United States District Court, D. Maine
DOE, Plaintiff, represented by GERALDINE G. SANCHEZ, ROACH
HEWITT RUPRECHT SANCHEZ & BISCHOFF, P.C..
STANDARD INSURANCE COMPANY, Defendant, represented by BROOKS
R. MAGRATTEN, PIERCE ATWOOD LLP, pro hac vice & KYLE N.
KIRBY, PIERCE ATWOOD LLP.
ORDER ON MOTIONS FOR JUDGMENT
Z. SINGAL, District Judge.
the Court are cross-motions for judgment by Defendant (ECF
No. 32) and Plaintiff (ECF No. 33). As explained herein, the
Court GRANTS Defendant's Motion for Judgment on the
Record (ECF No. 32) and DENIES Plaintiff's Motion for
Judgment on the Record (ECF No. 33).
STANDARD OF REVIEW
a party is entitled to summary judgment if, on the record
before the Court, it appears "that there is no genuine
issue as to any material fact and that the moving party is
entitled to judgment as a matter of law." Fed.R.Civ.P.
56(c)(2). The party moving for summary judgment must
demonstrate an absence of evidence to support the nonmoving
party's case. Celotex Corp. v. Catrett, 477 U.S.
317, 325 (1986). In determining whether this burden is met,
the Court must view the record in the light most favorable to
the nonmoving party and give that party the benefit of all
reasonable inferences in its favor. Santoni v.
Potter, 369 F.3d 594, 598 (1st Cir. 2004). This
"standard is not affected by the presence of
cross-motions for summary judgment." Alliance of
Auto. Mfrs. v. Gwadosky, 430 F.3d 30, 34 (1st Cir. 2005)
(citation omitted). Even when filed simultaneously,
"[c]ross-motions for summary judgment require the
district court to consider each motion separately, drawing
all inferences in favor of each nonmoving party in
turn." AJC Int'l, Inc. v. Triple-S
Propiedad, 790 F.3d 1, 3 (1st Cir. 2015) (internal
quotations and citations omitted).
when a case challenges the denial of benefits under Employee
Retirement Income Security Act of 1974 (ERISA), codified in
relevant part at 29 U.S.C. Â§Â§ 1001-1461, crossmotions 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
Massachusetts HMO Blue, Inc., 813 F.3d 420, 425 (1st
Cir. 2016); see also Orndorf v. Paul Revere Life Ins.
Co., 404 F.3d 510, 517 (1st Cir. 2005). With both
sides' arguments queued up via cross-motions, the Court
reviews the same record that was before the plan
administrator and "evaluates the reasonableness of an
administrative determination in light of the record compiled
before the plan fiduciary." Leahy v. Raytheon
Co., 315 F.3d 11, 17-18 (1st Cir. 2002) (applying this
standard when the parties moved for cross-summary judgment).
First Circuit explained in Colby v. Union Sec. Ins. Co. &
Mgmt. Co. for Merrimack Anesthesia Associates Long Term
Disability Plan, 705 F.3d 58 (1st Cir. 2013):
Where, as here, the administrator of an ERISA plan is imbued
with discretion in the interpretation and application of plan
provisions, its use of that discretion must be accorded
deference. It follows that judicial review is for abuse of
discretion. In the ERISA context, this metric is equivalent
to the familiar arbitrary and capricious standard. Whatever
label is applied, the relevant standard asks whether a plan
administrator's determination is plausible in light of
the record as a whole, or, put another way, whether the
decision is supported by substantial evidence in the
61 (quoting Leahy v. Raytheon Co., 315 F.3d 11, 17
(1st Cir. 2002) with other citations omitted). "Evidence
is deemed substantial when it is reasonably sufficient to
support a conclusion." Ortega-Candelaria v. Johnson
& Johnson, 755 F.3d 13, 20 (1st Cir. 2014) (citations
and internal quotations omitted). Notably, when a plan
administrator both evaluates and pays claims under a plan,
there is an inherent conflict of interest. "This
inherent conflict may be weighed as a factor in assessing the
reasonableness of [the plan administrator]'s decision,
but its existence does not perforce alter [the] standard of
review." Colby, 705 F.3d at 62 (citing
Metro. Life Ins. Co. v. Glenn, 554 U.S. 105, 115,
this standard in mind, the Court provides the factual
recitation that follows, which is drawn from the parties'
submissions of statements of material fact, and the responses
thereto,  as well as the Court's review of
those portions of the sealed Administrative Record
("AR") that the parties have cited to in these
Jane Doe was employed as an attorney at a law
firm in Maine for more than twenty-five years. (Pl. SMF Â¶ 3.)
She was an equity partner at the firm until August 2011. (Pl.
SMF Â¶ 1.) After August 2011, Plaintiff remained employed as a
non-equity partner until February 2012, when her employment
terminated. (Pl. SMF Â¶ 2.) In 2010, Plaintiff had K-1 income
of $175, 913.00. In 2011, Plaintiff's K-1 income dropped
by approximately sixty-six percent ($116, 249.00), yielding a
total 2011 income of $59, 664.00. (Pl. SMF Â¶ 28 & AR 391.)
Long-Term Disability ("LTD") Plan
was insured under a long-term disability plan offered by the
Law Firm to employees. (Pl. SMF Â¶ 4 & Def. SMF Â¶ 2.) The plan
was fully insured by a long term disability
policy issued by Defendant Standard Insurance
Company (also known as "The Standard"), which both
determines eligibility for benefits under the Policy and pays
the claims. (Pl. SMF Â¶Â¶ 5 & 6; Def. SMF Â¶ 5.) The Policy
provides coverage for (1) any total disability that prevents
the insured from performing her "Own Occupation" or
(2) or "Partial Disability." (Pl. SMF Â¶ 5.) The
plan defines the term "Mental Disorder" to include
"depression and depressive disorders." (Def. SMF Â¶
9 & AR 381.) Benefits under the plan are subject to a 90-day
Benefits Waiting Period, such that participants must be
"continuously Disabled" for at least 90 days before
any LTD benefits become payable. (Def. SMF Â¶ 7 & AR 363,
specifically, as it relates to the pending dispute, the
Policy provides the following material terms:
Definitions of Own Occupation and Partial Disability
You are Disabled if you meet one of the following definitions
during the period it applies:
A. Own Occupation Definition Of Disability; or
B. Partial Disability Definition.
A. Own Occupation Definition Of Disability
During the Benefit Waiting Period and the Own Occupation
Period you are required to be Disabled only from your Own
You are Disabled from your Own Occupation if, as a result
of... Mental Disorder, you are unable to perform with
reasonable continuity the Material Duties of your Own
[The Specialty Language]
If you are an attorney at law and you have practiced law for
at least 5 years, during the Benefit Waiting Period and
through the Own Occupation period, we will consider your Own
Occupation to be the one legal subject matter area or type of
legal practice in which you specialize, provided you have
earned at least 85% of your gross professional service fee
income in that area or type of practice during the 24 months
immediately before you become Disabled.
[B.]Partial Disability Definition
During the Benefit Waiting Period and the Own Occupation
Period, you are Partially Disabled when you work in your Own
Occupation but, as a result of... Mental Disorder, you are
unable to earn 80% or more of your Indexed Predisability
Earnings, in that occupation.
Definition of "Temporary Recovery "
You may temporarily recover from your Disability and then
become Disabled again from the same cause or causes without
having to serve a new Benefit Waiting Period. Temporary
Recovery means you cease to be Disabled for no longer than
the applicable Allowable Period...
Allowable Periods [means]
1. During the Benefit Waiting Period: a total of 30 days of
2. During the Maximum Benefit Period: 180 days for each
period of recovery.
If your Temporary Recovery does not exceed the Allowable
Periods...[t]he Predisability Earnings used to determine your
LTD Benefit will not change.
Definition of "Predisability Earnings"
[Y]our Predisability Earnings will be based on your
Employer's prior tax year....Predisability Earnings means
your average monthly compensation from your Employer during
the Employer's prior tax year.
(Pl. SMF Â¶ 12 & AR 369, 371-72 & 381.)
Plan confers upon Standard "full and exclusive authority
to control and manage the [plan], to administer claims, and
to interpret the [plan] and resolve all questions arising in
the administration, interpretation, and application of the
[plan]." (Def. SMF Â¶ 10 & AR 384.) It further provides
that all of The Standard's decisions in the exercise of
its authority are "conclusive and binding." (Def.
SMF Â¶ 11 & AR 384.) The Plan allows a participant to request
a review of any part of a claim that is denied, and that
review is to be conducted by someone other than the person
who denied the original claim. (Def. SMF Â¶ 12 & AR 383.) The
participant must request any review "in writing"
and "within 180 days after receiving notice" of the
decision to be reviewed. (Def. SMF Â¶ 13 & AR 383.)
had a "legal practice in which she specialized, "
meaning she had practiced law for more than five years and
had a specific type of specialized legal practice (the
"Specialty Own Occupation"). (Pl. SMF Â¶Â¶ 7 & 8; AR
November 30, 2011, Plaintiff appeared for a scheduled regular
examination with her gynecologist, Kathleen Petersen, M.D.
(Pl. SMF Â¶ 13.) Dr. Petersen's contemporaneous November
30, 2011 record (the "11/30/11 Petersen Record")
stated the following regarding Doe:
She hopes she can "unload some concerns on me"...
[O]ver the past year or so, she has become "bone
crushingly exhausted." She does not have any interest in
life.... She will fall asleep, but then wake up at 3 a.m.,
and "have a horrid time getting back to sleep. These
last couple of months have been just awful for her.... She
feels as though her husband is pressuring her to work more
and earn more money. She feels as though nobody would miss
her if she was gone....
(Pl. SMF Â¶ 14 & AR 520-21 (redacted).) Although Doe was
resistant to advice that she seek counseling, Dr. Petersen
increased her citalopram to 40 mg daily. (Id. (redacted).)
December 9, 2011, clinical psychologist Frederick White,
Ph.D., first saw Doe. His records from this first visit (the
"12/9/11 White Record") included the following
notes: symptoms included pervasive sadness, depressed mood,
fatigue, suicidal ideation ("SI"), decreasing
selfesteem, increasing frequency of tearfulness; the onset of
the symptoms had increased in the past year to the
"tipping point;" the mental status report concluded
"quite depressed" mood, decreased attention,
concentration and memory, her appetite and weight were down,
sleep was impaired but "most recently" she was
experiencing hypersomnia, speech was slowed, she had suicidal
ideation with means but "denies plan intent presently,
" but "contract for safety" was also noted.
(Pl. SMF Â¶ 15 & AR 480-81 (redacted).) Dr. White diagnosed
her with Major Depressive Disorder (ICD 296.23) with a GAF
score of 40. (Pl. SMF Â¶ 16 & AR 481.) In a letter
to Standard Insurance Company, dated May 22, 2013, Dr. White
Ms. [Doe] engaged my services beginning with her initial
intake at my office on December 9, 2011. I can verify that
her disability predates this initial session insofar as her
call requesting to be seen for evaluation and treatment
occurred early in November, 2011. Her report on interview
during intake stated that she became aware of onset of
symptoms no less than one year prior.
(Pl. SMF Â¶ 18 & AR 466.)
White saw Doe again on December 12, 2011 and December 15,
2011, and provided an assessment that Doe was having
continuing mental disorder with suicidal ideation. Doe and
Dr. White contracted for her safety. (Pl. SMF Â¶ 19 & AR 482
(redacted).) On January 5, 2012, Dr. White saw Doe after the
holidays. She reported doing better during holidays and
masking her depression. She appeared better rested and her
facial and posture were more upbeat. Her suicidal risk
continued to decrease. (Pl. SMF Â¶ 20 & AR 482
Petersen also saw Doe on January 5, 2012 (the "1/5/12
Petersen Record") and noted the following:
Doe has seeing Dr. Fred White.... [Dr. White] did call me
today. [Dr. White] did see [Doe] today and states [Doe] has
some suicidal ideation but no real plan or intent. [Dr.
White] did ...