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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 Hope Hall 

UNITED STATES DISTRICT COURT 

DISTRICT OF ARIZONA 

Hope Hall, 

 Plaintiff, 

 v. 

Aetna Life Insurance Company; Progressive 

Casualty Insurance Company; Progressive 

Casualty Insurance Company Disability Plan, 

 Defendants. 

Case No. 

COMPLAINT 

 

 Now comes the Plaintiff Hope Hall (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 Maricopa County, Arizona. 

3. Upon information and belief, Progressive Casualty Insurance Company 

(hereinafter referred to as the “Company”) sponsored, administered and purchased a group 

long-term disability insurance policy which was fully insured by Aetna Life Insurance 

Company (hereinafter referred to as “Aetna”). The specific Aetna long term disability 

group insurance policy is known as Group Policy No.: GP-468594 (hereinafter referred to 

as the "Policy"). The Company’s purpose in sponsoring, administering and purchasing the 

Policy was to provide long term disability insurance for its employees. Upon information 

and belief, the Aetna Policy may have been included in and part of an employee benefit 

plan, specifically named the Progressive Casualty Insurance Company Disability Plan 

(hereinafter referred to as the “Plan”) which may have been created to provide the 

Company’s employees with welfare benefits. At all times relevant hereto, the Plan 

constituted an “employee welfare benefit plan” as defined by 29 U.S.C. §1002(1). 

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

the Policy; however, pursuant to the relevant ERISA regulation, the Company and/or the 

Plan may not have made a proper delegation or properly vested fiduciary authority or power 

for claim administration in Aetna. 

5. Aetna operated under a conflict of interest in evaluating her long-term 

disability claim due to the fact that it operated in dual roles as the decision maker with 

regard to whether Plaintiff was disabled as well as the payor of benefits. Aetna’s conflict 

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existed in that if it found Plaintiff was disabled, it was then liable for the payment of her 

disability benefits. 

6. The Company, Aetna and the Plan conduct business within Maricopa County 

and all events giving rise to this Complaint occurred within Arizona. 

Venue 

7. 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 

8. Incident to her employment, Plaintiff was a covered employee pursuant to 

the Plan and the relevant Policy 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 

the Plan and the relevant Policy pursuant to §502(a)(1)(B) of ERISA, 29 U.S.C. 

§1132(a)(1)(B), as well as any other non-disability employee benefits she may be entitled to 

from the Plan and any other Company Plan, as a result of being found disabled in this 

action. 

Assuming the issue is ripe before the Court at the time of adjudication (i.e. the “Own 

Occupation” timeframe in the Plan and Policy has expired and the relevant definition of 

disability in the Policy is that Plaintiff must be disabled from “Any Occupation” to obtain 

benefits), Plaintiff also seeks a determination that she is disabled and meets the “Any 

Occupation” definition of disability set forth in the Plan and the relevant Policy as all the 

evidence she submitted to Aetna and which is in the Administrative Record supports such a 

determination by the Court. 

9. After working for the Company as a loyal employee, Plaintiff became 

disabled on or about December 24, 2014, due to serious medical conditions and was unable 

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to work in her designated occupation as a Customer Service Supervisor. Plaintiff has 

remained disabled as that term is defined in the relevant Policy continuously since that date 

and has not been able to return to any occupation as a result of her serious medical 

conditions. 

10. Following her disability, Plaintiff filed a claim for short-term disability 

benefits which was approved by the Company, and those benefits have been paid and 

exhausted. 

11. Upon information and belief, the short-term disability Plan contained only an 

“Own Occupation” definition of disability. The fact that the short-term disability Plan 

contained a similar definition of disability as is set forth in the Aetna Policy and a different 

entity approved Plaintiff’s short-term disability claim, is relevant evidence for this Court to 

consider with regard to the unreasonableness of Aetna’s decision to deny her long-term 

disability claim. The approval of Plaintiff’s short-term disability claim by another entity is 

evidence that Aetna’s unreasonable and unlawful denial of her long-term disability claim 

was influenced by its conflict of interest and its desire to save money. 

12. Following the exhaustion of her short-term disability benefits, Plaintiff then 

filed for long-term disability benefits under the relevant Policy which was administered by 

Aetna and it made decision in Plaintiff’s long-term disability claim, which was to deny it. 

13. Upon information and belief, the relevant Aetna Policy and definition of 

disability governing Plaintiff’s long term disability claim is as follows: 

“Test of Disability: 

From the date that you first became disabled and until monthly 

benefits are payable for 24 months you meet the test of 

disability on any day that: 

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-You cannot perform the material duties of your own 

occupation solely because of an illness, injury or disabling 

pregnancy related condition; and 

-Your work earnings are 80% or less of your adjusted 

predisability earnings. 

After the first 24 months of your disability that monthly 

benefits are payable, you meet the plan’s test of disability on 

any day you are unable to work at any reasonable occupation 

solely because of an illness, injury or disabling pregnancyrelated condition.” 

14. In support of her claim for long-term disability benefits, Plaintiff submitted to 

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

disability as defined in the relevant Policy. 

15. In a letter dated April 10, 2015, Aetna informed Plaintiff it was denying her 

claim for long-term disability benefits. 

16. Pursuant to 29 U.S.C. §1133, Plaintiff timely appealed Aetna’s April 10, 2015 

denial of her disability claim. 

17. In support of her appeal and claim for long term disability benefits, Plaintiff 

submitted to Aetna additional medical, vocational and lay witness evidence demonstrating 

that she met any definition of disability set forth in the Policy. 

18. Plaintiff submitted to Aetna a July 22, 2015 narrative letter authored by her 

board certified treating physician who opined, “I believe it is reasonable to assume that 

[Plaintiff] has been unable to work in any occupation since December 24, 2014 and this will 

continue indefinitely.” 

19. Plaintiff also submitted to Aetna a July 24, 2015 narrative letter authored by 

another treating physician who opined, “I believe that [Plaintiff] is not able to work in any 

full-time occupation, even at home, due primarily to her physical medical conditions.” 

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20. Plaintiff also submitted to Aetna a Functional Capacity Evaluation report 

dated June 5, 2015, wherein after an extensive several hour evaluation, a qualified physical 

therapist determined, “...[Plaintiff] would not be able to function at a sedentary work 

category.” (original emphasis). 

21. Further supporting her claim, Plaintiff submitted a vocational report from a 

certified vocational expert dated August 19, 2015, who after reviewing Plaintiff’s medical 

evidence and the definition of disability and interviewing Plaintiff concluded, “From a 

vocational perspective, [Plaintiff] is unable to engage in any employment that may exist in 

the national economy and fully meets the criteria set forth in her disability policy.” 

22. Plaintiff also submitted a complete copy of her short term-disability claim file 

from the Company containing the information and medical evidence the Company relied on 

in approving her short term disability claim. 

23. Plaintiff also submitted updated medical records from each of her treating 

providers and a list of her current medications, as well as the side effects they cause and the 

impact they would have on her ability to work in any work environment. 

24. In addition to the medical records and reports submitted to Aetna, Plaintiff 

submitted two sworn affidavits from her husband and her mother, who both confirmed 

Plaintiff is unable to work in any occupation and that her medical condition has not 

improved in any way since her date of disability. 

25. Plaintiff also submitted a sworn affidavit of her own explaining her medical 

conditions and the impact they have on her activities of daily living which also confirmed 

her inability to work in her previous occupation and in any occupation. 

26. As part of its review of Plaintiff’s claim for long term disability benefits, 

Aetna obtained medical records only "paper reviews" of Plaintiff’s claim from two 

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physicians of its choosing; however, through the present date Aetna has never disclosed to 

Plaintiff the names of these doctors or the reviews/reports the authored. 

27. Upon information and belief, Plaintiff alleges the reviewing physicians may 

be long time medical consultants for the disability insurance industry and/or Aetna. As a 

result, Plaintiff alleges the physicians may have an incentive to protect their own consulting 

relationships with the disability insurance industry and/or Aetna by providing medical 

records only paper reviews, which selectively review or ignore evidence such as occurred in 

Plaintiff’s claim, in order to provide opinions and report(s) which are favorable to insurance 

companies and which supported the denial of Plaintiff’s claim. 

28. In letters dated September 18, 2015 and October 19, 2015, in order to engage 

Aetna in a dialogue so she could perfect any alleged deficiencies in her claim, Plaintiff 

requested a complete copy of any and all medical records only “paper reviews” from Aetna 

and the opportunity for her and her treating physicians to provide responses to the reviews 

prior to Aetna rendering a determination in her claim. 

29. Prior to rendering its final denial in Plaintiff’s claim, Aetna never shared with 

Plaintiff its medical records only “paper reviews” authored by the reviewing physicians so 

she could respond to the reports and/or perfect her claim. Aetna’s failure to provide 

Plaintiff with the opportunity to respond to its reviewing physicians’ reports is an ERISA 

procedural violation and precluded a full and fair review. Aetna’s action in failing to 

disclose these reports also violates Ninth Circuit case law. 

30. In a letter dated November 11, 2015, Aetna notified Plaintiff it had denied her 

claim for long-term disability benefits under the Policy and that she had exhausted her 

administrative levels of review and could file a civil action lawsuit in federal court pursuant 

to ERISA. 

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31. Upon information and belief, Aetna’s November 11, 2015 denial letter 

confirms it failed to provide a full and fair review, and in the process it committed numerous 

procedural violations pursuant to ERISA. 

32. In evaluating Plaintiff’s claim, Aetna had an obligation pursuant to ERISA to 

administer it, “solely in her best interests and other participants” which it failed to do. 1

 

33. Aetna failed to adequately investigate Plaintiff’s claim and failed to engage 

her in a dialogue during the appeal of her claim with regard to what evidence was necessary 

so she could perfect her appeal and claim. Aetna’s failure to investigate the claim and 

engage Plaintiff in a dialogue, or to ask her for or to obtain the evidence it believed was 

necessary to perfect the claim is a violation of ERISA and Ninth Circuit case law and a 

reason she did not receive a full and fair review. 

34. 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 claim because its examining and reviewing medical professionals 

were not truly independent; by failing to credit Plaintiff’s reliable evidence; by 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 claim; by 

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

 

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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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; by failing to engage 

Plaintiff in a dialogue so she could respond to Aetna’s doctors’ reports by submitting the 

necessary evidence to perfect her claim and failing to consider the impact the side effects 

from Plaintiff's medications would have on her ability to engage in her won and in any 

occupation. 

35. Plaintiff alleges the 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 the payor of benefits. Aetna’s conflict of interest provided it with a 

financial incentive to deny Plaintiff’s claim, thereby saving itself money. 

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

interest and any individual who reviewed her claim and 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 her claim. 

37. With regard to whether Plaintiff meets the both the “own” and “any” 

occupation definitions of disability set forth in the Policy, the Court should review the 

evidence de novo, because even if the Court concludes the policy confers discretion, the 

unlawful violations of ERISA committed by Aetna as referenced herein are so flagrant they 

justify de novo review. 

38. As a direct result of Aetna’s decision to deny Plaintiff’s disability claim, she 

has been injured and suffered damages in the form of lost long-term disability benefits, in 

addition to losing other potential non-disability employee benefits she may have been 

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entitled to receive through or from the Plan, from any other Company Plan and/or the 

Company if Aetna had found that she was disabled and entitled to benefits. Plaintiff 

believes other potential non-disability 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 any premiums due on a life insurance policy which 

may provide coverage for her and her family/dependents. 

39. Pursuant to 29 U.S.C. §1132, Plaintiff is entitled to recover unpaid benefits, 

prejudgment interest, reasonable attorney's fees and costs from Defendants. 

40. 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 Defendants’ nonpayment of benefits. 

 WHEREFORE, Plaintiff prays for judgment as follows: 

 A. For an Order finding that Plaintiff is disabled and meets the definition of 

disability for the “Own Occupation” as defined in the relevant Plan and Policy and that 

she is entitled to all of those benefits due, and that she is also entitled to any other nondisability employee benefits that may be due as a result of being found disabled from the 

date she was first denied all of these benefits through the date of judgment, with 

prejudgment interest payable thereon; 

 B. Assuming the issue is ripe before the Court at the time of adjudication (i.e. the 

“Own Occupation” timeframe in the Plan and Policy has expired and Plaintiff’s claim has 

entered into the “Any Occupation” timeframe), for an Order that Plaintiff also meets the 

“Any Occupation” definition of disability set forth in the relevant Plan and Policy and that 

she is entitled to all of those benefits due as well as any other non-disability employee 

benefits she may be entitled to as a result of meeting this definition of disability, from the 

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date she was first entitled to these benefits through the date of judgment with 

prejudgment interest payable thereon; 

 C. For an Order directing Defendants to continue paying Plaintiff the all 

aforementioned benefits set forth in Plaintiff’s Prayer for Relief until such time as she meets 

the conditions for the termination of these benefits; 

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

pursuant to 29 U.S.C. §1132(g); and 

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

 

DATED this 23rd day of December, 2015. 

 SCOTT E. DAVIS. P.C.

 By: /s/ Scott E. Davis 

 Scott E. Davis 

 Attorney for Plaintiff

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