Case Name: Jane Doe v. Standard Insurance Company
Court: United States Court of Appeals for For the First Circuit.
Date of Decision: March 24, 2017.
Type of Claim: This was an ERISA benefits suit for long term disability (“LTD”) payments.
Insurance Company: Standard Insurance Company.
Claimant’s Employer: A law firm.
Claimant’s Occupation / Job Position: Doe worked at a Maine law firm for more than 25 years, and for many years she was an equity partner and then a non-equity partner.
Disabilities: Major Depressive Disorder. As symptoms stemming from her “mental health [and] related [psychological] disorders,” the claimant listed, inter alia, in her application: “unable to process or think clearly while at work,” “chronic fatigue,” “migraine headaches,” and “inability to function.”
Definition of Disability: “The Policy provides that a claimant is ‘Disabled’ if she is ‘unable to perform with reasonable continuity the Material Duties of [her] Own Occupation.’ The Policy also promises lawyers with at least five years’ experience that ‘[their] Own Occupation [is] the one legal subject matter area or type of legal practice in which [they] specialize, provided [they] have earned at least 85% of [their] gross professional service fee income in that area or type of practice’ during the 24 months before disability onset. There is no dispute that Doe met these criteria for specialty coverage.”
Other Key Provisions? “The Policy defines ‘Material Duties’ as ‘the essential tasks, functions and operations, and the skills, abilities, knowledge, training and experience, generally required by employers from those engaged in a particular occupation that cannot be reasonably modified or omitted.'”
“Under the Policy, those who become disabled due to a ‘Mental Disorder’ may receive LTD benefits for, at most, 24 months. The monthly benefit amount depends on the claimant’s
Benefits Paid? Yes. For a short period.
Basis For Denial / Termination of Benefits: On June 29, 2012, Standard denied Doe’s claim. The claim specialist explained that Standard, having used the generic “lawyer” job description, had found Doe to be disabled from January 18, 2012 onward but not disabled beyond the Policy’s “90 day Benefit Waiting Period.”
Procedural history: Standard asked Jan Cottrell, one of its “vocational case manager[s],” to evaluate Doe’s claim of disability. On April 12, 2012, Cottrell identified Doe’s Own Occupation under the Policy as “lawyer,” not “environmental lawyer.” Having chosen “lawyer,” Cottrell concluded that the material duties of a lawyer were “most reasonably represented by the Dictionary of Occupational Titles (DOT) occupation of Lawyer.”
Doe appealed with additional medical documentation.
Standard approved the claim but used a later disability onset date. Doe appealed and submitted more medical statements in support of a 2011 onset date.
Standard upheld its decision based on a 2012 onset date.
After hiring counsel, Doe requested a reconsideration of the Final Decision — specifically, the disability onset date — on August 29, 2014.
Key Physician Opinions: In February 2012, three treating doctors had independently completed Attending Physician’s Statements in connection with Doe’s LTD claim. Each physician diagnosed Doe with severe depression. Each also stated that he or she recommended Doe stop working.
Issues: whether the record contains substantial evidence that Doe was able to “perform with reasonable continuity the Material Duties” of an environmental
lawyer beyond 2011.
Holdings: “We agree with Doe that Standard’s reliance on the DOT description of a generic “lawyer,” rather than a job description that fully and accurately encompassed the material duties of Doe’s specialized area of legal practice, rendered Standard’s decision arbitrary and capricious.”
Other Noteworthy court comments: No evidence in the record supports the assumption that ‘environmental lawyer’ and ‘lawyer; are equivalent terms that may be used interchangeably. We think that they self-evidently are not and that Standard’s assumption of equivalence was arbitrary. Environmental law is a distinct specialty, and the expertise demanded from environmental lawyers distinguishes that specialty
from a generic ‘lawyer’ role.
Summary: “The wrinkle in the case is that the disability insurance involved is “Own Occupation” insurance, for which an additional premium is charged. Doe’s Own Occupation was “environmental lawyer.” Yet when the insurer assessed whether and when Doe became disabled, it chose not to use the material duties of an environmental lawyer, but rather those of a lawyer. In doing so, it eviscerated the Own Occupation coverage, and its evaluation as to Doe’s disability onset date was based on the wrong standards. Its denial of benefits from an onset date no later than November 2011 was arbitrary and capricious. The district court entered judgment on the record for the insurer. We reverse.”