ERISA plan beneficiaries sued Hartford after the company denied their claim for accidental death benefits arising from a death due to a self-inflicted gunshot wound.
Under the plan, "injury" was defined as "bodily injury resulting: (1) directly from an accident; and (2) independently of all other causes." The plan also contained exclusions for losses caused or contributed to by "intentionally self-inflicted injury" and "suicide or attempted suicide."
Plaintiffs claimed the insured's death occurred while he was cleaning a gun that he assumed to be unloaded. The autopsy report concluded that the insured died of a self-inflicted wound, and stated that the autopsy "failed to reveal any other trauma, and that the manner of death was suicide." On the death certificate, the coroner listed the cause of death as trauma arrest resulting from a self-inflicted gunshot wound to the chest. After reviewing the autopsy report, however, the coroner ultimately wrote that the manner of death was "undetermined," rather than suicide.
Hartford concluded that both exclusions applied, and that even an "undetermined" death would still be excluded from coverage because the loss "must have resulted directly from accident and independently of all other causes."
During the administrative appeal, plaintiffs submitted evidence that the insured was unfamiliar with guns, that the gun at issue jammed repeatedly, that the insured was found in a chair on his back porch with gun cleaning materials nearby, and that the gun did not have a clip in it.
On cross-motions for judgment on the administrative record, plaintiffs contended that the federal common law presumption against suicide and in favor of accidental death existed to resolve inconclusive cases, and that Hartford failed to apply it before denying benefits. Hartford argued that the presumption was inapplicable because the evidence was not inconclusive.
In applying the first step of the Eleventh Circuit's framework under the arbitrary and capricious standard of review, the court determined that Hartford's claim decision was "de novo wrong" because the evidence regarding the cause of death was at least inconclusive, if not more likely to support a conclusion that the death was accidental.
The court rejected Hartford's argument that the exclusion for losses "caused or contributed to by ... intentionally self-inflicted injury" was not subject to the presumption and that even if the insured did not intend to die or injure himself, he still intended to shoot himself in the chest, and that such a loss would be excluded because "the natural and probable consequence of shooting yourself in the chest is serious injury or death."
According to the court, the issue was not whether to resolve the question of the insured's intent to die by subjective or objective reasoning, but whether he intentionally pulled the trigger in the first place, and here, the record demonstrated only a "fatal mistake," not an intentionally self-inflicted injury.
The court also determined that even under the arbitrary and capricious standard of review, Hartford's decision was unreasonable. The court rejected Hartford's position that legal presumptions should not affect a court's deferential review because legal presumptions are not part of the administrative process.
The court relied on Schikore v. BankAmerica Supplemental Retirement Plan, 269 F.3d 956 (9th Cir. 2001), which addressed the application of the federal common law mailbox rule to a claim denial under an ERISA plan. Noting that the mailbox rule is a "settled feature of the federal common law" and a rebuttable presumption was to be used "in the face of inconclusive evidence," the Ninth Circuit found under its arbitrary and capricious analysis that the administrator abused its discretion for failing to apply the common law presumption. The court in Acree adopted this reasoning.
The court also disagreed that Hartford's decision was consistent with the federal common law standard announced in Wickman v. Northwestern National Insurance Company, 908 F.2d 1077 (1st Cir. 1990), which disposed of the distinction between "accidental means" and "accidental results." Hartford contended that even if the plaintiffs provided evidence to support their theory that the gun jammed while the insured was cleaning it, Wickman would still apply because he should have known that serious injury would be a probable outcome of continuing to handle a gun known to jam. The court distinguished Wickman, however, finding that there was little evidence in the record to suggest that the decedent intentionally shot himself.
Ultimately, the court remanded the case to Hartford, as claims administrator, for further review.
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