Court Opinion

ID: 4155594
Source: CourtListenerOpinion
Date Created: 2017-03-24 21:00:23.989522+00
Date Added: 2024-06-11T14:23:29.123247
License: Public Domain

United States Court of Appeals
                     For the First Circuit

No. 16-2085

                            JANE DOE,

                      Plaintiff, Appellant,

                               v.

                   STANDARD INSURANCE COMPANY,

                      Defendant, Appellee.

          APPEAL FROM THE UNITED STATES DISTRICT COURT
                    FOR THE DISTRICT OF MAINE

          [Hon. George Z. Singal, U.S. District Judge]

                             Before

                      Lynch, Circuit Judge,
                   Souter,* Associate Justice,
                  and Baldock,** Circuit Judge.

     Geraldine G. Sanchez, with whom Roach Hewitt Ruprecht Sanchez
& Bischoff PC was on brief, for appellant.
     Brooks R. Magratten, with whom Scott K. Pomeroy and Pierce
Atwood LLP were on brief, for appellee.

                         March 24, 2017

     *  Hon. David H. Souter, Associate Justice (Ret.) of the
Supreme Court of the United States, sitting by designation.
     ** Hon. Bobby R. Baldock, Circuit Judge of the United States

Court of Appeals for the Tenth Circuit, sitting by designation.
              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 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

                                       - 2 -
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.

                                  - 3 -
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

                                   - 4 -
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 condition 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 Conkling, for the first time since April 2011.

Dr. Conkling postponed Doe's scheduled physical exam because Doe

was "close to tears" and "appear[ed] 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

                                  - 5 -
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 13, 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

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."        The DOT is a compendium of job

                                  - 6 -
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., 783 F.3d 374, 380–81 (1st

Cir. 2015); see also, e.g., Armani v. Nw. Mut. Life Ins. Co., 840

F.3d 1159, 1162 (9th Cir. 2016).                  There is no separate DOT job

description for an environmental lawyer, and Standard did not look

elsewhere for a definition.

             Doe's claim specialist at Standard next asked Cottrell

to respond to the job description received from Doe's law firm.

On April 23, 2012, Cottrell responded that Doe did not meet the

Policy's   definition       of    "trial       attorney"      but    that    Doe's       "own

occupation     would   be    the        one    legal    subject       matter      area     of

environmental      law."         In    spite    of     that   conclusion,         Cottrell

reiterated that the DOT "lawyer" description "most reasonably

represented" Doe's "own occupation."

             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."              On January 25, 2013, Doe took her first

                                          - 7 -
formal appeal and submitted additional information from Dr. White

and Dr. Petersen.1

              On March 27, 2013, Standard told Doe that it would

approve her claim and that it would use January 28, 2012 as the

disability onset date. On May 14, 2013, Doe took her second appeal

and submitted additional statements from Dr. White, who wrote in

support of a 2011 onset date.

              Christopher      Powers,      another   senior       benefits     review

specialist at Standard, sought another "vocational review" from

Karol Paquette, a vocational case manager at Standard.                     In a memo

to   Powers,        dated   July   23,   2013,     Paquette    stated     that    "the

information in [Doe's] file document[ed] a significant change in

the character of [Doe's] work activity around November 2011, such

as area of specialization or subject matter, or in the type of

work activity performed."            "In my professional opinion," Paquette

further      explained,     "[Doe]    was    not   working    in    her   own    legal

specialty or area of expertise on a reasonably continuous basis

from       8/1/11    [to]   11/30/11."        However,    Paquette        continued,

       1  After Doe's appeal, Standard referred the claim to Dr.
Esther Gwinnell, a psychiatrist "who has done a significant number
of reviews for . . . Standard." Dr. Gwinnell's report, dated March
6, 2013, acknowledged that Doe had received medical care for
depression in late 2011 but concluded that Doe had not become
disabled until February 6 or February 9, 2012. Standard's senior
benefits review specialist, having reviewed the report, determined
that Doe's disability had begun on January 28, 2012 -- "the day
after [Doe] stopped work."

                                         - 8 -
"[al]though [Doe] was not performing her own specialty area of

expertise on a reasonably continuous basis prior to ceasing work,

it would be my professional opinion[] that she was performing the

work of a lawyer on a reasonably continuous basis" (emphasis

added).     This analysis highlighted the difference between using

Doe's specialty area of expertise as the measure and, by contrast,

using the general standard for lawyers.

            On July 24, 2013, Powers, to his credit, asked Paquette

via email whether "the demands, aptitudes and temperaments of

[Doe's] legal subject matter area [were] distinct from those of

other areas of expertise to the extent that they would differ from

those described in the DOT description for Lawyer."               Paquette

responded on July 30, 2013, observing that "[t]here are some

specialty    practices   defined   in   the   DOT   for   lawyers[,]   [but]

[e]nvironmental law is not one of them." Given that, she concluded

that "the demands, aptitudes and temperaments of [Doe's] legal

subject matter area are the same as that of [the] DOT occupation

of Lawyer" (emphasis added).2       The record does not support this

conclusion; it appears to be simply a repetition of her prior

     2    In each of her reports, Paquette claimed to have "relied
upon a variety of resources," including not only the DOT but also
the Occupational Outlook Handbook and the Occupation Information
Network. However, her reports contain no analysis or discussion
of those alternative resources.     Moreover, the reports do not
suggest that she used those alternative resources to find and use
a more specialized "environmental lawyer" job description, rather
than another generic one.

                                   - 9 -
decision to use a general "lawyer" standard, perhaps because there

was no separate DOT listing for "environmental lawyer."

          On August 21, 2013, on Standard's behalf, Powers issued

a decision ("the Final Decision"), which upheld Standard's March

27, 2013 decision to award benefits to Doe based on a 2012 onset

date.   The Final Decision observed that Doe had performed "non-

billable activities" from November 2011 to January 2012, "on an

essentially full time basis," including "work on various boards

and committees and pro bono work." "Therefore," the Final Decision

went on, "while we acknowledge that your client did cease work in

her particular area of legal expertise, she continued to work as

an attorney on a reasonably continuous basis until January 28,

[2012], in a position which would have had substantially similar

demands and requirements.   On that basis, we evaluated whether the

medical information in the file supported impairment from working

as an attorney within the scope of her license to practice law at

any time prior to January 28, 2012."    The Final Decision further

explained that "while we recognize that your client found her work

to be stressful and sought to transition to a different type of

practice, this does not correspond to an inability to perform the

Material Duties of her Own Occupation on a reasonably continuous

basis for any employer."

          After hiring counsel, Doe requested a reconsideration of

the Final Decision -- specifically, the disability onset date --

                              - 10 -
on August 29, 2014.          She submitted sworn statements from herself,

Dr. Petersen, and Dr. White. In a letter dated September 16, 2014,

Standard refused to reconsider the Final Decision or to consider

Doe's       new    information,   explaining     that   Standard   had   already

afforded Doe "the one administrative review to which Doe was

entitled."

                                          II.

                  As our review of the district court's judgment is de

novo, see McDonough, 783 F.3d at 379, we bypass recounting the

district court proceedings.           After cross-motions for judgment on

the record, the district court entered judgment for Standard.3

                  This appeal concerns only what disability onset year

should be used to calculate Doe's monthly benefit amount.                  There

is no dispute that Doe is entitled to a full 24 months of LTD

benefits with a disability onset in 2011, if Standard's decision

to use the 2012 onset date was arbitrary and capricious.

                  The   parties   agree   that   the    Plan   gives     Standard

discretionary authority to evaluate claims, so we review for abuse

of discretion -- that is, we determine "whether [Standard's]

decision is arbitrary and capricious or . . . whether that decision

        3 In the context of the Employee Retirement Income
Security Act of 1974 ("ERISA"), 29 U.S.C. §§ 1001–1461, "motions
for summary judgment . . . are nothing more than vehicles for
teeing up [the] case[] for decision on the administrative record."
Stephanie C. v. Blue Cross Blue Shield of Mass. HMO Blue, Inc.,
813 F.3d 420, 425 n.2 (1st Cir. 2016).

                                      - 11 -
is reasonable and supported by substantial evidence on the record

as a whole."      Id.; see also Metro. Life Ins. Co. v. Glenn, 554

U.S. 105, 111 (2008).    We "determine lawfulness by taking account

of several different, often case-specific, factors, reaching a

result by weighing all together."    Glenn, 554 U.S. at 117.4

             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.      The Plan defines the key inquiry as

whether Doe was disabled from performing the material duties of

her Own Occupation, and so "a reasoned determination of the

existence of disability vel non require[d], inter alia, a review

of the material duties of [Doe's] particular position." McDonough,

783 F.3d at 380.     Standard was obligated to "assess[] whether and

to what extent . . . [Doe's] impairments compromised h[er] ability

to carry out" the specialized duties of an environmental lawyer.

Id.       Standard charged an enhanced premium for the promise of

enhanced specialty coverage, and it was unreasonable for Standard

      4   One relevant factor is Standard's inherent conflict of
interest as the entity that "not only evaluates claims but also
underwrites the plan." Colby v. Union Sec. Ins. Co. & Mgmt. Co.
for Merrimack Anesthesia Assocs. Long Term Disability Plan, 705
F.3d 58, 62 (1st Cir. 2013); see also Glenn, 554 U.S. at 112, 117–
19; McDonough, 783 F.3d at 379. We do not rely on that factor
here.

                                - 12 -
to undercut that coverage by failing to ascertain and consider the

specific requirements of Doe's specialty.

              The vocational reports, and the conclusions Standard

drew   from    those   vocational    reports   in    the   Final    Decision,

demonstrate at most that Standard made a reasonable effort to

analogize Doe's specialty occupation to a job description in the

DOT.   Although a generic DOT "position description" may suffice if

it involves duties equivalent to those of the claimant's own

occupation, id. at 381 (citing Tsoulas v. Liberty Life Assurance

Co. of Bos., 454 F.3d 69, 78 (1st Cir. 2006)), that is not the

case   here.      It   was   unreasonable    for    Standard   to   base   its

decisionmaking on a generic DOT description that did not account

for the special expertise expected from environmental lawyers.

See id.; Miller v. Am. Airlines, Inc., 632 F.3d 837, 855 (3d Cir.

2011) ("[B]ecause the Plan provides 'own occupation' disability

benefits, it is essential to consider whether a pilot is capable

of working in that capacity, regardless of his ability to function

in a different position.").         The fact that the DOT does not have

a listing for "environmental lawyer" does not make Standard's

decision any less arbitrary.

              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.

                                    - 13 -
Environmental law is a distinct specialty, and the expertise

demanded from environmental lawyers distinguishes that specialty

from a generic "lawyer" role.           Standard received from Doe's former

law firm a job description outlining the duties and expectations

associated with Doe's specialized area of practice, as well as her

resume, which confirmed her expertise as an environmental lawyer.

That firm is by no means unique in treating environmental law as

a distinct specialty.           We take judicial notice that the firm

representing     Standard      in     this   matter,   for   example,   lists

"Environmental" as a distinct practice group on its website.               See

Environmental,       Pierce    Atwood    LLP,   http://www.pierceatwood.com

/environmental-land-use.        The American Bar Association, in similar

fashion, includes "Environment, Energy, and Resources" among its

"specialty groups that focus on a unique area of law."                     See

Sections,     Am.     Bar     Ass'n,     http://www.americanbar.org/groups

/sections.html.      And the U.S. Department of Justice has a discrete

Environment    and    Natural       Resources   Division.    See   About   the

Division, U.S. Dep't of Justice, http://www.justice.gov/enrd/about

-division.

             The proper inquiry, therefore, is whether the record

contains substantial evidence that Doe was able to "perform with

reasonable continuity the Material Duties" of an environmental

lawyer beyond 2011.         Standard conceded in the Final Decision that

Doe did not actually practice "in her own specialty area of

                                       - 14 -
expertise      .    .    .   after   November     2011."    And   Standard's    own

vocational case manager, Karol Paquette, opined that there had

been a significant change in the character of Doe's work activity

around November 2011 and that "[Doe] was not working in her own

legal specialty or area of expertise on a reasonably continuous

basis from 8/1/11 [to] 11/30/11."               Its choice of January 28, 2012

as Doe's disability onset date depended on Doe's completion of a

few generic lawyer tasks, such as attending committee meetings, in

December 2011 and January 2012.             As we have already explained, it

was arbitrary and capricious to use a generic lawyer's material

duties as the analytical benchmark.5

            The next question is the appropriate remedy.                   We have

"considerable latitude in the selection of a remedy in an ERISA

case,"   and       our   choice      "depends   on   the   circumstances   of   the

particular case."            Colby, 705 F.3d at 68; see also Buffonge v.

Prudential Ins. Co. of Am., 426 F.3d 20, 31–32 (1st Cir. 2005);

Glista v. Unum Life Ins. Co. of Am., 378 F.3d 113, 130–32 (1st

Cir. 2004) ("In [the ERISA] context, no single answer fits all

     5    To the extent Standard argues that Doe's volunteering to
do non-billable and pro bono work in November 2011 -- including
bar association work and "work on various boards and committees"
-- shows that she was not yet disabled from her Own Occupation at
that time, that too is arbitrary. The argument is a non sequitur.
Further, "[a] disabled person should not be punished for heroic
efforts to work by being held to have forfeited [her] entitlement
to disability benefits should [she] stop working."      Hawkins v.
First Union Corp. Long-Term Disability Plan, 326 F.3d 914, 918
(7th Cir. 2003).

                                         - 15 -
cases.").       In   light   of     Standard's        failure    to   apply    the   Own

Occupation      standard     correctly,         over    the     course   of    several

administrative       appeals,      we   think    it    most     equitable     in   these

circumstances to bring an end to this dispute and to award Doe

retroactive benefits instead of remanding the matter to Standard.

It is now 2017, and the dispute concerns events in 2011 and 2012.

See Colby, 705 F.3d at 68 ("[A court] is not obliged to make an

endless series of remands [in an ERISA case]."); Glista, 378 F.3d

at 131 (discussing the "range of remedial powers" Congress gave to

the   federal    courts      for    addressing         ERISA    violations     through

equitable relief (citing 29 U.S.C. § 1132(a)(3))); Cook v. Liberty

Life Assurance Co. of Bos., 320 F.3d 11, 23–24 (1st Cir. 2003)

(explaining that plan administrators often do not "get a second

bite at the apple" after making an arbitrary and capricious

determination (quoting Grosz-Salomon v. Paul Revere Life Ins. Co.,

237 F.3d 1154, 1163 (9th Cir. 2001))).

            Doe has requested attorney's fees, as ERISA allows.                      See

29 U.S.C. § 1132(g)(1).            That request is highly fact-sensitive,

and we leave it for the district court to address in the first

instance on remand.        See Gross v. Sun Life Assurance Co. of Can.,

763 F.3d 73, 85-86 (1st Cir. 2014).

                                         III.

            The judgment is reversed, and the district court is

directed to order Standard to award Doe retroactive benefits based

                                        - 16 -
on a disability onset date of no later than 2011.   Doe's request

for attorney's fees is remanded to the district court.

          The Clerk is directed to send a copy of this opinion to

the Superintendent of the Maine Bureau of Insurance.

                             - 17 -