guilty of a misdemeanor
except as provided in subdivision (d)(3) and shall be
punished as provided in subsection (d) of this section.
-33-
whether Mrs. Stamp is entitled to Occupational AD&D because that
policy requires death to occur "while at work."
IV. "While at Work" Exclusion
In order for Mrs. Stamp to qualify for Occupational AD&D
benefits she had to demonstrate that Mr. Stamp was "at work" when
he died. The policy clearly states that "while at work" "does not
include any personal time taken before, during or following a
Mobil-approved business trip." Mrs. Stamp argues that Mr. Stamp
was "at work" because the meeting he attended was mandatory and he
died on his way back from the meeting. ExxonMobil noted that Mr.
Stamp was no longer "traveling from" the work-related business
meeting when he died. ExxonMobil also noted Mr. Stamp stopped "for
several hours for a separate, purely personal purpose."
According to Mrs. Stamp, Mr. Stamp's co-workers, and
Kingsley, Mr. Stamp was not inebriated when he left his work
function. Mr. Stamp was legally inebriated when he died; his BAC
level was three-times the legal limit. Given the road conditions,
the weather, and Mr. Stamp's conversation with Kingsley at about
9:30 p.m., Mr. Stamp should have reached his parents' house by
10:30 p.m. Yet, by midnight, he still had not reached his
destination. The conclusion that Mr. Stamp became inebriated by
reason of some non-work related activity after he left the work
function is supported by circumstantial evidence. Thus, I would
find that ExxonMobil did not abuse its discretion when it
-34-
determined that Mr. Stamp's collision occurred during "personal
time taken . . . following" his trip and that Mrs. Stamp is not
entitled to recover under the Occupational AD&D policy.
V. Conclusion
For the reasons explained above, I dissent.
-35-
Stamp v. Metropolitan Life Insurance
Court: Court of Appeals for the First Circuit
Date filed: 2008-06-30
Citations: 531 F.3d 84
Copy CitationsCombined Opinion