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Scott E. Davis 

State Bar No. 016160 

SCOTT E. DAVIS, P.C. 

8360 E. Raintree Drive, Suite 140 

Scottsdale, AZ 85260 

Telephone: (602) 482-4300 

Facsimile: (602) 569-9720 

email: davis@scottdavispc.com

Attorney for Plaintiff Ruth Davis 

UNITED STATES DISTRICT COURT 

DISTRICT OF ARIZONA 

Ruth Davis, 

 Plaintiff, 

 v. 

Aetna Life Insurance Company; Aetna, Inc. 

Short-Term Disability Benefits Plan; Aetna, Inc. 

Long-Term Disability Benefits Plan, 

 Defendants. 

Case No. 

COMPLAINT 

 

 Now comes the Plaintiff Ruth Davis (hereinafter referred to as “Plaintiff”), by and 

through her attorney, Scott E. Davis, and complaining against the Defendants, she states: 

Jurisdiction 

 1. Jurisdiction of the court is based upon the Employee Retirement Income 

Security Act of 1974 (ERISA); and in particular, 29 U.S.C. §§1132(e)(1) and 1132(f). 

Those provisions give the district courts jurisdiction to hear civil actions brought to recover 

employee benefits. In addition, this action may be brought before this Court pursuant to 28 

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U.S.C. §1331, which gives the Court jurisdiction over actions that arise under the laws of 

the United States. 

Parties 

 2. Plaintiff is a resident of Pima County, Arizona. 

3. Upon information and belief, Aetna, Inc. and/or Aetna Life Insurance 

Company (hereinafter referred to as the “Aetna”) sponsored and administered a short-term 

disability (STD) Plan named the Aetna Inc. Short-Term Disability Benefits Plan and a longterm disability (LTD) Plan named the Aetna Long-Term Disability Benefits Plan 

(hereinafter referred to either as the “STD Plan,” the “LTD Plan” or the “Plans” where 

appropriate). Both Aetna Plans were funded and benefits were paid through the general 

assets of Aetna. Upon information and belief, the specific Aetna Group Control Number 

for the Plans may be 0698456. Aetna’s purpose in sponsoring, administering and funding 

the Plans was to provide disability benefits for its employees. Upon information and belief, 

at all times relevant hereto, the Plans constituted “employee welfare benefit plans” as 

defined by 29 U.S.C. §1002(1). 

4. Upon information and belief, Aetna functioned as the claim administrator and 

plan fiduciary of the Plans. However, pursuant to the relevant ERISA regulation, Aetna 

may not have made a proper delegation or properly vested fiduciary authority in itself for 

claim administration. 

5. Aetna operated under a conflict of interest in evaluating Plaintiff’s STD and 

LTD claims because it was the decision maker with regard to whether Plaintiff was 

disabled, and the payor of all benefits. 

6. Aetna’s conflict existed in that if it found Plaintiff was disabled, it was then 

liable for the payment of her STD and LTD benefits. 

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7. Aetna and the Plans conduct business within Gila County and all events 

giving rise to this Complaint occurred within Arizona. 

Venue 

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

U.S.C. §1391. 

Nature of the Complaint 

9. Incident to her employment with Aetna, Plaintiff was a covered employee 

and a “participant” as defined by 29 U.S.C. §1002(7). Plaintiff seeks disability income 

benefits in the form of “Own Occupation” benefits from both the STD and LTD Plans 

pursuant to §502(a)(1)(B) of ERISA, 29 U.S.C. §1132(a)(1)(B), as well as any other nondisability employee benefits she may be entitled to from either Plan, from Aetna and/or 

from any other Aetna employee benefit Plan as a result of being found disabled in this 

action. 

10. Assuming the issue is ripe before the Court at the time it adjudicates the case 

(i.e. the 30 month “Own Occupation” definition of disability and timeframe in the STD and 

LTD Plans has expired), Plaintiff also seeks a determination that she is disabled and meets 

the “Any Reasonable Occupation” definition of disability set forth in the LTD Plan as all 

the evidence she submitted to Aetna supports such a determination and Order from the 

Court. 

11. Plaintiff was employed by Aetna and a covered employee during all relevant 

periods. Plaintiff became disabled on or about March 10, 2014, due to serious medical 

conditions and was unable to work in her designated occupation with Aetna as a Case 

Management Coordinator. Plaintiff has remained disabled as that term is defined in the 

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relevant Aetna STD and LTD Plans continuously since that date and has not been able to 

return to work in “Any Reasonable Occupation” as that term is defined in the LTD Plan. 

12. Following the onset of her disability, Plaintiff filed a claim for STD benefits 

which was initially approved by Aetna, but STD benefits were subsequently terminated 

before the waiting period expired in the LTD Plan. Plaintiff would have been eligible for 

LTD benefits after the LTD waiting period expired. 

13. Aetna denied Plaintiff's LTD claim on or about at the same time it informed 

her that it was terminating her STD claim. Aetna’s rationale for its denial was that Plaintiff 

was not disabled from working in her own occupation during the entire STD waiting period 

(which was 26 weeks). As a result of Aetna’s STD denial, Plaintiff was also not eligible for 

LTD benefits. 

14. Plaintiff did not exhaust her STD claim and benefits due to the fact that Aetna 

only found her disabled from working in her occupation through August 8, 2014. Upon 

information and belief, Aetna evaluated Plaintiff's claim for LTD benefits while her STD 

benefits were still being pursuant to its own company policy, presumably to prevent a gap in 

coverage and benefits. 

15. Upon information and belief, the Aetna STD Plan paid benefits for a 

maximum of 26 weeks and contained the following definition of disability, in relevant part: 

 To be eligible, you and your Physician must provide evidence that due to a 

non-work related injury or illness, you are unable to perform the material 

duties of your own occupation. 

16. After a 26 week waiting period, the LTD Plan contained the following 

definitions of disability: 

You are disabled when Aetna determines that: 

 During the first 30 months that you are disabled, you and your 

Physician must provide evidence that you are unable to 

perform the material duties of your own occupation; 

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 For LTD benefits to continue beyond the first 30 months (oneweek waiting period, 25 weeks of STD benefits and 24 months 

of LTD benefits), you and your doctor must provide evidence 

that you are unable to perform the duties of any reasonable 

occupation. 

17. In support of her claim for STD and LTD benefits, Plaintiff submitted to 

Aetna medical evidence which supported her allegation that she met any definition of 

disability set forth in the relevant STD and LTD Plans. 

18. Upon information and belief, as part of its review, Aetna may have retained 

one of its employees, Ricky Snyder, D.O., to perform a medical records review of Plaintiff’s 

STD and LTD claims. Plaintiff alleges Aetna’s action in retaining one of its own physicians 

to review her claims is evidence of its conflict of interest at work. Plaintiff alleges that Dr. 

Snyder, as an employee of Aetna, was not independent or impartial and may have had an 

incentive to protect his employment status with Aetna by providing a review which 

provided Aetna with evidence to support a denial of her STD and LTD claims. In his 

review, Dr. Snyder minimized and de-emphasized Plaintiff’s evidence which proved that 

she was disabled and unable to work not only in her occupation at Aetna as the term is 

defined in the STD Plan, but also “Any Reasonable Occupation” as that term is defined in 

the LTD Plan. 

19. In the event Aetna retained a third party vendor to obtain the medical records 

review in Plaintiff’s STD and LTD claims, Plaintiff alleges the third party vendor may have 

an extensive business relationship with Aetna and may have an incentive to protect its 

relationship with Aetna by providing medical records reviews which minimize and deemphasize an insured’s evidence, as occurred in Plaintiff’s claim, which provided evidence 

that allowed Aetna to support the denial of her claims. 

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20. In a letter dated September 8, 2014, Aetna informed Plaintiff it was denying 

her claim for LTD benefits due to the fact that her STD claim had only been certified and 

approved through August 8, 2014. Aetna terminated Plaintiff’s STD claim only one month 

before the 26-week LTD waiting period ended and during a timeframe when her STD claim 

would be transitioning from STD to LTD benefits. 

21. In a letter dated September 15, 2014, Aetna informed Plaintiff that because it 

had terminated her STD claim and benefits as of August 8, 2014, she was also not eligible 

for LTD benefits because it did not find her disabled for the entire 26-week LTD waiting 

period. 

22. Pursuant to 29 U.S.C. §1133, Plaintiff timely appealed Aetna’s September 8, 

2014 denial of her LTD claim. 

23. Pursuant to 29 U.S.C. §1133, Plaintiff timely appealed Aetna’s September 15, 

2014 termination of her STD claim. 

24. In support of her appeal for both her STD and LTD claims, Plaintiff 

submitted to Aetna additional medical evidence demonstrating that she met the “Own 

Occupation” set forth in both the STD and LTD Plans and the “Any Reasonable 

Occupation” definition of disability set forth in the LTD Plan. 

25. Plaintiff also submitted to Aetna medical records from one of her treating 

medical professionals who concluded, "...it is my opinion that these conditions are chronic 

and are of severity that she is truly disabled at this time." 

26. Plaintiff also submitted medical records and disability forms from her primary 

medical professional who opined she had, "No ability to work. Severe limitation of 

functional capacity; incapable of minimal activity." 

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27. Plaintiff also submitted updated medical records and testing from her various 

treating medical providers, many which included the medications she was taking and the 

side effects they caused Plaintiff to experience not only while working in her occupation at 

Aetna, but also in any occupation. 

28. On February 25, 2015, notwithstanding the reliable and credible evidence 

submitted on appeal by Plaintiff in her STD and LTD claims, Aetna notified her that it had 

made a final administrative denial in both her STD and LTD claims and that she had 

exhausted her administrative remedies. 

29. As part of its review of Plaintiff’s claim for STD and LTD benefits, Aetna 

retained a third part vendor named MES Solutions (hereinafter referred to as “MES”) who 

hired medical professionals to only review her medical records in order to provide "paper 

reviews" of Plaintiff’s claims. 

30. Upon information and belief, Plaintiff alleges MES and the reviewing 

physicians it retained may have a extensive business relationships with each other. Plaintiff 

also alleges MES’s physicians may also have extensive business and consulting 

relationships with other disability insurance companies and/or Aetna. As a result, Plaintiff 

alleges MES and the physicians it retained may have had an incentive to protect their 

business relationship with MES, and with the disability insurance industry and/or Aetna by 

providing medical records only paper reviews, which selectively review, ignore and/or 

minimize evidence of disability such as occurred in Plaintiff’s claim, in order to provide 

opinions and report(s) which are favorable to MES and/or Aetna and which supported the 

denial of her STD and LTD claims. 

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31. In evaluating Plaintiff’s STD and LTD claims on appeal, Aetna had an 

obligation pursuant to ERISA to administer them “solely in her best interests and other 

participants” which it failed to do. 1

 

32. Aetna failed to adequately investigate and failed to engage Plaintiff in a 

dialogue during the appeal of her STD and LTD claims with regard to what evidence was 

necessary so Plaintiff could perfect her appeal and claims. Aetna’s failure to investigate her 

claims and to engage in this dialogue or to obtain the evidence that it believed was 

important to perfect Plaintiff's claims violates ERISA as well as Ninth Circuit case law, and 

is a reason she did not receive a full and fair review. 

33. Plaintiff alleges Aetna provided an unlawful review which was neither full 

nor fair and that violated ERISA, specifically, 29 U.S.C. § 2560.503-1, by failing to 

adequately investigate her claims because its and/or MES’s reviewing medical professionals 

were not truly independent or impartial; failing to request or obtain an Independent Medical 

Examination so it could better understand Plaintiff’s disabling medical diagnoses and 

limitations when the Plan(s) allowed it to obtain one; failing to credit Plaintiff’s reliable 

evidence; providing one sided reviews of Plaintiff’s claim that failed to consider all the 

evidence submitted by her and/or de-emphasizing medical evidence which supported 

Plaintiff’s claims; disregarding Plaintiff’s self-reported symptoms; failing to consider all the 

 

1

 It sets forth a special standard of care upon a plan administrator, namely, that the 

administrator "discharge [its] duties" in respect to discretionary claims processing "solely 

in the interests of the participants and beneficiaries" of the plan, § 1104(a)(1); it 

simultaneously underscores the particular importance of accurate claims processing by 

insisting that administrators "provide a 'full and fair review' of claim denials," Firestone, 

489 U.S., at 113, 109 S. Ct. 948, 103 L. Ed. 2d 80 (quoting § 1133(2)); and it 

supplements marketplace and regulatory controls with judicial review of individual claim 

denials, see § 1132(a)(1)(B). Metro. Life Ins. Co. v. Glenn, 128 S. Ct. 2343, 2350 (U.S. 

2008). 

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diagnoses and/or limitations set forth in her medical evidence as well as the impact the 

combination of those diagnoses and impairments would have on her ability to work in her 

“Own Occupation” and “Any Reasonable Occupation” as those terms are defined in the 

Plans; failing to engage Plaintiff in a dialogue so she could respond to Aetna’s doctors’ 

reports by submitting the necessary evidence to perfect her claims particularly since she was 

not represented by counsel during Aetna’s review; and failing to consider the impact the 

side effects of Plaintiff's medications would have on her ability to engage in any occupation. 

34. Plaintiff alleges a reason Aetna provided an unlawful review which was 

neither full nor fair and that violated ERISA, specifically, 29 U.S.C. § 2560.503-1, is due to 

its conflict of interest that manifested as a result of the dual roles Aetna undertook as the 

decision maker and payor of benefits. Aetna’s conflict of interest provided it with a 

financial incentive to deny Plaintiff’s claims because when it denied them, Aetna saved a 

significant amount of money. 

35. Plaintiff is entitled to discovery regarding Aetna’s aforementioned conflicts of 

interest and the potential conflicts of interest of any third party vendor, such as MES, and 

any medical professional who was involved in the review of her claims. The Court may 

properly weigh and consider extrinsic evidence regarding the nature, extent and effect of 

any conflict of interest and/or ERISA procedural violation which may have impacted or 

influenced Aetna’s decision to deny Plaintiff’s claims. 

36. With regard to whether Plaintiff meets the definitions of disability set forth in 

the STD and LTD Plans, the Court should review the evidence in Plaintiff’s claims de novo, 

because even if the Court concludes the Plans confer discretion, the unlawful violations of 

ERISA committed by Aetna as referenced herein are so flagrant they justify de novo review. 

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37. As a direct result of Aetna’s decision to terminate Plaintiff’s STD claim 

(benefits) and LTD claim, she has been injured and suffered damages in the form of lost 

STD and LTD benefits, in addition to other potential employee non-disability benefits she 

may have been entitled to receive through or from the Plans, from any other Aetna Plan 

and/or Aetna as a result of being found disabled. Plaintiff believes other potential nondisability employee benefits may include but not be limited to, health and other insurance 

related coverage or benefits, retirement benefits or a pension, life insurance coverage and/or 

the waiver of the premium on a life insurance policy providing coverage for her and her 

family/dependents. 

38. Pursuant to 29 U.S.C. §1132, Plaintiff is entitled to recover unpaid STD 

and LTD benefits, prejudgment interest, reasonable attorney's fees and costs from 

Defendants. 

39. Plaintiff is entitled to prejudgment interest at the legal rate pursuant to A.R.S. 

§20-462, or at such other rate as is appropriate to compensate her for losses she incurred 

as a result of Aetna’s nonpayment of benefits. 

 WHEREFORE, Plaintiff prays for judgment as follows: 

 A. For an Order finding the evidence in Plaintiff’s STD claim is sufficient to 

prove that she meets the “Own Occupation” definition of disability set forth in the STD 

Plan and that she is entitled to the remaining STD benefits she was not paid, along with 

other non-disability employee benefits she may be entitled to as a result of that Order, 

from the date she was first denied these STD benefits through the maximum date STD 

benefits are payable pursuant to the STD Plan with prejudgment interest thereon; 

 B. For an Order finding the evidence in Plaintiff’s LTD claim is sufficient to 

prove that she meets the “Own Occupation” definition of disability in the LTD Plan and 

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that she is entitled to these benefits, along with other non-disability employee benefits she 

may be entitled to as a result of that Order, from the date she was first denied these LTD 

“Own Occupation” benefits through the maximum date those benefits are payable 

pursuant to the LTD Plan with prejudgment interest thereon; 

C. Assuming the issue is ripe before the Court (i.e. the 30 month “Own 

Occupation” definition of disability and timeframe set forth in the STD and LTD Plans has 

expired), Plaintiff seeks an Order that she is disabled and meets the “Any Reasonable 

Occupation” definition of disability set forth in the LTD Plan and that she is entitled to 

these benefits from the date she is first eligible for them through the date of the Order with 

prejudgment interest thereon; 

 D. Alternatively, if the “Any Reasonable Occupation” issue is not ripe before the 

Court at the time of adjudication because the “Own Occupation” timeframe in the LTD Plan 

has not expired, or the timeframe has expired but the Court decides it is unable to make an 

“Any Reasonable Occupation” determination for any reason, then Plaintiff seeks an Order 

remanding the issue to the Plan Administrator so it can offer her an administrative review 

where she is afforded the opportunity to submit new and additional evidence in order for it 

to determine whether she meets the “Any Occupation” definition of disability in the LTD 

Plan; 

 E. Alternatively, if Aetna argues and/or the Court determines that Plaintiff has 

not exhausted her administrative remedies in her LTD claim pursuant to the LTD Plan, she 

seeks a remand to the Plan Administrator so it can offer her an administrative review where 

she is afforded the opportunity to submit new and additional evidence so it may determine 

whether she is entitled to any LTD benefits; 

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 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 and further relief as the Court deems just and proper. 

 

DATED this 4th day of February, 2016. 

 SCOTT E. DAVIS. P.C.

 By: /s/ Scott E. Davis 

 Scott E. Davis 

 Attorney for Plaintiff

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