Doe v. Standard Insurance Company

852 F.3d 118, 2017 WL 1101609, 2017 U.S. App. LEXIS 5232
CourtCourt of Appeals for the First Circuit
DecidedMarch 24, 2017
Docket16-2085P
StatusPublished
Cited by10 cases

This text of 852 F.3d 118 (Doe v. Standard Insurance Company) is published on Counsel Stack Legal Research, covering Court of Appeals for the First Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Doe v. Standard Insurance Company, 852 F.3d 118, 2017 WL 1101609, 2017 U.S. App. LEXIS 5232 (1st Cir. 2017).

Opinion

LYNCH, Circuit Judge.

In this ERISA benefits suit for long term disability (“LTD”) payments, the sum owed to the plaintiff, “Jane Doe,” turns on the year of disability onset, as the prior year’s earnings determine the monthly benefit amount. The parties disagree on whether Doe’s disability began in 2011 or in 2012: the insurer has paid Doe the benefits owed using a January 2012 onset date, but not the benefits owed if the onset date is in November 2011. The difference, we are told, amounts to over $100,000 in payments.

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 *120 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.

I.

A. Background

Doe worked at a Maine law firm for more than 25 years, and for many years she was an equity partner. In August 2011, Doe became a non-equity partner and remained employed in that capacity for about six months thereafter. Over the course of 2011, Doe billed far fewer hours than she had in previous years.

Defendant Standard Insurance Company (“Standard”) is the claim administrator and insurer of the employee welfare benefit plan (“the Plan”) offered by Doe’s law firm to its employees. The Plan was insured by an LTD policy (“the Policy”), which was also issued by Standard and which covered Doe. 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. 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.” The Predisability Earnings depend in turn on the claimant’s income during the “prior tax year” — that is, the calendar year before the year of disability onset. Doe’s income in 2011 was only one-third of what it had been in 2010, and so whether she became disabled in 2011 or in 2012 significantly affects the calculation of her monthly benefit payments.

For context, we recite briefly some of the medical evidence relevant to Doe’s LTD claim. On November 30, 2011, during her regular appointment with her gynecologist, Dr. Kathleen Petersen, Doe confessed that she had become “bone crushingly exhausted” in the preceding year and had lost “any interest in life,” among other symptoms. Dr. Petersen suspected that Doe was afflicted with a mental health problem. She recommended that Doe seek counseling — advice that Doe resisted — and also doubled Doe’s prescribed daily dose of citalopram, an antidepressant, which Doe had been taking for roughly four years.

On December 9, 2011, Doe met for the first time with Dr. Frederick White, a clinical psychologist. Dr. White’s notes from that visit state that Doe exhibited numerous symptoms consistent with Major Depressive Disorder — including suicidal ideation and diminished attention, concentration, and memory — and he diagnosed her with that disorder. In two follow-up appointments that same month, Dr. White observed that Doe “was having continuing mental disorder with suicidal ideation.”

Dr. Petersen saw Doe on January 5, 2012, after having discussed Doe’s condi *121 tion with Dr. White earlier that day. In her notes, Dr. Petersen observed that Doe did not appear to be an imminent suicide risk, but that Doe was “severely depressed.” When Dr. Petersen asked Doe about hospitalization for Doe’s depression, Doe responded that “she [could not], that it would be a severe detriment to her [law] practice.” At appointments later in January 2012, Dr. White and Dr. Petersen continued to observe that Doe was “dealing with ... significant depression.”

On February 8, 2012, Doe met with her primary care physician, Dr. Donna Con-kling, for the first time since April 2011. Dr. Conkling postponed Doe’s scheduled physical exam because Doe was “close to tears” and “appealed] anxious, depressed, and exhausted.” Doe continued to report problems with severe depression and thoughts of self-harm or suicide. Doe also relayed that “[h]er husband was not completely supportive of her stopping work.” Doe’s last day of logging hours of work at the firm was January 27, 2012.

B. Doe’s Claim

Doe filed an LTD claim with Standard “on or about March 22, 2012.” She reported that “she had suffered depression for approximately five years but became ’unable to work’ ... in October 2011.” As symptoms stemming from her “mental health [and] related [psychological] disorders,” she listed, inter alia, “unable to process or think clearly while at work,” “chronic fatigue,” “migraine headaches,” and “inability to function.”

In February 2012, Dr. Petersen, Dr. Conkling, and Dr. White 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.

On April 18, 2012, Doe’s former law firm sent Standard a job description for Doe’s specific occupation, environmental lawyer. Standard had requested the description from the law firm two days earlier, along with Doe’s payroll history and timesheets. The firm also sent Doe’s biography, which outlined Doe’s career accomplishments and specific areas of expertise. Standard never told Doe or her representatives that the provided description was incomplete or inadequate.

Standard asked Jan Cottrell, one of its “vocational case managers],” 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.” The DOT is a compendium of job descriptions and requirements, formerly published by the U.S. Department of Labor, which aims to define jobs as they are performed in the national economy and is commonly used by insurers. See McDonough v. Aetna Life Ins. Co.,

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951 F.3d 12 (First Circuit, 2020)
Roibas v. EBPA, LLC
346 F. Supp. 3d 164 (D. Maine, 2018)
Kamerer v. Unum Life Ins. Co. of Am.
334 F. Supp. 3d 411 (District of Columbia, 2018)
Doe v. Harvard Pilgrim Health Care, Inc.
904 F.3d 1 (First Circuit, 2018)

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Bluebook (online)
852 F.3d 118, 2017 WL 1101609, 2017 U.S. App. LEXIS 5232, Counsel Stack Legal Research, https://law.counselstack.com/opinion/doe-v-standard-insurance-company-ca1-2017.