Court Opinion

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Date Created: 2015-10-13 22:41:32.649535+00
Date Added: 2024-06-11T14:56:51.541577
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Opinions of the United
2007 Decisions                                                                                                             States Court of Appeals
                                                                                                                              for the Third Circuit

4-17-2007

Gambino v. Arnouk
Precedential or Non-Precedential: Non-Precedential

Docket No. 05-5422

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Recommended Citation
"Gambino v. Arnouk" (2007). 2007 Decisions. Paper 1279.
http://digitalcommons.law.villanova.edu/thirdcircuit_2007/1279

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                                                         NOT PRECEDENTIAL

                      UNITED STATES COURT OF APPEALS
                           FOR THE THIRD CIRCUIT

                                      No. 05-5422

                  ANTHONY GAMBINO; DANIELLE GAMBINO

                                           v.

              M.D. MUNZER ARNOUK; LIBERTY LIFE ASSURANCE
                          COMPANY OF BOSTON

                                      Liberty Life Assurance Company of Boston,

                                                         Appellant.

                   On Appeal from the United States District Court
                           for the District of New Jersey
                               (D.C. No. 03-cv-01611)
                      District Judge: Hon. Faith S. Hochberg

                             Argued on March 26, 2007

                Before: FISHER, JORDAN and ROTH, Circuit Judges

                            (Opinion filed April 17, 2007 )

Paul R. Rizzo, Esquire (ARGUED)
DiFancesco, Bateman, Coley, Yospin,
Kunzman, Davis & Lehrer
15 Mountain Boulevard
Warren, NJ 07059

             Counsel for Appellees Anthony and Danielle Gambino
Robert J. Mormile, Esquire (ARGUED)
Farkas & Donohue, LLC
389 Passaic Avenue
Fairfield, NJ 07004

              Counsel for Appellee Arnouk

Patricia A. Smith, Esquire (ARGUED)
Edward T. Groh, Esquire
Ballard, Spahr, Andrews & Ingersoll
Plaza 1000
Suite 500, Main Street
Voorhees, NJ 08043

              Counsel for Appellant Liberty Life Assurance
              Company of Boston

                                      OPINION

ROTH, Circuit Judge:

       Anthony Gambino was denied short-term disability benefits by his insurance provider.

He brought suit to recover benefits due pursuant to 29 U.S.C. § 1132(a)(1)(B). The District

Court awarded Gambino the short-term disability benefits for which he had applied, as well

as an opportunity to apply for long-term disability benefits, which he had never done. For

the reasons set forth below, the judgment of the District Court will be reversed in part and

vacated in part, and remanded for further proceedings consistent with the dictates of this

opinion.

                                             2
I. Background

       In March 2001, Gambino, a New Jersey resident, was employed as a sales manager

at IKON Office Solutions, Inc. IKON provided its employees with short-term disability

(STD) and long-term disability (LTD) plans. Gambino participated in both plans, which

were in effect in March 2001. In April, 2001, he applied for STD benefits. His claim was

denied, as was his appeal. He never applied for LTD benefits.

       A. Disability Policies

       Liberty Life Insurance Company of Boston (Liberty) insured and administered the

STD plan, pursuant to a Liberty policy purchased by IKON, and provided claims

administration services for the LTD plan, which was self-funded by IKON. When an IKON

employee applied for STD benefits, Liberty both evaluated the claim and paid the benefits

with its own funds. Liberty’s decisions regarding claims brought under the STD plan were

conclusive and binding.

       In contrast, IKON was the sponsor, insurer, and administrator of the LTD plan.

Liberty was responsible for processing LTD claims, but IKON retained the authority to

overrule Liberty’s determinations. Benefits were paid by IKON, not Liberty.

       Under both policies, a claimant was required to make the same showing to establish

disability. When Liberty or IKON, as relevant, received proof that a covered person was

disabled due to injury or sickness and required the regular attendance of a physician, Liberty

or IKON would pay the covered person periodic benefits upon conclusion of an elimination

                                              3
period during which disability had to be established but no benefits would be paid.

“Disability” was defined under both policies to mean that the covered person had to be

unable to perform all of the material and substantial duties of his or her occupation on an

active employment basis because of an injury or sickness. The proof furnished had to

establish the date on which the disability started, as well as the cause and degree of the

disability. Under the STD policy, Liberty had sole authority to interpret the terms of the

policy, and its decisions regarding the construction of the contract were conclusive and

binding. Under the LTD policy, Liberty’s determinations could be overruled by IKON.

       As the names suggest, the main difference between the two policies (besides the role

of IKON) was the duration of coverage. STD claims were for short-term benefits, up to 26

weeks, with an elimination period of two weeks. LTD claims were for long-term benefits,

with the standard for proving disability heightening after 24 months, and an elimination

period of six months. The difference between the lengths of the elimination periods meant

that a covered person seeking STD benefits had to prove disability within a narrow two-week

window, whereas a covered person seeking LTD benefits could prove disability lasting over

a six-month period.

       B. Gambino’s Claim

       Gambino left work at IKON on March 9, 2001, after suffering a panic attack. On

April 5, 2001, Gambino contacted Liberty to initiate a claim for STD benefits. Under the

terms of his policy, it was Gambino’s obligation to provide Liberty with proof of his

                                            4
disability during the elimination period and the benefit period. Gambino provided Liberty

with the name of only one health care provider — his primary care physician, Dr. Munzel

Arnouk — and by April 16, 2001, Liberty had received no further information regarding the

claim. Liberty repeatedly contacted Dr. Arnouk’s office to seek Gambino’s medical records

but received no response. On April 18, Liberty called Gambino to seek records and faxed

to Dr. Arnouk several forms for him to complete and return with copies of his records.

Liberty reminded Gambino of the terms of his policy and informed him that he had until July

2, 2001, to provide the necessary information. No new information came. On July 3, 2001,

Liberty determined that Gambino’s STD claim should be denied for failure to provide

medical proof of the claimed disability.

       On July 9, 2001, Liberty received a short fax from Dr. Arnouk, which consisted of a

certification of physician form, dated June 24, and an undated attending physician’s

statement.   These forms contained short diagnostic statements but did not include any

observations about Gambino’s objective symptoms. Dr. Arnouk did not provide any records

of Gambino’s office visits.1 Dr. Arnouk’s submission provided Liberty with a limited

amount of additional information, including a short diagnosis of “severe anxiety reaction

with depression and psychological set back” and an opinion that Gambino was unable to

return to work. These forms also established that Dr. Arnouk was an internist who referred

   1
    Item 9 of the Attending Physician’s Statement form specifies that the doctor must attach
“[o]ffice notes for the period of treatment” and “[t]est results showing objective findings.”

                                             5
Gambino for psychiatric care.     Finally, and somewhat confusingly, Dr. Arnouk listed

Gambino’s condition as having started a week before Gambino left work.

       Within several days of receiving the forms from Dr. Arnouk, Liberty received a fax

from Dr. Jean Ying-Chang, a psychiatrist at Saint Clare’s Behavioral Health Center, where

Gambino was being treated. She stated that Gambino’s diagnosis was “Social Phobia, Major

Depressive Disorder, r/o Bipolar Disorder” and provided answers to those questions on the

certification of physician form which Dr. Arnouk had left blank. In particular, Dr. Ying-

Chang represented that Gambino was unable to perform work of any kind as of March 27,

2001. Upon receipt of this information from Drs. Arnouk and Ying-Chang, Liberty notified

Gambino that it was reopening his claim.

       None of this information included actual copies of medical records, which Liberty

maintains are necessary so that it can independently verify the conclusions drawn by the

treating doctors. Liberty therefore requested copies of the office records necessary to

supplement the information it had already received.      Liberty later discovered, though

apparently not until the litigation process, that Dr. Arnouk had kept no records of treating

Gambino and therefore had no office records. Despite Liberty’s repeated requests for office

records, Dr. Arnouk never informed Liberty or Gambino that no office records existed.

       Liberty did manage to collect significant additional information about Gambino’s

treatment at Saint Clare’s Behavioral Health Center, including some office records. A brief

notation in the record revealed that after Gambino saw Dr. Arnouk on March 9, 2001, his

                                             6
next medical visit was to a Dr. Tintea at St. Clare’s, on March 27, 2001. Liberty never

received any documentation of this visit, though other records from Saint Clare’s indicated

that Dr. Tintea performed an initial intake and prescribed medication. Gambino also saw

M arion Robinson, a clinician who performed a psychiatric evaluation. According to this

evaluation, Gambino had experienced irritability and feelings of depression over the previous

one-and-a-half to two years.    The evaluation also provided Liberty with clinical notes

describing Gambino’s condition, which is described as “irritable, constricted, and tense,”

with “notable flight of ideas.” Records also described Gambino’s panic symptoms in detail.

       At Liberty, registered nurse Barbara McGivern and claims administrator Monica Dube

reviewed the file. Nurse McGivern recommended that the claim be denied and expressed her

reasons in internal notes. She expressed some confusion about “what changed” on March

9, 2001, to render Gambino disabled, since his condition was listed by Dr. Arnouk as starting

on March 2, and reports from Saint Clare’s suggested that he had been experiencing

problems of a similar nature for a year and a half. Because Dr. Arnouk provided no office

notes and no rationale for his medical decisions, Nurse McGivern felt that she was unable

to evaluate Gambino’s condition during the month of March (during which the entirety of

the elimination period ran). Moreover, because Dr. Arnouk indicated that he was seeing

Gambino on a weekly basis, Nurse McGivern assumed that a series of office records would

be available.   She was unable to determine much of anything regarding Gambino’s

appointment with Dr. Tintea on March 27, 2001, since no records of this visit were in the

                                             7
file. Monica Dube agreed with Nurse McGivern that the claim should be denied on the basis

of insufficient medical information.

       On August 14, 2001, Liberty issued to Gambino a determination letter in which it

explained that it was denying his claim for STD benefits because he had submitted

insufficient supporting documentation. Liberty explained that, although it had received

documentation relating to Gambino’s treatment at Saint Clare’s, this documentation did not

relate back to start of the elimination period. Liberty also informed Gambino of his rights,

including the right to appeal, under the Employee Retirement Income Security Act (ERISA).

On August 20, 2001, Gambino appealed his claim and assured Liberty that it would receive

all the information it needed as soon as possible.

       Liberty allowed Gambino until September 12, 2001, to supply the necessary

information from Dr. Arnouk. The information never arrived. On October 1, 2001, Liberty

informed Gambino that it was maintaining its original decision to deny benefits and closing

his file. The same day, Liberty sent a letter informing IKON that Gambino’s claim for STD

benefits had been denied. On November 9, 2001, IKON contacted Gambino and informed

him that it had learned that his STD claim had been denied retroactive to March 9, 2001, and

that he would be required to return to work on November 19, 2001. Gambino did not return

to IKON and was terminated in December 2001. Gambino never applied for LTD benefits.

       C. District Court Review

       Gambino and his wife, Danielle, brought suit in the District of New Jersey against

                                               8
Liberty, alleging violations of ERISA that caused the loss of both STD and LTD benefits,

and against Dr. Arnouk, claiming that his office’s failure to supply information caused

Liberty to deny Gambino’s claim. Judge Hochberg presided over a bench trial at which she

heard testimony from Gambino and his wife, Dr. Arnouk, and Harriett Michael, the case

manager at Liberty who handled Gambino’s appeal. During theGambinos’ and Dr. Arnouk’s

testimony, counsel for Liberty frequently objected that the witnesses were providing

testimony as to facts that were not in the administrative record, upon which Liberty based its

denial of STD benefits, and which were not otherwise permissibly relevant.

       At the conclusion of the bench trial, the District Court dismissed the suit against Dr.

Arnouk, finding inconclusive proof of liability. Gambino v. Liberty Life Assurance

Coompany of Boston, 2005 WL 4839146, at *1 (D.N.J. 2005). The District Court found

Liberty’s denial of Gambino’s STD claim to be “arbitrary and capricious” and awarded

Gambino STD benefits pursuant to 29 U.S.C. § 1132(a)(1)(B), in the amount of $22,749.13.

Id. at *8. The District Court also found that Gambino “could not have been expected to have

applied for” LTD benefits after being denied STD benefits, as it was “entirely foreseeable”

that a denial of STD benefits “would likely cause a beneficiary to assume that an LTD claim

would be futile.” Id. at *9. Because the District Court found that Liberty had violated the

provisions of ERISA by denying Gambino’s STD claim in an arbitrary and capricious

manner, the court determined that Gambino was also entitled to equitable relief with respect

to his request for LTD benefits. Id. As an equitable remedy, the court ordered Liberty,

                                              9
which had the authority to process claims for LTD benefits, to process Gambino’s claim for

LTD benefits as if it had been timely filed and to make a recommendation to IKON

following the usual and customary procedures for evaluating LTD claims. Id. The District

Court did not explain what effect its ruling would have on IKON, a non-party to the suit,

which serves as the insurer for the LTD plan and would be responsible for making any LTD

benefit payments to Gambino.

III. Jurisdiction

       Liberty timely appealed the order of the District Court. The District Court had subject

matter jurisdiction over this case pursuant to 29 U.S.C. § 1132(e). We have appellate

jurisdiction pursuant to 28 U.S.C. § 1291.

IV. Discussion

    A. STD Benefits

       When a claims fiduciary has discretionary authority to determine eligibility for

benefits, we employ an arbitrary and capricious standard of review in reviewing a denial by

that fiduciary of a request for benefits under an ERISA-regulated plan. Firestone Tire &

Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989). Under the arbitrary and capricious standard,

we may overturn a fiduciary’s decision “only if it is without reason, unsupported by

substantial evidence or erroneous as a matter of law.” McLeod v. Hartford Life and Acc. Ins.

Co., 372 F.3d 618, 623 (3d Cir. 2004). Where the entity with discretionary authority to

determine eligibility for benefits is also the entity that will be paying the benefits, we

                                             10
recognize this structural conflict of interest by employing a “heightened” arbitrary and

capricious standard of review. Pinto v. Reliance Standard Life Ins. Co., 214 F.3d 377, 392.

We have adopted a “sliding scale” approach under which arbitrary and capricious review is

a range, not a point, and our review is more or less probing depending on the degree of

conflict present. Id. at 392-93. Nonetheless, the ultimate burden to establish that the claim

determination was improper remains with the beneficiary. Id. at 392. In determining the

degree of the conflict, we look not only to the ultimate decision, but also to the process by

which the result was achieved. Id. at 393.

       The District Court correctly summarized this law, but it did not determine where

within the range of arbitrary and capricious review Gambino’s case fell. Indeed, the District

Court never explicitly discussed Liberty’s degree of conflict. Thus, when it determined that

Liberty’s determination was “arbitrary and capricious,” it did not specify the level of scrutiny

that Liberty had faced. This was error.

       The correct standard of review in this case is a deferential one, only slightly

heightened by Liberty’s structural conflict. Liberty made repeated attempts to supplement

Gambino’s file with the medical information it needed. Moreover, once it obtained some

information, it reopened his file. The District Court intimates that evidence of a heightened

conflict might be present because “Liberty seized upon any possible basis to ignore the ample

and strong evidence of psychiatric disability.”     2005 WL 4839146, at *8 n.11. Strict

application of an insurer’s policies, without more, is not evidence of a heightened conflict;

                                              11
if lack of sufficient documentation relating to the two-week elimination period is an adequate

basis for denial under the STD policy, then a denial on that basis cannot be evidence of a

heightened conflict.

         Moreover, by engaging in de novo factfinding, the District Court committed clear

error which infected its review of the case. In Lasser v. Reliance Standard Life Ins. Co., we

held that “de novo factfinding is improper in reviewing a claims administrator’s decision

under the arbitrary and capricious standard of review.” 344 F.3d 381, 385 n.3 (3d Cir. 2003).

The District Court’s factual findings are a pastiche of evidence drawn from the

administrative record and testimony provided at the bench trial. The District Court relied on

trial testimony to make findings regarding, inter alia, Gambino’s panic attack at work, visit

to Dr. Arnouk, termination from IKON, attempts to work in 2002, and continued psychiatric

care. 2005 WL 4839146, at *5. M ore surprisingly, the District Court found it relevant to

comment upon Gambino’s demeanor at trial, which “showed aberrant agitation and highly

unusual affect.” It is clear that the District Court did not base its decision on the record that

was before Liberty when Liberty denied the claim. Moreover, Gambino had the burden of

establishing disability.2

     2
      Neither was Liberty obligated to inquire into Gambino’s work-related duties. The
District Court relied on Quinn v. Blue Cross and Blue Shield Ass’n, 161 F.3d 472 (7th Cir.
1998), to suggest that an insurer’s failure to make such an inquiry is per se arbitrary and
capricious. Quinn supports no such conclusion. In Quinn, the insurer made an affirmative
determination that the beneficiary could perform her duties, even though the insurer did not
know what those duties were. 161 F.3d at 476. The Seventh Circuit found such action by
the insurer to be arbitrary and capricious. Gambino’s case is quite different. Liberty found

                                               12
       The District Court erred by collecting information which Liberty did not have in the

record before it and by deciding the case on that expanded record. We will therefore vacate

the District Court’s award of STD benefits and remand this case for further proceedings –

i.e., a largely deferential review of the administrative record that was before Liberty when

it made its decision.

       B. LTD Benefits

       The District Court’s equitable remedy of granting Gambino an opportunity to pursue

his LTD is legally unsupportable. We will reverse the judgment as to that claim. As an

initial matter, IKON retains final authority to determine whether Gambino is entitled to LTD

benefits, and IKON is the party obligated to pay any LTD benefits due. IKON, however, is

not a party to this suit. We therefore approach with skepticism an equitable “remedy” which,

in reality, is likely to remedy nothing.

       More importantly, Gambino never filed a claim with Liberty for LTD benefits.

Except in limited circumstances, a federal court will not entertain an ERISA claim unless the

plaintiff has exhausted the remedies available under the plan. Harrow v. Prudential Ins. Co.

of America, 279 F.3d 244, 249 (3d Cir. 2002); Weldon v. Kraft, Inc., 896 F.2d 793, 800 (3d

that Gambino had not provided sufficient evidence to establish disability during the
elimination period. Liberty denied Gambino’s claim because it lacked sufficient medical
evidence regarding his condition. Without knowing the details of Gambino’s condition,
Liberty could not go on to the next step of determining whether that condition rendered him
unable to perform his duties, whatever those duties might have been. Liberty’s lack of
knowledge regarding Gambino’s specific duties was therefore irrelevant.

                                             13
Cir. 1990). The exhaustion requirement serves a number of important policy interests,

including helping reduce the number of frivolous lawsuits under ERISA, promoting

consistent treatment of claims, providing a nonadversarial method to settle claims, and

minimizing costs of settlement. Harrow, 279 F.3d at 249. Gambino’s failure to seek LTD

benefits in the first place surely qualifies as a failure to exhaust. Thus, if Gambino is to find

a remedy under ERISA, he must demonstrate that his failure to exhaust falls within an

exception to the exhaustion requirement.

       A plaintiff is excused from exhausting his remedies if it would be futile to do so. Id.;

Berger v. Edgewater Steel Co., 911 F.2d 911, 916 (3d Cir. 1990). The law is clear that the

plaintiff must show, by making a “clear and positive showing of futility,” that it would have

been actually futile to pursue the claim. Harrow, 279 F.3d at 249 (citation omitted). In

Harrow, we quoted the Sixth Circuit as holding that “[a] plaintiff must show that it is certain

that his claim will be denied on appeal, not merely that he doubts that an appeal will result

in a different decision.” Fallick v. Nationwide Mut. Ins. Co., 162 F.3d 410, 419 (6th Cir.

1998) (internal quotation marks and citation omitted).

       The District Court granted Gambino relief on the ground of futility because it was

“entirely foreseeable” that a denial of STD benefits “would likely cause a beneficiary to

assume that an LTD claim would be futile.” 2005 WL 4839146, at *8. The District Court

found that Liberty had offered no proof of any instance in which an individual who had been

denied STD benefits was nonetheless awarded LTD benefits and that Liberty had never

                                               14
notified Gambino of his right to apply for LTD benefits despite denial of his STD claim. Id.

These findings, however, are not relevant as to whether it would actually have been futile for

Gambino to apply for LTD benefits. The STD and LTD plans contain different elimination

periods. It is possible for a covered person who lacked sufficient medical evidence to

establish disability within a two-week window to nonetheless amass sufficient medical

evidence to establish disability under the longer six-month period. There are a number of

subsequent records of treatment within a six-month period which could have supported an

award of LTD benefits. Thus, Gambino’s failure to apply for LTD benefits should not have

been excused.

V. Conclusion

       For the foregoing reasons, the judgment of the District Court will be reversed in part

and vacated in part and the case remanded for further proceedings consistent with this

Opinion.

                                             15