Opinion ID: 6317310
Heading Depth: 1
Heading Rank: 4

Heading: The Second & Third DOS

Text: We next turn to Wilson’s challenge to the district court’s dismissal—for failure to exhaust remedies—of his claims based on United’s denial of coverage for services provided during the Second and Third DOS. Wilson asserts he was excused from exhausting those remedies because he initiated an appeal and requested copies of documents, but United failed to respond to either, thwarting the Plan’s internal review 18 process and making exhaustion futile. He contends the district court erred in holding that counsel’s January 26 and February 24 letters (collectively “the 2017 letters”) did not initiate an “appeal” of United’s initial decisions to deny coverage and that United was required to respond and also to provide copies of requested materials to which he was entitled under ERISA and the Plan. In response, United urges us to affirm the district court’s dismissal of these claims. It asserts that the district court properly construed the 2017 letters to request something short of an unequivocal appeal of the denial of coverage. Further, it contends the 2017 letters could not operate as an appeal of any coverage denials falling within the Third DOS that post-date when the letters were written, i.e., claims that were provided or denied after February 24, 2017. United also argues that it had no duty to respond to the letters’ request for production of documents because all of the requested materials are privileged by HIPAA and the HIPAA authorization form was defective because it was not properly signed. A. ERISA’s Exhaustion Requirement Although “ERISA does not contain an explicit exhaustion provision,” “an ERISA claimant generally is required to exhaust the remedies provided by the employee benefit plan in which he participates as a prerequisite to an ERISA action for denial of benefits under 29 U.S.C. § 1132.” Makar v. Health Care Corp. of Mid-Atlantic (CareFirst), 872 F.2d 80, 82 (4th Cir. 1989). Courts have imposed this requirement because it is consistent with the “Act’s text and structure as well as the strong federal interest encouraging private resolution of ERISA disputes.” Id. The exhaustion requirement means that claimants must 19 follow the Plan’s internal procedures for a “full and fair review” of a plan administrator’s denial of a claim for benefits. Id. at 83. We have previously recognized that a failure to exhaust may be excused when pursuing internal remedies would be “futile.” Id. More than “bare allegations of futility” must be demonstrated, however, as a claimant must come forward with a “clear and positive showing” to warrant “suspending the exhaustion requirement.” Id. (internal quotation marks omitted); see Hickey v. Digital Equip. Corp., 43 F.3d 941, 945 (4th Cir. 1995) (rejecting an assertion of futility when claimant did not file a written claim and alleged, with no further foundation, that doing so would have been “a mere formality if not a charade”). Further, an administrator’s failure to “provide a reasonable claims procedure” under ERISA “entitle[s] [beneficiaries] to pursue any available remedies” and thus to “be deemed to have exhausted the administrative remedies available under the [P]lan.” 29 C.F.R. § 2560-503-1(l)(1). 5 When exhaustion is excused, the district court may consider “the claimant’s entitlement to benefits in the first instance.” Riggs v. Ballard Tire & Oil Co. Pension Plan 5 Courts have taken different approaches in classifying the grounds for excusing exhaustion. Some courts have grouped a variety of reasons to excuse exhaustion under the umbrella term “futility.” E.g., Brown v. J.B. Hunt Transp. Servs., Inc., 586 F.3d 1079, 1085 (8th Cir. 2009) (citing other circuit courts). Others use a narrower definition of futility, requiring, for example, proof that the claim would have been denied, and classifying other grounds for excusing exhaustion as something other than “futility.” Id. at 1085–87 (declining to label an argument as “futility,” but observing that it nonetheless was “a winner” that excused the claimant’s failure to exhaust). While our cases have only previously discussed “futility,” the labels don’t necessarily matter because they lead to the same result—sufficient evidence, rather than a mere assertion, that relieves the claimant of navigating the administrative process before filing suit. 20 & Tr., 979 F.2d 848, 1992 WL 345584, at  (4th Cir. 1992) (unpublished table decision) (citing Licensed Div. Dist. No. 1 MEBA/NMU, AFL-CIO v. Defries, 943 F.2d 474, 478–80 (4th Cir. 1991)). But in the case of procedural noncompliance with ERISA’s full and fair review process, we have recognized that the appropriate relief is to remand for the administrative process to be properly applied. Gagliano v. Reliance Standard Life Ins. Co., 547 F.3d 230, 239–42 (4th Cir. 2008). We review the district court’s determination that Wilson failed to exhaust his administrative remedies for abuse of discretion. DuPerry v. Life Ins. Co. of N. Am., 632 F.3d 860, 876 (4th Cir. 2011). A district court “abuses its discretion when it acts arbitrarily or irrationally, fails to consider judicially recognized factors constraining its exercise of discretion, relies on erroneous factual or legal premises, or commits an error of law.” Newport News Shipbuilding & Dry Dock Co. v. Holiday, 591 F.3d 219, 226–27 (4th Cir. 2009). B. The Claims Affected by the 2017 Letters Before analyzing the substantive requests made in the 2017 letters, we must first determine which claims they relate to and therefore which claims our analysis affects. Although the district court and the parties have treated the Second and Third DOS claims identically, we conclude that a more nuanced approach is required. The 2017 letters indisputably address the claims for the entire Second DOS, that is, the services CALO provided on July 16–31, 2016; August 1–15, 2016; and November 1– 30, 2016. As noted, the 2017 letters’ subject lines referenced three claim numbers that corresponded with Wilson’s claims for these three specific timeframes. The district court 21 and the parties carved out the claims for services provided during these three delineated timeframes as the “Second DOS.” J.A. 2955. Because of this explicit cross-reference in the letters, any analysis of the 2017 letters’ contents applies to the denial of coverage for services provided during the Second DOS so defined. The record is less developed for the claims designated as the “Third DOS.” J.A. 2958. This label served as a catch-all for claims relating to J.W.’s residential treatment at CALO that did not fall within the First DOS or Second DOS and for which United had denied coverage. Put another way, as described by the parties and the district court, the Third DOS encompasses claims submitted for services provided from May 16, 2016, (the day after the First DOS ended) to July 31, 2017, (the date of J.W.’s discharge), except for the claims submitted for services provided during the three timeframes comprising the Second DOS. We conclude that it’s appropriate to consider claims for services denied before the date of the January 26 letter as part of the analysis of the 2017 letters’ substance, but that claims for services denied after that date do not reasonably fall within its scope. The text of the January 26 letter expressly stated that its requests pertained to “the claims referenced above as well as any and all denied claims related to treatment received at [CALO].” J.A. 2930 (emphasis added). Thus, the plain language of the letter encompasses more than just the claims for the Second DOS; it also refers to additional claims United had denied as of the letter’s date. But it does not follow that the letter references all other past and future claims Wilson submitted for coverage of his son’s treatment at CALO. 22 Setting aside the question of whether a letter could effectively pull in future denials of coverage, the January 26 letter did not do so. The letter repeatedly characterized both counsel’s representation of Wilson and its specific requests in terms of claims that United had already denied. For example, the letter stated counsel’s retention to represent Wilson “in connection with the . . . denial of his health insurance benefits,” and elsewhere referenced Wilson’s “denied claims” and the “denial of Mr. Wilson’s claim.” Id. (emphases added). This language looks only to United’s past conduct. It does not make any requests about United’s process for reviewing then-pending or not-yet-submitted claims, let alone clearly indicate that the letter’s requests encompass future claims for services that had not yet been provided. Consistent with this reading, one of the January 26 letter’s purposes was to notify United that Wilson “d[id] wish a review” or an “appeal.” Id. Regardless of what this request actually accomplished under the Plan, one cannot “review” or “appeal” a decision that has not yet been made. Similarly, the letter requested “medical documents” United relied on to deny coverage. J.A. 2931. Regardless of whether United needed to respond to that request, the request itself could only be made for claims that had been denied as of the time it was made. For these reasons, although the January 26 letter’s contents pulled in more than just the claims comprising the Second DOS, it only encompasses additional claims for which United had already denied coverage. The February 24 letter did not expand the scope of the January 26 letter because it merely cross-referenced and reiterated the requests made in the earlier letter. 23 In sum, when analyzing the substantive requests made in the 2017 letters, we are discussing a narrower number of claims than what the district court addressed—only those claims for which United had denied coverage as of January 26, 2017. 6 We will adopt the phrase “modified Third DOS” to refer to the subset of Third DOS claims affected by our analysis of the 2017 letters’ requests. To reiterate, the modified Third DOS consists of any claims that are not part of the First DOS or Second DOS and that United had denied coverage for as of January 26, 2017. The analysis that follows concerning the 2017 letters relates solely to the Second DOS and the modified Third DOS. C. 2017 Letters’ Request for Documents Our review convinces us that the district court abused its discretion in dismissing Wilson’s claims based on the denial of coverage during the Second and modified Third DOS. Given the interconnectedness of the various arguments, we begin our analysis with the thread that leads to the cleanest untangling for the parties upon remand: the 2017 letters’ request for production of documents. 1. Underlying Facts & Law Four facts are beyond dispute—First, quite apart from whether they initiated an appeal, the 2017 letters unequivocally requested that United provide certain materials to Wilson’s counsel. The January 26 letter stated as its “second purpose” “to request a complete copy of each and every document upon which [United had] based [its] denial of 6 On the record before us we cannot say what specific claims for which dates of service comprise the modified Third DOS. We leave for the parties to settle that issue on remand, with the cut off being that United denied coverage for those claims on or before January 26, 2017, (and are not part of the First DOS). 24 Mr. Wilson’s claims. Such documents include any medical documents, substantive documents, the plan document and any internal guidelines or regulations which [United had] used in evaluating [the] claim.” J.A. 2931. And, as noted earlier, the letter expressly referenced Wilson’s right to review this “documentation” to prepare a response that would be used during the full and fair review of the prior adverse benefits determination. Id. The February 24 letter similarly informed United that counsel had not received “any documents” requested in the earlier January 26 letter, all of which counsel deemed necessary to prepare Wilson’s response to the denial of coverage. J.A. 2933. Second, United did not provide any of the requested materials or respond to the letters in any fashion. Third, as a general matter, Wilson—whom the 2017 letters identified as a Plan participant, a fact uncontested by United—had the right to request and receive copies of the requested documents, which United would ordinarily be obligated to provide. For example, 29 U.S.C. § 1133 gives beneficiaries the right to a “full and fair review” of denied claims, part of which includes the right to request—and the obligation on administrators to “provide[], upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the claimant’s claim for benefits.” 29 C.F.R. § 2560.503-1(h)(2)(iii); see also id. § 2560.503-1(h)(3) (stating this requirement applies to group health plans); 29 U.S.C. § 1024(b)(4) (stating that copies of plan documents are to be provided to participants “upon written request”); 29 U.S.C. § 1132(c) (addressing the forms of relief available when administrators refuse to supply information to which beneficiaries are entitled upon request). As it was required to do, the Plan 25 incorporated these principles. E.g., UnitedHealthcare Choice Plus Certificate of Coverage (“Plan Document”) at 242, Wilson v. UnitedHealthcare Ins. Co., No. 2:17-cv-03059-DCN (D.S.C. filed June 19, 2019), ECF No. 35-4 (stating that “[s]pecific guidelines and protocols [to assist in determining if services are medically necessary] are available for [Plan participants] upon request”); 7 see also id. at 304, 312. Fourth, Plan participants can authorize third parties to request copies of materials on the participants’ behalf. See, e.g., 29 C.F.R. § 2560.503-1(b)(4) (permitting “an authorized representative of a claimant” to “act[] on behalf of such claimant in pursuing a benefit claim or appeal of an adverse benefit determination”); Plan Document at 304, ECF No. 35-4 (permitting Plan participants to authorize a third party to request copies of the participants’ health information). 2. United’s HIPAA Defense United does not dispute these factual points and acknowledges that it ordinarily would have had a duty to provide Wilson with copies of the requested documents. Nonetheless, United insists that it had no obligation to produce any materials because they are all protected by HIPAA and Wilson’s HIPAA authorization form was fatally defective. Specifically, United asserts the signature on the authorization form does not satisfy HIPAA’s requirements for a valid authorization. The authorizing signature, which is 7 United filed this document as part of its evidentiary appendix to the parties’ joint stipulation in the district court below. See Evidentiary App. to Joint Stipulation, Wilson v. UnitedHealthcare Ins. Co., No. 2:17-cv-03059-DCN (D.S.C. filed June 19, 2019), ECF No. 35. It is not included in full in the Joint Appendix, so the opinion cites the document that is part of the district court record as appropriate. 26 illegible, was on the line for a “client/patient” to sign “on his or her own behalf” as opposed to the line designated for a “client” to sign “on behalf of another person.” J.A. 2932. United contends that because J.W. was a minor, he could not sign the HIPAA authorization form personally and was required to have an authorized individual sign on his behalf. Thus, United posits, either J.W. signed the form and that was ineffective, or else Wilson signed the form and it’s ineffective because he signed on the incorrect line and failed to identify his authority to do so as required by 45 C.F.R. § 164.508(c)(vi). Either way, United argues the form did not comply with HIPAA’s exacting standards and, as such, no documents could be provided to Wilson’s counsel. United further contends that it had no obligation under the Plan, ERISA, or HIPAA to notify Wilson’s counsel that it would not produce any materials or to explain why. Indeed, United maintains that it could not contact counsel because doing so would itself violate HIPAA by disclosing protected information about J.W. Related to this broad view of HIPAA’s scope, United asserts that HIPAA protected all the materials requested in the 2017 letters, including copies of the Plan and any internal guidelines or regulations that United used to evaluate any Plan participant’s claims for coverage, including Wilson’s. 3. Analysis of United’s HIPAA Defense HIPAA is a sometimes confusing and obtuse federal law that prohibits covered entities from “knowingly” disclosing an individual’s “individually identifiable health information” “without authorization.” 42 U.S.C. § 1320d-6(a), (b); 45 C.F.R. 27 § 164.508(a)(1). 8 “Individually identifiable health information” is “a subset of health information,” 45 C.F.R. § 160.103, and understanding the difference between the two terms of art aids in understanding the flaws in United’s argument. “Health information” means information that “is created or received by a health care provider, health plan, public health authority, employer, life insurer, school or university, or health care clearinghouse” that “relates to the past, present, or future physical or mental health or condition of an individual, the provision of health care to an individual, or the past, present, or future payment for the provision of health care to an individual.” 42 U.S.C. § 1320d(4); 45 C.F.R. § 160.103. “Individually identifiable health information” has the same initial requirements, but must also either “identif[y] the individual” or be of a type “to which there is a reasonable basis to believe that the information can be used to identify the individual.” 42 U.S.C. § 1320d(6); 45 C.F.R. § 160.103. a. Request for Plan-Related Documents Applying these definitions to the 2017 letters, it is clear that some of the requested materials should have been disclosed because they do not constitute and would not lead to J.W.’s “individually identifiable health information” and thus would not require a HIPAAcompliant authorization form before being provided to Wilson’s counsel. Further, it’s undisputed that the 2017 letters plainly identified Wilson as a Plan participant, such that he 8 It is uncontested that United is a covered entity subject to HIPAA’s limitations on the use and disclosure of protected health information. See generally 45 C.F.R. §§ 160.102(a), 164.500, 164.502. 28 had a right under the Plan and ERISA to obtain copies of certain generally applicable Planrelated documents upon request (or upon his authorized representative’s request). As the definition of “individually identifiable health information” demonstrates, to fall within this term’s scope, the material must either identify or be such that it could reasonably be used to identify a specific individual. We fail to see how a copy of the Plan— applicable to all beneficiaries—could conceivably identify J.W. directly or indirectly. Similarly, the “internal guidelines or regulations” established pursuant to the Plan for determining medical necessity would not identify J.W. or lead to his identification. J.A. 2931. These are generic documents governing United’s assessment of any beneficiary’s claims. Further, the 2017 letters requested any “substantive documents” used to deny coverage as part of a utilization review. Id. United may have had in its possession additional documents that fall within this category, must be disclosed under ERISA, and do not bear the individual identifiers that would subject it to HIPAA. These three categories of materials share the common feature of lacking any contents that either identifies or could reasonably be used to identify J.W. personally. See 45 C.F.R. § 164.514(a) (“Health information that does not identify an individual and with respect to which there is no reasonable basis to believe that the information can be used to identify an individual is not individually identifiable health information.”). United was required under ERISA and the Plan to provide copies of all the foregoing information to Wilson’s counsel irrespective of the validity of the HIPAA authorization form. E.g., Plan Document at 312, ECF No. 35-4 (reiterating that Plan participants “are entitled to obtain, upon written request to the Plan Administrator, copies of documents 29 governing the operation of the plan”); 29 C.F.R. § 2560.503-1(g)(v) (setting out a group health plan’s obligation to provide copies of “an[y] internal rule, guideline, protocol, or other similar criterion . . . relied upon in making [an] adverse [benefit] determination”); id. § 2560.503-1(h)(iii) (setting out a plan administrator’s obligation to provide “upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the claimant’s claim for benefits”). It possessed the January 26 letter describing the request as well as Wilson’s confirmation of representation designating his counsel as a third party who could act on his behalf. As an undisputed plan participant, Wilson—or his designated representative—had the right to request these materials under both the Plan and ERISA, and United had a corresponding duty to provide them. Responding to that request would not have disclosed anything to identify J.W., as it would disclose only the Plan and related documents governing any plan participant’s claims. United, however, failed to respond in any way. Without copies of the Plan and guidelines, Wilson was put at a distinct disadvantage in understanding how to proceed. Ellis, 126 F.3d at 236–37 (observing that ERISA’s extensive procedural requirements “have been read as ensuring that a full and fair review is conducted by the administrator[] [and] that a claimant is enabled to prepare an appeal for further administrative review or recourse to the federal courts” (emphasis added)). As but one example, United contends that the January 26 letter was not a proper request for an appeal under the Plan by pointing to criteria set out in the Plan documents (and not contained in the EOBs). But by failing to provide these documents, United violated its fiduciary obligations under ERISA and the Plan, and impeded the appeal process. 30 Upon hearing nothing from United in response to either of the 2017 letters, Wilson had reason to believe that United was not going to comply with the procedures set out in the Plan as to the Second DOS and modified Third DOS. The EOBs accompanying United’s initial denial of coverage informed Wilson that he could “request copies (free of charge) of information relevant to [his] claim by contacting [United] at the above address.” E.g., J.A. 2907. Moreover, ERISA obligates administrators to respond to requests for information that ERISA requires the administrator to provide participants “within 30 days after [the] request.” 29 U.S.C. § 1132(c)(1); Plan Document at 312, ECF No. 35-4 (reciting this participant right and administrator duty in the Plan’s notice of ERISA rights). 9 The letters were sent January 26, 2017, and February 24, 2017, respectively, and Wilson heard nothing from United for well over 30 days. United’s failure to provide the requested Plan-related documents provides a “clear and positive showing of futility” in attempting further communications with it about the production of documents and warrants excusing Wilson from the exhaustion requirement. Makar, 872 F.2d at 82 (internal quotation marks omitted); e.g., Brown, 586 F.3d at 1085– 86 (concluding claimant was excused from failing to exhaust after the administrator failed to respond to repeated requests for documents she was entitled to under the plan and ERISA because, “[w]ithout the Administrative Record and other requested documents in hand, [she] was unable fully and fairly to prepare her appeal”); Lanfear v. Home Depot, Inc., 536 9 Copies of materials relating to the Plan and benefits determinations are not a mere courtesy. Indeed, ERISA authorizes courts to impose a daily fine for an administrator’s failure to timely provide copies of materials that must be turned over upon request. 29 U.S.C. § 1132(c)(1). 31 F.3d 1217, 1224–25 (11th Cir. 2008) (observing that past cases had found “exhaustion was futile because plan administrators had denied a participant meaningful access to administrative proceedings by repeatedly ignoring requests for documents supporting the denial of benefits”). b. Request for J.W.-Specific Documents In addition to the request to provide Plan-oriented documents, the 2017 letters also requested materials that do fall within the definition of “individually identifiable health information,” most notably any “medical documents” United relied on to deny coverage. J.A. 2931. J.W.’s medical records and opinions about his diagnoses and treatment would contain J.W.’s name and other contents from which he could be reasonably identified. As such, those and similar materials with such markers that were responsive to the request required a HIPAA-compliant authorization form before they could be disclosed to counsel. See 45 C.F.R. § 164.508(a)(1) (“Except as otherwise permitted or required by this subchapter, a covered entity may not use or disclose protected health information without an authorization that is valid under this section. When a covered entity obtains or receives a valid authorization for its use or disclosure of protected health information, such use or disclosure must be consistent with such authorization.”). United therefore was precluded by HIPAA from turning over these materials without a “valid” HIPAA authorization form. As to the documents protected by HIPAA, it’s not clear that Wilson’s signed HIPAA authorization form complied with the relevant regulations. Id. To be valid, the form must meet certain criteria, including containing several “core elements.” Id. § 164.508(b), (c). In relevant part, the authorization form must contain the “[s]ignature of the individual and 32 date,” and “[i]f the authorization is signed by a personal representative of the individual, a description of such representative’s authority to act for the individual.” Id. § 164.508(b)(1)(ii), (c)(1)(vi); see also id. § 164.508(b)(2)(ii) (stating that an authorization from is “defective” if it has “not been filled out completely, with respect to an element described by paragraph (c) of this section”). But Wilson’s HIPAA authorization form contained an illegible signature. The top of Wilson’s HIPAA authorization form identifies J.W. as the patient; provides his social security number and date of birth; and identifies the Foster Law Firm, L.L.P., as the entity to whom HIPAA-protected information can be disclosed. The form is signed illegibly; it is simply not readable to determine who actually signed it. Nor does any surrounding information clear up that illegibility. The signature appears in the subsection for a “client/patient” to sign “on his or her own behalf” and appears above the typed word, “Client,” suggesting it was signed by the individual who hired the Foster Law Firm, L.L.P., Wilson, despite being a request to disclose J.W.’s HIPAA-protected records. J.A. 2932. The next section’s signature line is left blank, but is where a client should have signed “on behalf of another person.” Id. That section also contains a designated space for identifying the document being attached to verify the signatory’s authority to sign on behalf of the named patient, but that too was left blank. As noted, however, to be a valid signature authorizing the release of another individual’s protected health information, HIPAA requires that the authorization form describe the basis for that authority. 45 C.F.R. § 164.508(c)(1)(vi). It’s not clear that the signature on the form here satisfies HIPAA’s requirements. 33 Separate from United’s valid refusal to produce J.W.-specific materials without a valid HIPAA authorization form is the independent question of whether—as United contends—HIPAA prohibited it from alerting Wilson’s counsel that the signature on the authorization form was illegible and that as a consequence it could not determine that the HIPAA authorization form complied with 45 C.F.R. § 164.508. The answer to that question is that HIPAA did not prohibit United from contacting Wilson’s counsel. Doing so would take no particular legal expertise and would not disclose any individually identifiable health information. For example, United could have simply responded that it was in possession of counsel’s January 26 letter, but the attached HIPAA authorization form contained an illegible signature that meant United could not determine whether the signature complied with 45 C.F.R. § 164.508’s requirements for a valid authorization form. Such a straightforward response would not disclose any “health information” at all, let alone “individually identifiable” health information. United’s arguments to the contrary find no support in the definition of individually identifiable health information or the case law on which it relies. In response to questioning at oral argument, United cited Tate v. N.C. Pepsi-Cola Bottling Co. of Charlotte, Inc., No. 3:09CV36–RJC–DSC, 2009 WL 3242117 (W.D.N.C. Oct. 5, 2009), as its “best case” to support the argument that it could not respond in any manner to the 2017 letters without violating HIPAA. There, the plaintiff’s lawyer sought production of medical records from an entity subject to HIPAA, but failed to provide a HIPAA-compliant medical authorization form. The district court held that the covered entity could not “release [the plaintiff’s] medical records, even to his attorney,” without a HIPAA-compliant 34 authorization, nor could the entity “even confirm whether [p]laintiff received health care services from it” without that form. Id. at . Tate is inapposite. Confirming that a specific individual received services from a specific provider may well involve individually identifiable health information because it conveys information about “the provision of health care” to an identified person. 42 U.S.C. § 1320d(4); 45 C.F.R. § 160.103. But responding to counsel’s request for production of documents by noting that the attached HIPAA authorization form contains an illegible signature does not implicate any aspect of HIPAA-protected information. 10 To be sure, concluding that HIPAA did not prohibit United from alerting Wilson’s counsel to the illegible signature does not mean that United had an obligation to do so. That requires us to consider the scope of United’s fiduciary duties under the Plan, ERISA, and our case law describing the plan administrator’s duties in providing claimants with a full and fair review of the denial of their claims for benefits. Our assessment leads to the narrow conclusion that under the specific circumstances of this case, United had an obligation to notify Wilson’s counsel of the illegible signature. At the outset, ERISA’s overarching structure supports our conclusion. The Act generally “imposes broad fiduciary responsibilities on plan trustees,” requiring them to 10 At the Court’s instruction, the parties submitted supplemental letters on the question of whether HIPAA prohibited United from disclosing nonmedical documents in response to the 2017 letters. The cases United cites to support its position are distinguishable and reaffirm that the specific inquiry is not whether the materials conceivably or actually relate to health information in the abstract, but rather center on whether the recipient would be able to use that information or surrounding circumstances to connect that information to a specific individual’s health, conditions, health care treatment, or payment for health care. 42 U.S.C. § 1320d(4); 45 C.F.R. § 160.103. 35 “perform their obligations with diligence” and to “discharge their duties ‘solely’ in the interest of plan participants and their beneficiaries.” Makar, 872 F.2d at 83 (quoting 29 U.S.C. § 1104(a)(1)); Aetna Health Inc. v. Davila, 542 U.S. 200, 220 (2004) (observing that a plan administrator acts as a plan fiduciary when carrying out ERISA’s “extensive requirements to ensure full and fair review of benefit denials”); see also Plan Document at 312, ECF No. 35-4 (notifying Plan participants that ERISA imposes duties on the plan fiduciaries to operate the Plan “prudently and in the interest of you and other plan participants and beneficiaries”). To permit a fiduciary such as United to remain silent under the circumstances presented in this case would hardly be consistent with this objective. It would sanction an administrator’s silence in the face of attempts by an undisputed bona fide Plan participant, Wilson, to obtain materials to which he had a right under the Plan and ERISA. United’s failure to answer regarding the illegible signature is counter to an administrator’s role under ERISA as a fiduciary who must discharge its duties in the interests of its participants and beneficiaries. We have previously recognized, for example, that although claimants bear “primary responsibility” for presenting their claims for review, ERISA does not envision that the claims process will mirror an adversarial proceeding where the [claimant] bear[s] almost all of the responsibility for compiling the record, and the [fiduciary] bears little or no responsibility to seek clarification . . . . Rather, the law anticipates, where necessary, some back and forth between administrator and beneficiary. Harrison v. Wells Fargo Bank, N.A., 773 F.3d 15, 21 (4th Cir. 2014) (internal quotation marks and citation omitted) (first three alterations in original). 36 Had United alerted Wilson’s counsel to the problem with the HIPAA authorization form, Wilson could have timely cured it and continued with the process established in ERISA for a full and fair review of the denial of his claims for coverage during the Second DOS and modified Third DOS rather than turning to the courts. That course would further ERISA’s intended framework: “[t]he full and fair review procedural requirements serve two complementary purposes,” “permit[ting] a plan’s administrators to resolve disputes in an efficient, streamlined, non-adversarial manner” while also “ensur[ing] that a plan participant is protected from arbitrary or unprincipled decision-making.” Ellis, 126 F.3d at 236. We are careful to note the fact-specific nature of our holding as ERISA clearly places on claimants the ultimate burden of pursuing their claims. While we have recognized that plan administrators are not required to hand-hold a claimant through the review process, they are not entitled to sandbag the process either. Cf. id. at 237. We have previously recognized that because “plan administrators possess limited resources, and . . . there are practical constraints” on processing requests, the governing rule should be “one of reason.” Harrison, 773 F.3d at 22. Here, as noted, United had multiple requests from Wilson’s counsel, a signed confirmation of representation, and an illegibly signed HIPAA authorization form that implicated whether HIPAA’s signature requirement had been satisfied. United’s limited fiduciary duty was solely to notify Wilson’s counsel about the illegible signature on the attached form. Doing so would not violate HIPAA because it would not have disclosed any individually identifiable health information, but would have fulfilled a limited fiduciary duty of United as the Plan administrator. 37