• Menu
  • Skip to right header navigation
  • Skip to main content
  • Skip to secondary navigation
  • Skip to primary sidebar
  • Skip to footer

Before Header

Has your disability claim been wrongfully denied or terminated? Call us today for help!  (888) 321-8131

  • Facebook
  • Instagram
  • LinkedIn
  • Twitter
  • YouTube

National Disability Law Firm | Ortiz Law Firm

We appeal wrongful long term disability insurance and Social Security Disability denials.

  • ABOUT US
    • Our Team
    • Our Results
    • Areas We Serve
    • Core Values
  • PRACTICE AREAS
    • Administrative Appeals
    • Lawsuits
    • Lump Sum Settlement Offers
  • RESOURCES
    • Top 10 Mistakes That Will Destroy Your Long Term Disability Claim
    • Lump Sum Disability Settlement Calculator
    • Physical RFC Form
    • Mental RFC Form
    • Ultimate Appeal Checklist
    • Long Term Disability Case Study
  • BLOG
    • Long Term Disability Denials and Appeals
    • Medical Eligibility for Long Term Disability Claims
    • Eligibility for Long Term Disability Claims
    • Your Chances of Getting Approved for Disability Benefits
    • Additional Parts Of A Claim That Do Not Happen in Every Case
  • Search
  • CONTACT
  • ABOUT US
    • Our Team
      • Nick Ortiz
      • Jessica Ortiz
      • Dawn Keller
      • Tory Nelson
      • Sarah Palag
    • Core Values
    • Our Results
      • Why Choose Ortiz Law Firm
      • What Our Clients Say
      • Testimonials
  • PRACTICE AREAS
    • Long Term Disability Claims
      • Administrative Appeals
      • Lawsuits
      • Lump-Sum Settlement Offers
      • Qualifying Conditions
      • Disability Insurance Companies
      • Qualifying Occupations
      • Case Summary Archives
      • FAQs
    • Social Security Disability Claims
      • Initial Application
      • Request for Reconsideration
      • Hearing Before an Administrative Law Judge
      • Qualifying Conditions
      • FAQs
    • Personal Injury Claims
      • Car Accident Claims in Pensacola, Florida
      • Bicycle Accident Claims in Pensacola, Florida
      • Motorcycle Accident Claims in Pensacola, Florida
      • Truck Accident Claims in Pensacola, Florida
      • Slip & Fall
      • Insurance Companies
      • FAQs
  • AREAS WE SERVE
  • RESOURCES
    • Top 10 Mistakes That Will Destroy Your LTD Claim
    • Top 10 Mistakes That Will Destroy Your SSD Claim
    • Lump Sum Disability Settlement Calculator
    • Physical Residual Functional Capacity Form
    • Mental Residual Functional Capacity Form
    • Ultimate LTD Appeal Checklist
    • LTD Case Study: Fibromyalgia
    • Top 10 Mistakes That Will Destroy Your FL Car Accident Claim
  • BLOG
    • Long Term Disability
      • Eligibility for Long Term Disability Claims
      • Medical Eligibility for Long Term Disability Claims
      • Your Chances of Getting Approved for Disability Benefits
      • Long Term Disability Denials and Appeals
      • Additional Parts Of A Claim That Do Not Happen in Every Case
    • Social Security Disability
    • Personal Injury
  • REFER A CASE
  • Search
  • CONTACT

Mobile Menu

Schedule A Free Consultation Now!

Find out how our law firm can help you win your case or you don’t pay a cent.

(888) 321-8131

  • Facebook
  • LinkedIn
  • Twitter
  • YouTube

Own Occupation Review: Lawyer Vs. Environmental Lawyer

April 8, 2020

Case Name: Jane Doe v. Standard Insurance Company

Court: United States Court of Appeals 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
‘Predisability Earnings.’”

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.”

Disclaimer: This was not a case handled by disability attorney Nick A. Ortiz. The court case is summarized here to give readers a better understanding of how Federal Courts decide long term disability ERISA claims.
Here is a copy of the decision in PDF:
Doe v. Standard

Insurance Company: StandardOccupation: Attorney

Primary Sidebar

View All Resources


Kris K.

Mr. Ortiz was pleasant and compassionate towards me since my very first phone call to him. He and Suzie made sure that I understood every step along the way about my medical disability claim. They were very professional and attentive to my case and took care of everything! I definitely felt like I was represented by a compassionate and "real" person, not just some attorney who is fake. He was very kind. I feel like Mr. Ortiz is an absolute expert with the Disability system! I thank God that I found Mr. Ortiz as my disability attorney and will not hesitate to recommend him to everybody!

View All Testimonials

Complete this CONFIDENTIAL form or call (888) 321-8131 for a FREE case evaluation

  • This field is for validation purposes and should be left unchanged.

Navigation

  • Free Resources
  • Qualifying Conditions for LTD
  • LTD Insurance Companies
  • Qualifying Occupations for LTD
  • Case Summary Archives
  • LTD FAQ
  • Qualifying Conditions for SSD
  • SSD FAQ
  • PI FAQ
  • PI Insurance Companies
  • Disclaimer

Footer

Our Team

  • Nick Ortiz
  • Jessica Ortiz
  • Dawn Keller
  • Sarah Palag
  • Tory Nelson

Our Law Office

ORTIZ LAW FIRM
(888) 321-8131

823 E. Jackson St.
Pensacola, FL 32501
Monday - Thursday: 9:00 AM - 5:00 PM Friday: 9:00 AM - 2:00 PM

Saturday - Sunday: Closed

Practice Areas

  • Long Term Disability Claims
  • Social Security Disability Claims
  • Personal Injury Claims
  • Facebook
  • LinkedIn
  • Twitter
  • YouTube
  • Free Long Term Disability Resources
  • Long Term Disability Frequently Asked Questions
  • Medical Conditions That May Qualify for Long Term Disability
  • LTD Insurance Carriers
  • Occupations That May Qualify for LTD
  • LTD Blog
  • LTD Federal Court Case Summaries
  • Contact
  • Disclaimer

Site Footer

©2020 Ortiz Law Firm, All Rights Reserved. Reproduced with Permission | Privacy Policy