Mary Jane Wickman v. Northwestern National Insurance Company
908 F.2d 1077, 1990 U.S. App. LEXIS 12175, 28 Employee Benefits Cas. (BNA) 1071 (1990)
Rule of Law:
Under federal common law governing ERISA plans, an injury or death is not "accidental" if the insured's intentional conduct makes serious injury or death highly likely to occur or substantially certain, even if the insured did not specifically intend the harmful result; this framework rejects the distinction between accidental means and accidental results.
Facts:
- Paul Wickman was covered by a group life and accidental death and dismemberment (AD&D) policy issued by Northwestern National Life Insurance Company through his employer, Dexter Corporation, which named his wife as the beneficiary.
- On July 11, 1984, Michael Blanchette observed Wickman standing outside the guardrail of a bridge on Route 495, holding on with only his right hand, approximately 40-50 feet above railroad tracks.
- Blanchette then witnessed Wickman fall from the bridge to the tracks below.
- After the fall, Blanchette administered first aid and repeatedly asked Wickman why he had jumped, but Wickman did not respond to that question.
- Upon admission to St. Luke's Hospital, when asked what had happened, Wickman told emergency admissions secretary Trudy Dooley, "I jumped off."
- The bridge guardrail was three to four feet high, with no area or lip outside for walking, indicating that climbing over it required a conscious effort.
- Wickman died later that evening from injuries sustained in the fall.
- Northwestern denied Mrs. Wickman’s claim for AD&D benefits, asserting that the death was not accidental and citing a policy exclusion for suicide or intentionally self-inflicted injury.
Procedural Posture:
- Mrs. Wickman sued Northwestern National Life Insurance Company in the United States District Court for the District of Massachusetts, alleging breach of contract.
- The district court dismissed the common law complaint, ruling that the insurance policy was part of an ERISA plan and thus preempted state law claims, but allowed Mrs. Wickman leave to amend.
- Mrs. Wickman amended her complaint to include claims under ERISA, and the district court summarily dismissed the common law claim again.
- The parties waived their right to a jury trial under ERISA and consented to a trial before a United States Magistrate.
- After a full trial, the magistrate performed a de novo review, concluding that Paul Wickman's death was not accidental, and consequently denied Mrs. Wickman's claim for accidental death benefits.
- Mrs. Wickman (Appellant) appealed this decision to the United States Court of Appeals for the First Circuit.
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Issue:
Does a death qualify as "accidental" under an ERISA-governed accidental death and dismemberment policy when the insured's voluntary actions, while not specifically intending death, make serious injury or death a probable consequence substantially likely to occur?
Opinions:
Majority - Rosenn, Senior Circuit Judge
No, a death does not qualify as "accidental" under an ERISA-governed accidental death and dismemberment policy when the insured's voluntary actions, while not specifically intending death, make serious injury or death a probable consequence substantially likely to occur. The court first affirmed that the accidental death policy was part of an ERISA plan, preempting state law claims, because the employer, Dexter Corporation, established and maintained a comprehensive insurance program with a long-term commitment, rather than merely purchasing an isolated policy. Developing federal common law for ERISA, the court rejected the "accidental means" versus "accidental results" distinction, deeming it artificial and confusing. Instead, the court adopted a standard that judges "accident" from the insured's perspective. This involves considering the insured's actual expectations regarding the injury; if these expectations are patently unreasonable or if actual expectations are unascertainable, an objective analysis is applied. The objective standard asks whether a reasonable person, with background and characteristics similar to the insured, would have viewed the injury as highly likely or substantially certain to occur as a result of the insured's intentional conduct. Applying this standard, the court upheld the magistrate's finding that Wickman "knew or should have known that serious bodily injury or death was a probable consequence substantially likely to occur as a result of his volitional act" of climbing over the guardrail and hanging on with one hand, given the height of the bridge and the lack of extraordinary skills.
Analysis:
This case is significant for solidifying the breadth of ERISA's preemption doctrine over state insurance law for employer-provided plans and for establishing a federal common law definition of "accident" in ERISA-governed policies. By explicitly rejecting the "accidental means" versus "accidental results" distinction, the court streamlined the interpretation of such policies, focusing on the insured's reasonable expectations. This ruling provides a clear framework for future cases involving similar benefit claims, requiring an objective analysis of foreseeability when subjective intent is ambiguous, thus limiting recovery for deaths resulting from highly risky intentional actions.
