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First Circuit Finds for Plaintiff and Awards Retroactive Mental Health Benefits

Attorney Rachel AltersAuthor: Attorney Rachel Alters

In Jane Doe v. Standard Insurance Company, plaintiff Doe spent more than 25 years as an environmental attorney for a Maine law firm prior to become ill with depression and anxiety. She filed a claim for mental health disability benefits under the law firm’s disability policy. Her claim was approved, but based on a disability date of January 2012, when she claimed the date should be October 2011. Standard also awarded benefits based on the general occupation of an attorney instead of her own occupation as an environmental attorney.

After several administrative appeals, Doe filed an ERISA lawsuit in the Maine District Court, which ruled in favor of the insurer and Doe appealed. The Court of Appeals for the First Circuit reversed the lower court decision and ruled that Standard was wrong on both issues. By using the definition of a general attorney instead of environmental attorney the Court stated that Standard “eviscerated the Own Occupation coverage, and its evaluation as to Doe’s disability onset date was based on the wrong standards.”

Onset Date of Disability

On March 22, 2012, plaintiff filed a claim for mental health disability benefits stating she had been unable to work since October 2011. Standard argued she was not disabled until January 28, 2012. The date is significant in that benefits are calculated based on the prior year’s earnings. In this case, the difference in onset made a difference of more than $100,000 in payments.

After reviewing the medical reports and Doe’s work history, the appeals Court agreed that she had become disabled in October 2011. The amount of benefits then turned on whether her own occupation was that of an environmental lawyer or a general lawyer.

Own Occupation Standard

Doe paid an additional premium to Standard in order to have coverage if she was disabled from working in her own occupation: that of an environmental lawyer. When Standard calculated benefits, it did so on the basis of earnings of a general lawyer and used the Dictionary of Occupational Titles (DOT) for the job description and calculation of benefits.

The Court disagreed noting that “No evidence in the record supports the assumption that ‘environmental lawyer’ and ‘lawyer’ are equivalent terms that may be used interchangeably. Environmental law is a distinct specialty, and the expertise demanded from environmental lawyers distinguished that specialty from a generic ‘lawyer’ role.”

After determining that Standard’s use of the 2012 disability onset date was wrong, and the calculation of benefits on the basis of work of a general lawyer instead of an environmental lawyer, the Court then sought to determine the appropriate remedy.

Remedy is to Order Insurer to Pay Retroactive Benefits

The Court noted that it had “considerable latitude” in selecting a remedy in an ERISA case. Plaintiff here suffered through several administrative appeals over several years period of time.

The Court concluded, “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 remanded to the district court with orders to Standard to calculate benefits based on the 2011 onset date under plaintiff’s own occupation as an environmental lawyer.

This case was not handled by our office, but we think it can be beneficial to those struggling to obtain long-term disability or mental health benefits based on the policy definition of their own occupation. If you have any questions about your own disability claim, contact one of our attorneys at Dell & Schaefer for a free case evaluation.