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Law Office of Patrick Mause, PLLC

Patrick W. Mause

290 North Meyer

Tucson, Arizona 85701

State Bar No. 24269

520.342.0000

520.342.0001 (Fax)

EMail: Patrick@PMauseLaw.com

Attorney for Plaintiff Tricia Sanchez

UNITED STATES DISTRICT COURT

DISTRICT OF ARIZONA

Tricia Sanchez,

Plaintiff,

vs.

Life Insurance Company of North America, 

a foreign corporation

Defendant.

Case No.

COMPLAINT

For her Complaint, Tricia Sanchez (“Plaintiff”), alleges as follows:

Parties, Venue, and Jurisdiction:

1. Plaintiff Tricia Sanchez is a resident and citizen of Pima County, Arizona, 

and was a resident and citizen of Pima County, Arizona at all times material to the 

Complaint.

2. Plaintiff’s claim is for long-term disability (LTD) benefits, the waiver of 

her life insurance premiums under the life insurance plan’s Life Waiver Of Premium 

(LWOP) provision, and for other benefits to which she may be entitled and which were 

provided to her under her employer’s ERISA-governed benefits plan (the “Plan”).

3. Defendant Life Insurance Company of North America, d/b/a Cigna

(“LINA” or “Cigna”) is a foreign corporation that is authorized to do business in Arizona 

and is doing business in Arizona. 

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4. The Court has jurisdiction under the Employee Retirement Income Security 

Act of 1974 (ERISA), 29 U.S.C. § 1001 et seq.

5. Venue is proper in this district pursuant to 29 U.S.C. § 1132(e)(2) and 28 

U.S.C. § 1391 because the “breach” of the LTD plan occurred in Pima County, Arizona, 

and because defendant LINA a.k.a. Cigna may be found in Pima County, Arizona. 

Background: Ms. Sanchez Became Disabled After Suffering 

A Burst Cerebral Aneurysm In 2009

6. In February 2009, while having her son’s birthday party in her home, Ms. 

Sanchez collapsed on the table. She was non-responsive. She had just asked her husband 

to bring the children inside to sing Happy Birthday. 

7. Neighbors who were at the party called 911, the ambulance came, and Ms. 

Sanchez was rushed to St. Joseph’s hospital. 

8. The physicians diagnosed Ms. Sanchez with a subarachnoid hemorrhage. 

She had suffered a burst cerebral aneurysm. They told Ms. Sanchez’s husband she likely 

would not live. 

9. St. Joseph’s quickly transferred Ms. Sanchez to Tucson Medical Center’s 

specialized neurological unit where she underwent multiple medical procedures that 

saved her life. TMC’s neurosurgeon documented that Ms. Sanchez “was found slumped 

down on the chair at a birthday party of one of her children, yesterday afternoon.” He 

also documented that she “has had repeated nausea and vomiting” since her aneurysm. 

10. Ms. Sanchez’s post-aneurysm treatment included implanting a drainage 

shunt in her brain and multiple aneurysm “coil embolizations.” 

11. In a “coil embolization,” a catheter is threaded through the patient’s blood 

vessels into her brain, and a thin “coil” is packed into a bulging blood vessel; i.e. a 

bulging weak spot in a cerebral blood vessel, or aneurysm, but which has not yet burst. 

The “coil” fills the aneurysm and prevents blood from flowing into the bulge. The “coil” 

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thus should prevent the aneurysm from bursting and flooding the brain with pressurized 

blood, as had happened to Ms. Sanchez at her son’s birthday party. 

12. As of June 10, 2010, Ms. Sanchez had undergone “a total of eight 

procedures related to the aneurysm.”

After Attempting To Work, Ms. Sanchez Applied For Disability Benefits In 2012, 

Cigna Denied Her Claim, But Then Approved Her Claim On Appeal

13. After undergoing extensive rehabilitation and multiple medical procedures, 

Ms. Sanchez attempted to return to work. 

14. However, following her burst cerebral aneurysm, Ms. Sanchez suffered 

multiple problems that affected her ability to work, including but not limited to: frequent, 

debilitating headaches with nausea, vomiting, photophobia, and phonophobia; cognitive 

problems; dizziness; weakness; balance changes; and speech problems; among other 

things. 

15. Ms. Sanchez also suffered side effects from the high-doses of pain 

medications she was required to take in an effort to reduce the severity of her pain. 

16. In August of 2012, Ms. Sanchez stopped work and applied for short-term 

disability (STD) benefits with Cigna. Cigna denied Ms. Sanchez’s STD claim on 

September 19, 2012. 

17. On March 28, 2013, Ms. Sanchez timely appealed Cigna’s denial and 

included multiple records confirming her ongoing disability, including but not limited to:

A. Multiple MRIs (magnetic resonance imaging) and MRAs (magnetic 

resonance angiogram) objectively documenting Ms. Sanchez’s 

aneurysms and multiple surgeries and procedures to treat her aneurysm. 

B. Records documenting that Ms. Sanchez continued to suffer vasospasm 

(spasming of the blood vessels), and residual right-sided weakness of the 

arm and leg.

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C. Records documenting that Ms. Sanchez suffered severe headaches and 

that it is not uncommon for patients with subarachnoid hemorrhage to 

suffer from chronic headaches.

D. Neuropsychological evaluation by Dr. Shannah Biggan documenting 

multiple cognitive deficits from which Ms. Sanchez suffered.

E. A letter from Ms. Sanchez’s primary care physician documenting that 

Ms. Sanchez continued to suffer severe, debilitating headaches, suffered 

multiple impairments due to the medications she took, and was unable to 

work in any occupation due to her conditions.

F. Headache journal and video declaration of Ms. Sanchez in which she 

testified about, among other things, the frequency and horrific severity of 

her headaches.

G. Home videos taken by Ms. Sanchez’s husband showing the effects of 

headaches Ms. Sanchez rated as a “7” or “8” on a scale of 1-10. 

18. On April 8, 2013, Cigna reversed its decision denying Ms. Sanchez’s STD 

claim, reinstated her benefits, and “transitioned” her claim for evaluation of her LTD 

claim.

19. By letter dated April 18, 2013, Cigna forwarded Ms. Sanchez several 

forms. In that letter, Cigna also told Ms. Sanchez that she should apply for Social 

Security Disability Insurance (SSDI) benefits and that if she failed to do so, Cigna would 

“estimate the amount of Social Security benefits you and your dependents would be 

entitled to receive and to reduce your Long Term Disability benefits accordingly.”

20. To receive SSDI benefits, a claimant must prove their “inability to engage 

in any substantial gainful activity” in the national economy. See 42 U.S.C. § 

423(d)(1)(A). The standard to receive SSDI is stricter than Cigna’s definitions of 

disability under the LTD and LWOP plans. 

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21. Under the LTD Plan, if Ms. Sanchez’s claim for SSDI benefits were 

approved, Cigna would apply a dollar-for-dollar offset to her LTD monthly LTD benefit, 

substantially reducing Cigna’s liability under the Plan. 

22. On April 30, 2013, Ms. Sanchez forwarded her completed forms to Cigna 

and also forwarded confirmation that she had applied for SSDI benefits.

23. On May 22, 2013, Cigna approved Ms. Sanchez’s LTD claim effective 

January 24, 2013. 

24. Under the LTD Plan, Ms. Sanchez was entitled to a maximum of two years’ 

of LTD benefits as long as she was unable to perform the material duties of her “own 

occupation.” Under the LTD plan, the “own occupation” benefit period would end 

January 22, 2015.

25. After two years of benefits, i.e. beginning January 23, 2015, Ms. Sanchez 

was entitled to benefits as long as she was “unable to perform the material duties of any 

occupation for which he or she is, or may reasonably become, qualified based on 

education, training or experience.” 

26. Also on May 22, 2013, Cigna sent Ms. Sanchez a letter stating that it had 

started reviewing her Life Waiver Of Premium (LWOP) claim. Under the life insurance 

plan, Cigna would keep Ms. Sanchez’s life insurance in effect and waive the premiums 

for that insurance as long as Ms. Sanchez was “unable to perform all the material duties 

of any occupation for which he or she may reasonably become qualified based on 

education, training or experience.” Essentially, the LWOP claim applied the same “any 

occupation” standard that the LTD Plan applied after two years’ of LTD benefits had 

been paid.

27. On July 2, 2013, Cigna approved Ms. Sanchez’s LWOP claim; thus 

agreeing that due to her conditions, Ms. Sanchez was “unable to perform all the material 

duties of any occupation” for which she was reasonably qualified. This is effectively the 

same standard to receive “any occupation” benefits under the LTD plan.

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28. Under the plan’s LWOP provision, Ms. Sanchez is entitled to $145,000 in 

continued life insurance coverage and her premiums on that coverage are waived.

29. On January 14, 2014, the Social Security Administration approved Ms. 

Sanchez’s SSDI claim after finding she was unable to perform “any work for gain” in the 

national economy. The standard to receive SSDI benefits is stricter than the LTD Plan’s 

“own occupation” standard. The standard to receive SSDI benefits is also stricter than 

the LTD Plan’s “any occupation” standard. The standard to receive SSDI benefits is 

stricter than the life insurance plan’s “any occupation” standard to receive LWOP 

benefits.

30. After multiple delays, Ms. Sanchez received her payment for retroactive 

SSDI benefits in the fall of 2014 (this was after the government shutdown and sequester, 

which caused significant delays in the Social Security Administration’s processing of Ms. 

Sanchez’s SSDI claim). After receiving that retroactive SSDI payment, Ms. Sanchez 

reimbursed Cigna for the overpayment that resulted from her receipt of past-due SSDI 

payments. 

Cigna Terminated Ms. Sanchez’s Benefits Based On The Review Of Its 

Employee-Physician And Undisclosed “Reed Group Guidelines”

31. In the fall of 2014, Cigna began requesting updated records and forms 

regarding Ms. Sanchez’s claim. After receiving that information, Cigna requested that an 

in-house nurse and in-house physician review Ms. Sanchez’s file to opine regarding her 

restrictions and limitations. The purpose of Cigna’s request was to evaluate whether Ms. 

Sanchez — who had been approved for and was receiving SSDI benefits, and whose life 

insurance waiver of premium claim had been approved — was entitled to benefits under 

the LTD Plan’s “any occupation” standard, which would begin to apply on January 23, 

2015.

32. Cigna’s employee-nurse who reviewed Ms. Sanchez’s claim was Shelley 

Hill, RN. After reviewing limited information, but without reviewing Ms. Sanchez’s 

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complete file, Ms. Hill opined that Ms. Sanchez’s claim was unsupported. Among other 

things, Ms. Hill noted that the CT scan taken at Ms. Sanchez’s August 12, 2014 

emergency room visit “showed no acute intracranial hemorrhage and no significant 

change from 6/5/13... 12/10/14 head MRA showing previously embolized left internal 

carotid artery aneurysm and right posterior communicating artery aneurysm. No 

recurrences and no new aneurysm.”

33. Cigna then referred Ms. Sanchez’s claim to its employee-physician, Dr. 

Steven St. Clair. Like Nurse Hill, Dr. St. Clair reviewed only limited information, and 

not Ms. Sanchez’s complete file. After rejecting the opinions of Ms. Sanchez’s treating 

physician as reflected in a form he submitted, and noting that Ms. Sanchez’s December 

2014 brain MRA “describes stable prior findings without recurrence or new aneurysm,” 

Dr. St. Clair opined: “Duration of disability has exceeded maximal guidelines provided 

by the widely accepted external resource from the Reed Group for described conditions 

without evidence of complication, co-morbidity, or ongoing impairment — headache 3 

days.” 

34. Dr. St. Clair also rejected Ms. Sanchez’s claim of cognitive problems, 

stating: “No informal clinical mini-mental status examination or formal neuropsychiatric 

cognitive assessment is documented. There is no formal cognitive testing on file.” To 

the contrary, Dr. Biggan’s 2013 formal neuropsychological examination documenting 

Ms. Sanchez’s multiple cognitive problems was in Ms. Sanchez’s claim file and therefore 

available to Dr. St. Clair. He simply did not review it. 

35. Addressing Ms. Sanchez’s SSDI award, Dr. St. Clair said: “The Social 

Security Disability system uses different standards of review than those used for this 

assessment.” While that is actually correct — the SSDI standard to receive disability is 

stricter than Cigna’s — Dr. St. Clair failed to appreciate or consider the differences.

36. Finally, Dr. St. Clair stated: “On review and separate analysis of the claim, 

focusing particularly on the area or areas of disagreement between [treating physician] 

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Dr. Sanjeev and [Cigna employee] Nurse Case Manager NCM Shelley Hill, in my 

opinion with a reasonable degree of medical certainty the position of NCM Hill is 

correct. Dr. Sanjeevs [sic] opinion is not well supported by medically acceptable clinical, 

laboratory, and/or imaging findings and is inconsistent with other substantial evidence in 

the claim file.” 

37. Dr. St. Clair therefore opined that Ms. Sanchez should be able to “sit 

occasionally stand and walk frequently reach at desk level and perform fine manipulation 

and simple and firm grasping occasionally lift, carry, push and pull up to 10 pounds [sic]. 

There are no documented impairments of speech, hearing, sight, or cognition.” Of 

course, Dr. St. Clair provided this theory without reviewing Ms. Sanchez’s complete file. 

38. Nobody from Cigna ever identified any ways in which Ms. Sanchez’s 

condition had changed or improved from when it approved her LTD and LWOP claims. 

Recall, to obtain LWOP benefits, the claimant must be unable to perform the material 

duties of “any occupation” they are reasonably qualified to perform; essentially the same 

standard as the “any occupation” standard under the LTD plan. 

39. By letters dated January 22, 2015, Cigna terminated Ms. Sanchez’s LTD 

and LWOP claims.

After Cigna Refused To Provide All Relevant Information,

Ms. Sanchez Timely Appealed Cigna’s Decisions On June 24, 2015

40. On January 28, 2015, Ms. Sanchez requested “a complete copy of [her] 

disability claim file, including but not limited to any and all medical records, medical 

reviews and notes, correspondence, and any other documents Cigna relied upon in 

terminating Ms. Sanchez’s LTD claim.” She also requested a copy of the LTD plan 

document.

41. Under ERISA, Cigna has 30 days to provide requested information. 29 

U.S.C. § 1132(c)(1)(B). As the claim administrator, as the Plan’s agent and/or joint 

venture and/or as the de facto plan administrator, if Cigna fails to provide the requested 

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information within 30 days of the request, it may be liable for statutory penalties of up to 

$110 per day for each day it fails to provide the information. Id.; 29 C.F.R. § 2575.502c1. 

42. On March 9, 2015, more than 30 days after her request, Cigna mailed Ms. 

Sanchez what it claimed was a complete copy of her claim file.

43. On April 28, 2015, Ms. Sanchez wrote to Cigna noting that the claim file it 

had mailed did not include the medical review of Dr. St. Clair, on which Cigna had based 

its adverse claim decisions. Ms. Sanchez asked Cigna to “please immediately send me 

Dr. St. Clair’s medical review, and any other information that was not included in the 

claim file Cigna previously provided.” 

44. On May 1, 2015, Cigna sent Dr. St. Clair’s medical review to Ms. Sanchez. 

Cigna did not forward any additional information.

45. Additional information that appears to be missing from the claim file that 

Cigna provided includes previous medical reviews. 

46. On May 27, 2015, Ms. Sanchez wrote to Cigna stating: “Cigna based its 

decision terminating Ms. Sanchez’s LTD claim on an Internal Resource Response 

medical review by its in-house physician, Dr. St. Clair. As part of his opinion, Dr. St. 

Clair says that Ms. Sanchez ‘had exceeded maximal guidelines provided by the widely 

accepted external resource from the Reed Group for described conditions without 

evidence of complication, co-morbidity, or ongoing impairment-headache 3 days’... 

Please immediately provide me a copy of the alleged ‘widely accepted external resource 

from the Reed Group’ which Dr. St. Clair cited in his review and upon which he relied in 

evaluating Ms. Sanchez’s claim.”

47. Cigna, however, refused to provide the “Reed Group” guidelines on which 

its employee-physician had relied in opining that Ms. Sanchez was capable of full-time 

work. 

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48. The “Reed Group” is a for-profit company owned by another disability 

insurer. Like Cigna, the Reed Group has a financial interest in minimizing claim duration 

and financial exposure. 

49. On June 24, 2015, Ms. Sanchez timely appealed Cigna’s decision 

terminating her LTD and LWOP claims by faxing her appeal letter, and mailing her 

appeal letter with a DVD containing her appeal documentation. Because Cigna had 

refused to provide all pertinent information, including the Reed Group guidelines Cigna 

relied upon but refused to provide, Ms. Sanchez noted that she filed her appeal “under 

protest.” 

50. In her appeal letter, Ms. Sanchez noted that Cigna had violated ERISA and 

continued to violate ERISA by withholding material information. 

51. Under ERISA, Cigna has 45 days following its receipt of Ms. Sanchez’s 

appeal to make a decision on her claim. 29 C.F.R. §§ 2560.503-1(i)(1)(i) and (i)(3)(i) 

(administrator shall notify claimant of decision no later than 45 days “after receipt of the 

claimant’s request for review by the plan”). If “special circumstances” exist, Cigna may 

extend its deadline by an additional 45 days. Id. The 45-plus-45 day deadlines begin to 

run on the date the appeal is filed “without regard to whether all the information 

necessary to make a benefit determination on review accompanies the filing.” 29 C.F.R. 

§ 2560.503-1(i)(4). 

52. Thus, under ERISA, Cigna’s maximum, 90-day deadline (i.e. two 45-day 

periods) to make a decision on Ms. Sanchez’s appeal was September 23, 2015; 90 days 

from when Ms. Sanchez faxed her appeal request to Cigna, not including the date she 

faxed her request.

53. With her appeal, Ms. Sanchez sent Cigna medical records, a headache 

journal, and a video declaration in which Ms. Sanchez testified about her debilitating 

conditions. 

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54. On June 29, 2015, Cigna sent Ms. Sanchez a letter stating: “We are in 

receipt of a request for appeal of Ms. Tricia Sanchez’s Long Term Disability Claim.” 

Cigna further stated that “as part of the appeals process, Ms. Sanchez may have access to 

information relevant to her claim, which will be provided upon request free of charge.” 

55. On July 8, 2015, Cigna sent Ms. Sanchez a letter stating that it was 

reviewing her appeal and that “[a]s this constitutes special circumstance [sic] we are 

requesting the permissible extension of 45 days that is allowed under the ERISA 

Regulations.”

56. On July 9, 2015, in response to her repeated requests for the “Reed Group” 

guidelines, Cigna sent Ms. Sanchez a letter directing her to the Reed Group’s website.

57. On July 16, 2015, Ms. Sanchez faxed Cigna additional information 

confirming her ongoing disability, including a letter from her primary care physician, Dr. 

Bijay Sanjeev, explaining among other things that: “Her migraines are debilitating and 

last as long as four days, they are accompanied by the following symptoms: nausea, 

vomiting, visual changes, insomnia, depression and difficulty with her short term 

memory... I feel very strongly that Tricia will never be able to maintain employment due 

to her medical condition.” 

58. Ms. Sanchez’s forwarding additional information to Cigna did not restart 

Cigna’s 45-day deadline to make a decision on her appeal, nor its maximum 90-day 

deadline. 29 C.F.R. §§ 2560.503-1(i)(1)(i) and (i)(3)(i); 29 C.F.R. § 2560.503-1(i)(4);

accord Lewis-Burroughs v. Prudential Ins. Co. of Am., 2015 WL 1969299 (D.N.J. Apr. 

30, 2015). Nor does Ms. Sanchez’s forwarding information operate to “toll” Cigna’s 

deadline for making a decision on her appeal. 29 C.F.R. § 2560.503-1(i)(3) 

(administrator may only “toll” deadline for making decision “due to a claimant’s failure 

to submit information necessary to decide a claim”); 29 C.F.R. § 2560.503-1(i)(4); LewisBurroughs, 2015 WL 1969299 at * 6 (tolling does not apply if claimant submits 

additional information); Lavino v. Metro. Life Ins. Co., 779 F. Supp. 2d 1095, 1101 (C.D. 

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Cal. 2011) (“MetLife contends that March 23 should be the relevant start date for 

calculating the decision because ‘Each time plaintiff submitted additional information in 

support of her claim, the deadline for MetLife to make its claim determination was 

extended.’ (Def. Trial Brief at 21). This contention is meritless.”); Tomassi v. Prudential 

Ins. Co. of Am., 2007 WL 1772117, at *4 (N.D. Ill. June 19, 2007) (“Restarting 

Prudential’s clock every time a claimant submits up records would in many situations 

give Prudential an endless amount of time to consider appeals and might discourage 

claimants from submitting relevant new medical information. That cannot be correct.”).

59. On July 20, 2015, Ms. Sanchez wrote to Cigna stating that she was entitled 

to the Reed Group guidelines under ERISA; that the Reed Group website charged for 

access to the guidelines; that under ERISA “a provision or practice that requires payment 

of a fee or costs as a condition to making a claim or appealing an adverse benefit 

determination would be considered to unduly inhibit the initiation and processing of 

claims for benefits,” 29 C.F.R. § 2560.503-1(b)(3); that Cigna’s referring Ms. Sanchez to 

a pay-for-use website violates ERISA; that Cigna’s January 22, 2015 termination letter 

stated she was entitled to information relevant to her claim “free of charge”; and 

requesting the immediate production of the complete set of Reed Group guidelines that 

Cigna relies upon in administering LTD claims to enable her to determine whether the 

guidelines were misapplied or whether other, relevant guidelines were ignored.

60. On August 3, 2015, Cigna sent Ms. Sanchez a letter saying it had received 

her July 20, 2015 letter and would respond soon.

61. On August 18, 2015, Cigna sent Ms. Sanchez a letter saying that it had 

requested a “peer review” of her claim, that this constituted a “special circumstance” 

entitling it to extend its deadline to make a decision on her appeal by another 45 days, 

and that it would make a decision soon.

62. On September 1, 2015, 43 days after Ms. Sanchez’s last request for the 

Reed Group guidelines, Cigna responded to her request. In its letter, Cigna stated: “Ms. 

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Sanchez is entitled to reasonable access to relevant documents that were relied on in 

reaching the benefit determination on her claim. We are providing information below 

consistent with that entitlement... Guidelines are not used to deny LTD claims, but are 

utilized as a tool to support ongoing benefits.” Cigna’s letter further explained that: 

“The Reed Group MD Guidelines indicate that the length of disability for headaches, 

medical or supported treatment, is a minimum of 0 days, optimum of 1 day, and 

maximum of 3 days, for any class [of work]. Guidelines indicate that the length of 

disability for a ruptured cerebral aneurysm, medical or supported treatment, is a 

minimum of 91 days, optimum of 182 day [sic], and maximum of indefinite days, for 

any class [of work]” (emphasis added).

63. Recall, Dr. St. Clair, upon whose medical review Cigna terminated Ms. 

Sanchez’s LTD and LWOP claims, wrote “Duration of disability has exceeded maximal 

guidelines provided by the widely accepted external resource from the Reed Group for 

described conditions without evidence of complication, co-morbidity, or ongoing 

impairment — headache 3 days.”

64. In reaching that decision, Dr. St. Clair failed to apply other, relevant 

guidelines, specifically the guideline for “ruptured cerebral aneurysm,” which Cigna 

acknowledged that it had in its possession, which Dr. St. Clair did not reference, and 

which provides a guideline maximum disability period of “indefinite days.” 

65. In its September 1, 2015 letter, Cigna again refused to provide the actual 

guidelines. Instead, Cigna purportedly summarized the guidelines that it had determined 

were relevant to Ms. Sanchez’s claim, while potentially ignoring or refusing to disclose 

the existence of other relevant guidelines. 

66. On September 10, 2015, Ms. Sanchez again wrote to Cigna noting that 

Cigna’s letter only purported to contain a summary of two guidelines, noting that Cigna 

“sill has not provided the actual guidelines,” noting that Cigna “is clearly failing to apply 

all relevant guidelines,” noting that Cigna’s response was therefore deficient, and 

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renewing her request for a copy of the complete Reed Group guidelines Cigna has in its 

possession or relies upon in administering disability claims. 

67. Cigna’s deadline for making a decision on Ms. Sanchez’s appeal was

September 23, 2015. 

68. Cigna did not make a final decision on Ms. Sanchez’s claim within its 

ERISA deadlines. Therefore Ms. Sanchez is deemed to have exhausted her 

administrative remedies. 29 C.F.R. § 2560.503-1(l) (“In the case of the failure of a plan 

to establish or follow claims procedures consistent with the requirements of this section, a 

claimant shall be deemed to have exhausted the administrative remedies available under 

the plan and shall be entitled to pursue any available remedies under section 502(a) of the 

Act on the basis that the plan has failed to provide a reasonable claims procedure that 

would yield a decision on the merits of the claim.”). 

69. Ms. Sanchez’s claims are therefore ripe.

Count One: Claim for Benefits Under ERISA

70. Cigna has failed to make a decision on Ms. Sanchez’s appeal within the 

deadlines imposed by ERISA. Accordingly, Ms. Sanchez is deemed to have exhausted 

her administrative remedies and her claim is ripe for judicial review. 29 C.F.R. § 

2560.503-1(l). 

71. Under the Plan, Ms. Sanchez was, and remains entitled to ongoing LTD 

benefits since the date her benefits were terminated. 

72. Ms. Sanchez’s disability is permanent. 

73. Ms. Sanchez has been damaged by Cigna’s improper decision terminating 

her LTD benefits.

74. Ms. Sanchez has been damaged by Cigna’s failure to make a timely 

decision on her LTD appeal. 

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75. The Plan does not grant Cigna discretion to determine entitlement to 

benefits. Therefore the Court must review Cigna’s decisions under the de novo standard 

of review.

76. Furthermore, because Cigna failed to make a final decision on Ms. 

Sanchez’s claim within the deadlines prescribed by ERISA, she is entitled to de novo

review of her claims. 

77. Under the de novo standard or review, Cigna’s decision was erroneous, 

contrary to the plan terms, and contrary to the medical evidence. Ms. Sanchez is entitled 

to continuing LTD and LWOP benefits under the Plan.

78. Even under the abuse of discretion standard of review, Cigna abused its 

discretion because its decisions terminating Ms. Sanchez’s benefits were arbitrary and 

capricious and because they were caused or influenced by Cigna’s, its reviewing 

physicians’, and the Plan’s financial conflicts of interest or improper behaviors or 

motivations. These conflicts of interest precluded the full and fair review required by 

ERISA, 29 U.S.C. 1133(2) and 29 C.F.R. § 2560.503-1(g)(1) and (h)(2). Ms. Sanchez is 

entitled to continuing LTD and LWOP benefits.

79. Upon information and belief, Cigna and its employees and consultants who 

evaluated Ms. Sanchez’s claim suffer from financial conflicts of interest which infected

the claim process and which precluded a full and fair review of Ms. Sanchez’s claim. 

80. Cigna and the Plan have a parsimonious claims handling history. See e.g. 

Salomaa v. Honda Long Term Disability Plan, 642 F.3d 666, 678 (9th Cir. 2011); see 

also Cigna March, 2013 Regulatory Settlement Agreement.

1

81. Cigna has a history of improper claim administration. Id. 

82. Cigna violated the terms of the Regulatory Settlement Agreement in 

administering Ms. Sanchez’s claim. 

 1 Available at: 

https://www1.maine.gov/pfr/insurance/Admin_Enforcement_Actions/RSA_2013/CIGNA

_RSA.pdf

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83. Ms. Sanchez is entitled to discovery regarding the effects of the procedural 

irregularities that occurred during the claims handling process and regarding the effects 

of Cigna’s, its reviewing physicians’, its employees’, and the Plan’s financial conflicts of 

interest, biases, and motivations on the decision terminating Ms. Sanchez’s LTD claim. 

84. Ms. Sanchez has been injured and suffered damages in the form of lost 

LTD and LWOP benefits as a result of Cigna’s and/or the Plan’s wrongful decision to 

terminate her disability benefits and their failure to timely reinstate her benefits. 

85. Ms. Sanchez has been further injured and suffered damages by losing other 

benefits to which she may have been entitled under her employer’s ERISA-governed 

benefits plan. 

86. Pursuant to ERISA, 29 U.S.C. § 1132, Ms. Sanchez is entitled to recover 

unpaid disability benefits, reinstatement of her LTD and LWOP benefits, prejudgment 

interest, reasonable attorney’s fees, and costs from the Plan, and/or Cigna; and/or is 

entitled to an order enforcing her right to disability benefits under the LTD plan and 

under the LWOP provision of the life insurance plan. 

Count Two: Claim For Statutory Penalties Under ERISA

87. The written plan document provided by LINA/Cigna during the claim 

process does not identify University Physicians Healthcare as the Plan Administrator.

88. The written plan document disclosed by LINA/Cigna during the claim 

process does not provide an address for University Physicians Healthcare.

89. The written plan document disclosed by LINA/Cigna during the claim 

process does not provide any contact information for University Physicians Healthcare.

90. Upon information and belief, University Physicians Healthcare is no longer 

in business or operation and/or is inactive or has been administratively dissolved. 

91. Upon information and belief, the plan administrator is no longer in business 

or operation and/or is inactive or has been administratively dissolved. 

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92. Defendant LINA/Cigna insures and administers LTD benefits under the 

Plan. 

93. Defendant LINA/Cigna is the named fiduciary for deciding claims for 

benefits under the Plan.

94. Defendant LINA/Cigna is the named fiduciary for administering claims 

under the Plan. 

95. Defendant LINA/Cigna is responsible for all claim-handling activities 

under the Plan. 

96. Defendant LINA/Cigna is responsible for determining what information to 

consider and/or rely upon in making claim decisions. 

97. Defendant LINA/Cigna is responsible for maintaining records of what 

information it considered and/or relied upon in making claim decisions.

98. Defendant LINA/Cigna is responsible for providing claimants with the 

information it considered and/or relied upon in making claim decisions to claimants upon 

their written request. 

99. Defendant LINA/Cigna has actual and/or apparent authority to provide 

claimants with information it considered and/or relied upon in making claim decisions to 

claimants upon their written request.

100. In providing claim information to Ms. Sanchez upon her written request, 

Defendant LINA/Cigna was acting within the scope of its actual and/or apparent 

authority. 

101. Defendant LINA/Cigna is the Plan’s agent for administering claims under 

the Plan. 

102. Defendant LINA/Cigna is the Plan’s agent for providing information 

relating to claim decisions made by LINA/Cigna to claimants upon the claimant’s written 

request. 

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103. For purposes of providing information relating to claim decisions made by 

LINA/Cigna to claimants upon their written request, LINA/Cigna and the plan 

administrator have a contractual agreement whereby LINA/Cigna is responsible for 

providing claim-related information to claimants.

104. For purposes of providing information relating to claim decisions made by 

LINA/Cigna to claimants upon their written request, LINA/Cigna and the plan 

administrator have a joint interest in having LINA/Cigna provide claimants with claimrelated information to claimants.

105. For purposes of providing information relating to claim decisions made by 

LINA/Cigna to claimants upon their written request, LINA/Cigna and the plan 

administrator have joint control over the venture.

106. For purposes of providing information relating to claim decisions made by 

LINA/Cigna to claimants upon their written request, LINA/Cigna and the plan 

administrator share profits and losses from the venture.

107. For purposes of providing information relating to claim decisions made by 

LINA/Cigna to claimants upon their written request, LINA/Cigna and the plan 

administrator are joint venturers. 

108. Defendant LINA/Cigna is the de facto Plan administrator.

109. Under ERISA, Ms. Sanchez is entitled to all information relevant to her 

claim, free of charge. 29 U.S.C. §§ 1132(a)(1)(A) and (c)(1)(B).

110. Under ERISA, if an administrator fails to provide requested information 

within 30 days of a request, it is liable for statutory penalties in the amount of $110 per 

day for each day the information is delayed. Id.; see also 29 C.F.R. 2575.502c-1. 

111. The Plan delegated the authority for administering claims and providing 

claimants with relevant information to Cigna, in its capacity as the Plan administrator’s 

agent and/or in its capacity as a joint venturer and/or in its capacity as the de facto Plan 

administrator. 

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112. The Plan administrator does not have access to Ms. Sanchez’s claim file.

113. Cigna’s privacy policies prevent it from providing Ms. Sanchez’s claim file 

to the Plan administrator. 

114. The Plan administrator did not rely on so-called Reed Group guidelines in 

administering Ms. Sanchez’s claims.

115. Cigna is the Plan administrator’s agent for providing claimants with claimrelated information upon the claimant’s request.

116. Cigna and the Plan administrator are joint venturers with respect to the 

obligation to provide claimants with claim-related information upon the claimant’s 

request. 

117. Cigna is the de facto Plan administrator. 

118. On January 25, 2015, Ms. Sanchez requested all information relevant to her 

claims from Cigna.

119. While Cigna provided some information relevant to Ms. Sanchez’s claim, it

failed to provide all relevant and requested information, and failed to timely provide other 

information.

120. Because Cigna failed to timely provide all relevant information, Ms. 

Sanchez was prejudiced in her ability to prepare her appeal.

121. Because Cigna failed to provide all relevant information, Ms. Sanchez was 

prejudiced in her ability to develop the ERISA administrative record.

122. Because Cigna failed to provide all relevant information, and because 

Cigna is the Plan’s agent and/or joint venturer and/or is the de facto plan administrator

with respect to Ms. Sanchez’s claim and her request for information pursuant to ERISA,

Ms. Sanchez is entitled to statutory penalties of $110 per day for each day the production 

of that information has been delayed.

123. Because Cigna failed to provide all relevant information, Ms. Sanchez is 

entitled to discovery to enable her to fully develop the ERISA administrative record. 

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Among other things, Ms. Sanchez should be entitled to receive the entire Reed Group 

guidelines Cigna relies upon in administering LTD claim, and should be entitled to any 

and all policies and procedures for applying those guidelines.

WHEREFORE, Plaintiff Tricia Sanchez prays for judgment as follows:

A. For long-term disability benefits due under the Plan and/or an order 

enforcing her right to benefits under the Plan; 

B. For reinstatement of her life insurance waiver of premium claim and/or an 

order enforcing her right to LWOP benefits under the Plan;

C. For any other benefits to which Ms. Sanchez may be entitled due to her 

disability;

D. For statutory penalties against Cigna in the amount of $110 per day until 

such time as all relevant information is provided to her;

E. For prejudgment interest at the maximum legal interest rate until paid; 

F. For attorney’s fees and costs incurred as a result of prosecuting this suit 

pursuant to 29 U.S.C. § 1132(g); and

G. For such other relief as the Court deems just and proper.

DATED this 28th day of September, 2015.

LAW OFFICE OF PATRICK MAUSE, PLLC

By s/ Patrick W. Mause

Patrick W. Mause

Attorney for Plaintiff

Case 4:15-cv-00459-LAB Document 1 Filed 09/28/15 Page 20 of 20