Easter v. Cayuga Medical Center at Ithaca Prepaid Health Plan (217 F. Supp. 3d 608, 2016)

MEMORANDUM-DECISION AND ORDER

Hon. Brenda K. Sannes, United States District Court Judge:

I. INTRODUCTION

Plaintiff Jennifer Easter brings this action on behalf of her son, B.E., under the Employee Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. §§ 1001, et seq. In the Second Amended Complaint, Plaintiffs allege that Defendants Cayuga Medical Center at Ithaca Prepaid Health Plan (“Plan”), Cayuga Medical Center (“CMC”), and Excellus Health Plan, Inc. (“Excellus”) violated ERISA with their “denial of Plaintiffs’ claims for medical benefits and failure to provide requested information.” (Dkt. No. 27, p. 1). Currently pending before the Court are the CMC Defendants’ motion for summary judgment (Dkt. No. 41), Excellus’ motion for summary judgment (Dkt. No. 42), and Plaintiffs’ cross-motion for summary judgment (Dkt. No. 43). For the reasons set forth below, each party’s motion for summary judgment is granted in part and denied in part. The Court remands consideration of Plaintiffs’ claims for benefits to Defendants for renewed consideration in accordance with this Opinion.

II. BACKGROUND

A. Plaintiffs’ Allegations Regarding B.E.’s Treatment History

B.E. is a minor dependent of Plaintiff Easter, who is an employee of the Cayuga Medical Center at Ithaca. (Dkt. No. 43-3, ¶¶ 5-6; Dkt. No. 47-1, ¶¶ 5-6; Dkt. No. 48-1, ¶¶ 5-6). In 2006, when B.E. was eight years old, he received a “speech articulation evaluation at the Sir Alexander Ewing-Ithaca College Speech and Hearing Clinic” and was subsequently “referred for a comprehensive psychological education evaluation to aide [sic] in school placement and instructional planning.” (Dkt. No. 27, ¶ 14; Dkt. No. 27-2, p. 2). A series of tests performed by a psychologist “showed diversely developed cognitive abilities and inconsistencies in performance that are associated with learning disabilities” and the psychologist “recommended specific supportive strategies to improve B.E.’s academic performance.” (Dkt. No. 27, ¶ 16; Dkt. No. 27-2, pp. 5, 10-11).

In 2009, when B.E. was eleven years old, school personnel “referred [him] for psychotherapy and [he] began working with ... a licensed therapist” over weekly outpatient meetings “to assist B.E. in managing distractibility, frustration, and organizational tasks.” (Dkt. No. 27, ¶¶ 16-17; Dkt. 27-3, p. 2). The therapist “diagnosed B.E. with dysthymia ,,., a reading disorder, an anxiety disorder not specified, and educational problems.” (Dkt. No. 27, ¶ 18; Dkt. No. 27-3, p. 2). Though B.E. “initially responded well to traditional therapy,” his progress “decline[d] considerably.” (Dkt. No. 27, ¶ 19; Dkt. No. 27-3, pp. 2-3).

In this period, B.E. also “underwent a Comprehensive Neurodevelopmental Assessment at the Yellin Center for Student Success in New York City to obtain a learning profile which was used by B.E.’s elementary school to help B.E. academically.” (Dkt. No. 27, ¶ 20; Dkt. No. 27-3, p. 3). B.E.’s parents “continued to consult with several doctors” through early 2010 “to evaluate and treat B.E.’s dysthymia and anxiety.” (Dkt. No. 27, ¶ 21; Dkt. No. 27-3, p. 3).

“As B.E. entered adolescence, [his] emotional and academic functioning steadily deteriorated, and B.E.’s behavior raised concerns about both B.E.’s and others’ safety.” (Dkt. No. 27, ¶ 22; Dkt. No. 27-3, p. 3). Plaintiffs assert that relevant symptoms and incidents included: (1) “night terrors on a regular basis” that were “extremely violent and scary” and sometimes caused B.E. to be “afraid to go to sleep;” (2) “seem[ing] sad[] and developing] a profound lack of interest and a loss of enthusiasm in doing most things;” (3) “irrational fears ... including a recurring fear that the sun would burn the earth,” which would “very often ... when it was a bright, sunny morning” cause B.E. to “become anxious and panic because [he] was fearful the sun was falling from the sky;” (4) repeated threats to jump from moving vehicles, including an incident on the highway where he also “threatened to grab the steering wheel and crash the car;” (6) “physically aggressive” behaviors that made Easter “ready to call 911” or leave the house “out of fear ... in hopes that B.E. would calm down;” (6) running away; and (7) threats of self-harm and suicide. (Dkt. No. 27, ¶ 22).

In May 2012, a doctor diagnosed B.E. with “conduct disorder; mixed mood and anxiety disorder; a learning disability in language, reading, memory, and sequencing; and antisocial personality disorder.” (Id. at ¶ 23; Dkt. No. 27-4, p. 4). Despite attempts to utilize “comprehensive, multifaceted out-patient treatment ..., B.E. had increasing problems with anger, mood swings, [] unpredictable behavior, declining academic performance, and learning disabilities.” (Dkt. No. 27, ¶ 24; Dkt. No. 27-3, p. 3). Consequently, B.E.’s parents consulted with an educational specialist “to help find a residential treatment facility that would meet B.E.’s needs.” (Dkt. No. 27, ¶ 26; Dkt. No. 27-5, p. 2). In October 2012, following consultation with other specialists including B.E.’s therapist, the consultant “developed a treatment plan for B.E. taking into consideration [his] diagnoses and other evident challenges, including a mood disorder, anxiety, adoption issues, racial-identity developmental issues, gender-orientation issues, anger management, and learning disabilities.” (Dkt. No. 27, ¶ 27; Dkt. No. 27-5, pp. 2-3). According to the plan, that “there were no facilities in close proximity that met B.E.’s complex needs” and recommended a “short-term intensive program that would be followed by a longer-term residential program.” (Dkt. No. 27, ¶¶ 28-29; Dkt. No. 27-6, p. 3).

For the short-term program, B.E. entered the Second Nature Wilderness Program, “a licensed adolescent treatment program,” in November 2012. (Dkt. No. 27, ¶ 30; Dkt. No. 27-6, p. 2). A doctor who worked with B.E. during the program recommended that B.E. “be followed closely by a child and adolescent psychiatrist as medications may continue to be an important part of [his] ongoing treatment” and indicated a belief that B.E. “would certainly do best in a residential treatment setting that can address all of [his] issues at once.” (Dkt. No. 27, ¶ 31; Dkt. No. 27-7, p. 19) (internal quotation marks omitted). “On discharge from [the program] in February 2013, B.E. had diagnoses of pervasive development disorder not otherwise specified (NOS), depressive disorder NOS, reading disorder, disruptive behavior disorder NOS, and parenVchild relational problems.” (Dkt. No. 27, ¶ 32; Dkt. No. 27-6, p. 2). A doctor from the program stated in B.E.’s “Discharge Summary” that a return to B.E.’s home environment “would most certainly result in significant regression and a return to [his] previous level of functioning.” (Dkt. No. 27, ¶ 33; Dkt. No. 17-6, p. 4).

On February 5, 2013, B.E. was admitted to Maple Lake Academy (“Maple Lake”) in Utah (Dkt. No. 27, ¶¶ 35-36; Dkt. No. 27-8, p. 2), a facility licensed by the State “to provide residential treatment.” (Dkt. No. 45-5). Patti Hollenbeck-Dial, one of its founders and owners who has “a doctorate in Marriage and Family Therapy”, and has “specialized in working as a therapist with adolescents,” stated in an affidavit that Maple Lake “provides 24-hour continuous, individually-planned residential treatment including daily clinical assessment, a structured daily therapeutic program that provides a minimum of 20 hours of therapy per week, daily medication management, 24-hour-per-day on-site supervision, a full-time nurse, a part-time child-adolescent psychiatrist, and discharge planning.” (Dkt. No. 45-4, ¶¶ 1, 6). Hollenbeck-Dial also stated that “[programs such as the one offered by Maple Lake to children like B.E. are a critical intermediate level of care between inpatient and outpatient treatment of mental, emotional, and behavioral conditions” and that “without an intermediate level of care and constant supervision, children with conditions such as those B.E. had in 2014 are likely to have worsening psychiatric, emotional, and cognitive problems.” (Id. at ¶¶ 11-12). B.E.’s treatments at Maple Lake included “weekly individual therapy, weekly family therapy, daily group therapy, full participation in a residential program, participation in daily chores and exercise, as well as educational instruction.” (Dkt. No. 27, ¶ 38; Dkt. No. 27-8, pp. 3-7). B.E. remained at Maple Lake through most of 2014, before admission to another facility in the end of that year.

B. The Cayuga Medical Center Health Plan

“Cayuga Medical Center at Ithaca Prepaid Health Plan [ (‘Plan’) ] is a self-funded employer-provided welfare benefit plan,” for which Cayuga Medical Center at Ithaca (“CMC”) “is the Plan Sponsor, Plan Administrator and a named fiduciary.” (Dkt. No. 43-3, ¶ 1-2; Dkt. No. 47-1, ¶ 1-2; Dkt. No. 48-1, ¶¶ 1-2). Under the terms of Defendants’ Administrative Services Contract (“ASC”), Excellus Health Plan, Inc. (“Excellus”), a licensee of the BlueCross Blue Shield Association, is “the Plan’s third-party claims administrator,” which “processes claims and determines benefits” for the Plan. (Dkt. No. 43-3, ¶ 3-4; Dkt. No. 47-1, ¶¶ 3-4; Dkt. No. 48-1, ¶¶ 3-4; Dkt. No. 48-3, p. 3). The ASC further provides that CMC “shall serve as the appropriate ‘named fiduciary,’ as defined by ERISA, for the purpose of reviewing and making decisions on claims denials.” (Dkt. No. 43-4, ¶ 5.11(c)). Plaintiff Easter is a Plan participant and has been since January 1, 2013. (Dkt. No. 43-3, ¶ 5; Dkt. No. 34, ¶ 8; Dkt. No. 48, ¶ 5). Through Easter, B.E. was a beneficiary of the Plan during the periods of treatment for which Plaintiffs seek benefits. (Dkt. No. 43-3, ¶ 6; Dkt. No. 47-1, ¶ 6; Dkt. No. 48-1, ¶ 6).

1) Claims Procedures

The “Plan Document,” in which the Plan is memorialized, provides that CMC is responsible for “establishing] and maintaining] claims procedures in accordance with ERISA.” (Dkt. No. 42-2, ¶ 5). To that end, CMC executed the ASC, under which Excellus has authority to process claims by Plan participants and “make[ ] the initial claims determination.” (Dkt. No. 45-1, ¶ 7; Dkt. No. 42-14, ¶ 7; Dkt. No. 43-4, ¶ 5.11). If Excellus denies a claim, the claimant “may file an initial appeal with Excellus,” and if Excellus upholds the denial, the claimant may appeal to CMC, “which will then render a final determination.” (Dkt. No. 45-1, ¶ 9; Dkt. No. 42-14, ¶¶ 9-10; Dkt. No. 43-4, ¶ 5.11).

To obtain benefits for medical services, a claimant must complete and submit to Ex-cellus a “medical benefits subscriber claim form.” (Dkt. No. 41-13, p. 2). Additionally, the claim form instructs claimants to submit:

ITEMIZED BILL(S) FOR SERVICES OR SUPPLIES MUST BE SUBMITTED WITH THIS FORM IN ORDER FOR REIMBURSEMENT TO BE CONSIDERED. THE ITEMIZED BILL MUST CLEARLY INDICATE ALL OF THE FOLLOWING: ...

- NAME AND ADDRESS OF THE PROVIDER OF SERVICE ON THEIR OFFICE LETTERHEAD, INCLUDING PROVIDER ID NUMBER AND CREDENTIALS

- DATE FOR EACH SERVICE RENDERED

- DESCRIPTION AND/OR VALID PROCEDURE CODE FOR EACH SERVICE RENDERED

- CHARGE FOR EACH SERVICE RENDERED

- DESCRIPTION OF ILLNESS/INJURY AND/OR VALID DIAGNOSIS CODE FOR EACH SERVICE RENDERED

(See, e.g., Dkt. No. 41-23, p. 7; Dkt. No. 41-13, p. 2) (internal numbering omitted, all emphasis in original). In cases where a claimant has omitted necessary information, the PPO Member Contract (“PPO Contract”) establishes the Excellus procedure for requesting additional information. It provides:

If we have all information necessary to make a determination regarding a retrospective claim, we will make a determination and provide notice to you and your provider within 30 calendar days of receipt of the claim.. If we need additional information, we will request it within 30 calendar days. You or your provider will then have 45 calendar days to provide the information. We will make a determination and provide notice to you and your provider within 15 calendar days of the earlier of our receipt of the information or the end of the 45-day time period.

(Dkt. No. 43-4, p. 32). According to the ASC, Excellus is empowered to determine whether a claimant’s treatment is medically necessary and whether the Plan documents provide for coverage. (Id. at p. 15; Dkt. No. 41-6, p. 41).

2) Relevant Coverage Provisions

The PPO Contract, which contains “a detailed description of the health coverage provided by the Plan, as well as the claims and appeal process” states that Exeellus “will not provide coverage for hospitalization that is for mental health care, coverage for care in a licensed night or day care program for mental health care, or coverage for care in a residential treatment facility.” (Dkt. No. 42-4, p. 11; Dkt. No. 43-3, ¶ 109; Dkt. No. 47-1, ¶109; Dkt. No. 48-1, ¶ 109). However, the appended “Rider for Mental Health Care,” amends that provision and notes available coverage “for Medically Necessary diagnosis and treatment of Mental Illnesses.” (Dkt. No. 42-4, p. 11; Dkt. No. 47-4, p. 3). It states:

When your Contract, Certificate or Group Health Plan currently covers 30 days of inpatient mental health care in a Calendar Year, or does not provide coverage for at least 30 days of inpatient mental health care in a Calendar Year, we will instead provide benefits for up to 30 days of active treatment in a Calendar Year in a hospital as defined by subdivision ten of section 1.03 of the New York Mental Hygiene Law.

(Dkt. No. 47-4, p. 3).

C. Plaintiffs’ Interactions with Defendants

The causes of action in this case arise from Plaintiffs’ attempts to obtain benefits for B.E.’s time at Maple Lake from January 2014 through October 2014 (Dkt. No. 45-1, ¶ 10) and communications between and among Plaintiffs, Exeellus, and the CMC Defendants.

1) Requests for Plan Information

In 2013, Easter sought information about what coverage was available for her son under the Plan. “As early as February 12, 2013,” Plaintiff Easter contacted Bill Toth, CMC’s Benefits Manager, and provided “some of B.E.’s diagnoses and treatment information” as part of a request for information on the Plan’s mental health coverage. (Dkt. No. 43-3, ¶¶ 9-10; Dkt. No. 48-1, ¶¶ 9-10; Dkt. No. 43-5, pp. 7-9). In email correspondence with Toth, Easter sought information on “what, if any, coverage [B.E.] would get” under the Plan. (Dkt. No. 43-5 pp. 7-9). On March 15, 2013, Easter emailed Toth to ask for “a copy of CMC’s insurance policy” so that she could “make an informed decision” about whether to place B.E. under her coverage. (Dkt. 43-5, p, 23). On March 21, CMC sent Plaintiffs’ attorney “the Excel-lus Blue PPO health insurance spreadsheet,” and on April 8, the attorney replied that she needed the “Plan Document” and not “the SPD or a summary of benefits.” (Id. at p. 36).

On May 14, 2013, Plaintiffs’ attorney contacted CMC via email, noting that she had spoken with Toth via telephone about the request for documents and had yet to receive what she needed. (Id. at p. 39). She continued:

I also discussed this request by phone with [Toth], and stated that I needed to evaluate eligibility and coordination of benefits provisions, thus the SBC would not suffice. While the summary plan description could possibly meet our needs if it is detailed and in compliance with ERISA, my experience with insured plans is that they typically do not have such SPDs, thus you will likely need to send me the certifícate of insurance or whatever serves as your full plan document. Please provide that to me as soon as possible. ...

I’m sure you are aware that if this is a plan governed by ERISA that you are required to provide a plan or SPD to the participant or her representative within 30 days of a written request. ... We are well past the 30 days so please provide this to me as soon as possible.

(Id.). Toth responded on May 20, 2013, “enclosing copies of the following documents used in the administration of the Health Plan: Plan Document; Summary Plan Description; and Summary of Benefits and Coverage.” (Dkt. No. 45-1, ¶ 46).

Plaintiffs’ attorney emailed Toth again on October 9, 2013, writing, “Last May you were kind enough to send me an SPD and plan document for the CMC plan for your employee, Ms. Eastman [sic].” (Dkt. No. 43-5, p. 40). The email goes on to ask “if there will be a difference in benefits related to mental health care” for 2014. (Id.). Toth replied that “[t]he current plan ... will be continued in 2014 and substantially unchanged.” (Id. at p. 41).

On or about March 26, 2014, Easter requested “a list of [insurance] documents.” (Dkt. No. 43-3, ¶ 104; Dkt. No. 47-1, ¶ 104; Dkt. No. 48-1, ¶ 104). On April 2, 2014, CMC provided a “Summary of Benefits and Coverage” and stated that there were “no significant changes” to benefits from 2013. (Dkt. No. 41-21, p. 14). Plaintiffs did not receive the PPO Contract, which “contains detailed coverage information for mental health benefits,” or the related “Custom PPO Grid” until discovery in this litigation. (Dkt. No. 43-3, ¶¶ 107-11; Dkt. No. 48-1, ¶¶ 107-11; Dkt. No. 47-1, ¶¶ 107-11).

2) Claims Submissions

Plaintiffs switched to the Plan, and B.E. became covered under it for the year 2014. (Dkt. No. 45-1, ¶¶ 2-8; Dkt. No. 46-1, ¶ 21). Seeking information about how to file a benefits claim for B.E.’s treatment at Maple Lake, Plaintiffs contacted Toth on February 24, 2014, stating:

The claim form ... does not have a place to enter diagnosis codes, etc, and states only that the provider’s invoice be attached. Because of the way [Maple Lake] does its residential treatment billing, the invoice is not a traditional medical form with treatment codes similar to one from a medical doctor’s office. Is there another type of claim form for this Excellus plan for mental health or for medical claims where we can provide the diagnosis codes?

(Dkt. No 48-5, pp. 46-50). Toth, after consultation with “the Account Manager at Exeellus,” replied with guidance the next day:

The invoice from the provider should be attached to the claim form. If you have separate correspondence or a Dr.’s office notes indicating diagnosis codes, they can also be attached to the claim form. Alternatively, if the diagnosis codes were provided verbally, you can attach a written explanation referencing the diagnosis codes. Most providers do an intake evaluation and [BlueCross BlueShield] may contact the residential provider for a copy of the intake evaluation if they need further documentation for the claim.

(Dkt. No. 43-3, ¶ 19; Dkt. No. 43-5, pp. 47-48). Plaintiffs’ attorney replied to Toth’s email that day, thanking him and noting that it was “great information.” (Dkt. No. 43-5, p. 47).

On or about February 27, 2014, Plaintiffs submitted claims for reimbursement to Exeellus for B.E.’s January and February 2014 services at Maple Lake. (Dkt. No. 45-1, ¶ 12). Plaintiffs submitted the “medical benefits subscriber claim form,” two invoices from Maple Lake—one dated January 1, 2014 and the other February 1, 2014—and a document listing the names and license numbers of a psychiatrist and therapists under Maple Lake’s masthead. (Dkt. No. 43-6, pp. 2-7). Plaintiffs also submitted a copy of a December 2013 email from a Maple Lake therapist that listed ICD-9 diagnosis codes for bipolar disorder, mild cognitive impairment, developmental dyslexia, “[o]ther specific developmental learning difficulties,” and “[f]amily disruption due to parent-child estrangement,” and CPT-4 treatment codes for several therapies. (Id.) The email did not, however, specify when the therapies were conducted or who provided the services. (Id.). Instead, it noted that B.E. “normally” received individual and family psychotherapy on Monday and Wednesday, respectively, and participated in group therapy “3x a week Monday, Wednesday, <& Thursday.” (Id.). Although the email indicated that B.E. received “Evaluation and Management Psychiatry,” it did not specify the time or frequency of this service. (Id.). Finally, the email states that the charge for each service is listed in an attached document; however, that document is not in the record and there is no indication that it was included in the claims submissions. (Id.). The last document Plaintiffs included were handwritten notes labeled “Drinkwater 12/10/13” and appear to include procedure codes. (Id.).

In a March 4, 2014 form letter, Excellus responded to Plaintiffs’ claim for reimbursement for B.E.’s January and February 2014 residence at Maple Lake, stating, “We were unable to process the enclosed claim for payment” because (1) “[a] valid procedure code and/or detailed description of service is missing or invalid” for “Procedures, Services or Supplies” and “Diagnosis or Nature of Illness or Injury” and (2) they were “unable to identify the patient as an active member.” (Dkt. No. 43-7, p. 41). Plaintiffs “submitted the Excellus ID number for B.E.” but “[bjetween March 30, 2014 and May 8, 2014 Excellus neither decided the claims submitted February 28th nor contacted Plaintiff[s] to request additional information.” (Dkt. No. 43-3, ¶¶ 23-25; Dkt. No. 47-1, ¶¶ 23-25). Plaintiffs “never submitted any additional information” to support their February 2014 claims submission. (Dkt. No. 45-1, p. 7; Dkt. No. 42-14, ¶ 33).

Plaintiffs, through counsel, telephoned Excellus on May 8, 2014 “to request the status of the claims” and were advised that the Utah “local plan” was making a decision “because services were rendered out of the area.” (Dkt. No. 43-7, pp. 7-8). The Excellus representative advised Plaintiffs to “give it a couple weeks” before checking in again. (Id.).

On or around May 13, 2014, Plaintiffs submitted claims for reimbursement for B.E.’s March, April, and May 2014 services at Maple Lake. (Dkt. No. 43-3, ¶ 29; Dkt. No. 41-15, p. 2). Plaintiffs’ attorney included a cover letter in this submission, but it otherwise matched the prior submission in that it included identical supporting documentation. (See Dkt. No. 41-15; Dkt. No. 43-6). Plaintiffs allege that they received no response from Excellus with respect to them March, April, and May 2014 claims; indeed, there is no response in the record. (Dkt. No. 43-3, ¶ 45). Excellus asserts that it responded to these claims. According to the declaration of an Excellus “claims project manager,” Excellus “returned [the] claim with notice of what was wrong with it.” (Dkt. No. 42-1, ¶ 17). The claims manager explains that there is no response in the record because Excellus “does not save a copy of its claim return notification letters after sending them to the claimant.” (Dkt. No. 47-1, ¶ 45; Dkt. No. 42-1, ¶¶ 17-18, n.4).

Plaintiffs telephoned Excellus again on May 28, 2014. (Dkt. No. 61; Dkt. No. 43-3, ¶¶ 31-32). During this call, Plaintiffs and an Excellus representative discussed issuance of a denial letter so that Plaintiffs could appeal. (Dkt. No. 45-1, ¶¶ 65-66; Dkt. No. 46-1, ¶¶ 53-55; Dkt. No. 50-1, ¶ 65; Dkt. No. 51-2, ¶¶ 53-55; Dkt. No. 61). The Excellus customer service management system contains internal notes reflecting that, during the call, Plaintiffs “requested] something in writing such as a denial so they can move forward and appeal if possible” and shows the internal process of seeking an answer. (Dkt. No. 61; Dkt. No. 43-3, ¶¶ 31-32). Though the Defendants argue that Plaintiffs knew generally that Excellus needed itemized information, it is undisputed that Plaintiffs never received a response from Excellus regarding a written denial or an appeal for any of their benefits claims. (Dkt. No. 43-3, ¶¶ 31-33; Dkt. No. 47-1, ¶¶ 31-33; Dkt. No. 48-1, ¶¶ 31-33; Dkt. No. 61).

On June 25, 2014, Plaintiffs submitted “invoices for mental health services provided in June and July 2014.” (Dkt. No. 43-3, ¶ 34; Dkt. No. 47-1, ¶ 34; Dkt. No. 48-1, 34; Dkt. No. 41-17). The supporting documentation contained no more information than that which Plaintiffs had previously submitted. (Dkt. No. 41-17). Plaintiffs then received a June 30, 2014 letter from Excel-lus, which does not indicate the specific claim or claims to which it refers. (Dkt. No. 43-7, p. 42). It states in its entirety:

June 30, 2014

Subscriber ID: 200767140 Dear Member:

Your claim is being returned for the following reason(s):

Need an itemized statement showing, To and From dates of service are missing from itemized statement.

Please resubmit with the requested information.

Thank you.

Claims Department

Kari R

(Id.).

On August 20, 2014, Plaintiffs resubmitted the July claims and added a claim for reimbursement for August 2014 services. (Dkt. No. 43-6, pp. 22-27). Again, they provided the same supporting documentation as in prior submissions, along with the Excellus form and the Maple Lake invoices. (Id.). On October 2, 2014, they submitted claims for services provided in September and October 2014 and likewise provided the same supporting documentation. (Id. at pp. 28-33).

Defendants argue that each of Plaintiffs’ claims for benefits omitted the following required information: “an itemization of professional services rendered to B.E.; the dates Maple Lake rendered each service; the charges for each service rendered; the procedure code(s) for each service rendered; the names and credentials of the providers rendering the services; and the specific treatment provided to B.E.” (Dkt. No. 41-23, p. 8; Dkt. No. 42-15, pp. 10-13) (internal numbering omitted). Excellus argues that without the missing information, they cannot process the claims and cannot determine “whether any part of the services at-issue are ‘covered services’ under the Plan, [whether] the provider was qualified to render the services, [whether] the services were medically necessary, [whether] the services were subject to day or visit limitations, the provider’s charges for each service, and the amount of the allowable expense.” (Dkt. No. 42-15, p. 13). Plaintiffs respond that they “submitted a claim form with all the information (and more) that was requested by .,. Excellus and Bill Toth at CMC and the Plan.” (Dkt. No. 53, p. 5).

III. APPLICABLE LEGAL STANDARDS

A. Summary Judgment

Under Federal Rule of Civil Procedure 56(a), summary judgment may be granted only if all the submissions taken together “show that there is no genuine issue as to any material fact and that the moving party is entitled to judgment as a matter of law.” Celotex Corp. v. Catrett, 477 U.S. 317, 322, 106 S.Ct. 2548, 91 L.Ed.2d 265 (1986); see also Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 247-48, 106 S.Ct. 2505, 91 L.Ed.2d 202 (1986). The moving party bears the initial burden of demonstrating “the absence of a genuine issue of material fact.” Celotex, 477 U.S. at 323, 106 S.Ct. 2548. A fact is “matei'ial” if it “might affect the outcome of the suit under the governing law,” and is genuinely in dispute “if the evidence is such that a reasonable jury could return a verdict for the nonmoving party.” Anderson, 477 U.S. at 248, 106 S.Ct. 2505; see also Jeffreys v. City of New York, 426 F.3d 549, 553 (2d Cir. 2005) (citing Anderson). The movant may meet this burden by showing that the nonmov-ing party has “fail[ed] to make a showing sufficient to establish the existence of an element essential to that party’s case, and on which that party will bear the burden of proof at trial.” Celotex, 477 U.S. at 322, 106 S.Ct. 2548; see also Selevan v. N. Y. Thruway Auth., 711 F.3d 253, 256 (2d Cir. 2013).

If the moving party meets this burden, the nonmoving party must “set forth specific facts showing a genuine issue for trial.” Anderson, 477 U.S. at 248, 106 S.Ct. 2505; see also Celotex, 477 U.S. at 323-24, 106 S.Ct. 2548. The nonmoving party “must do more than simply show that there is some metaphysical doubt as to the material facts,” Matsushita Elec. Indus. Co. v. Zenith Radio Corp., 475 U.S. 574, 586, 106 S.Ct. 1348, 89 L.Ed.2d 538 (1986), and cannot rely on “mere speculation or conjecture as to the true nature of the facts to overcome a motion for summary judgment.” Knight v. U.S. Fire Ins. Co., 804 F.2d 9, 12 (2d Cir. 1986) (quoting Quarles v. Gen. Motors Corp., 758 F.2d 839, 840 (2d Cir. 1985)). Furthermore, “[m]ere conclusory allegations or denials cannot by themselves create a genuine issue of material fact where none would otherwise exist.” Hicks v. Baines, 593 F.3d 159, 166 (2d Cir. 2010) (quoting Fletcher v. Atex, Inc., 68 F.3d 1451, 1456 (2d Cir.1995) (internal quotation marks and citations omitted)). When ruling on a summary judgment motion, “the district court must construe the facts in the light most favorable to the non-moving party and must resolve all ambiguities and draw all reasonable inferences against the movant.” Dallas Aerospace, Inc. v. CIS Air Corp., 352 F.3d 775, 780 (2d Cir. 2003).

B. ERISA

“ERISA was enacted to promote the interests of employees and their beneficiaries in employee benefit plans, and to protect contractually defined benefits.” Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 113, 109 S.Ct. 948, 103 L.Ed.2d 80 (1989). Plans must “provide adequate notice in writing to any participant or beneficiary whose claim for benefits under the plan has been denied, setting forth the specific reasons for such denial, written in a manner calculated to be understood by the participant.” 29 U.S.C. § 1133(1). Further, the Plan procedures must “afford a reasonable opportunity for a full and fair review” of adverse claim determinations. 29 U.S.C. § 1133(2). Full and fair review “requires that administrators follow proper procedural protocols in how they review claims, how much weight they assign different types of records, and how they reach decisions.” Martucci v. Hartford Life Ins. Co., 863 F.Supp.2d 269, 274 (S.D.N.Y. 2012) (citing Hobson v. Metro. Life Ins. Co., 574 F.3d 75, 86-87 (2d Cir. 2009)). ERISA also provides a Plan beneficiary with a right to judicial review of a benefits, termination. 29 U.S.C. § 1132(a)(1)(B). A claimant bears the burden of proving that she is eligible for disability benefits. Miles v. Principal Life Ins. Co., 720 F.3d 472, 488 (2d Cir. 2013) (citing Mario v. P & C Food Mkts., Inc., 313 F.3d 758, 765 (2d Cir. 2002)).

C. Standard of Review

“ERISA does not set out the appropriate standard of review for actions under § 1132(a)(1)(B) challenging benefit eligibility determinations.” Firestone Tire & Rubber Co., 489 U.S. at 109, 109 S.Ct. 948. Rather, the Supreme Court has held that a Plan Administrator’s decision to deny benefits is reviewed de novo, unless the Plan gives the “administrator or fiduciary discretionary authority to determine eligibility for benefits or to construe the terms of the plan.” Id. at 115, 109 S.Ct. 948. When the Plan gives the administrator such discretionary authority, judicial review of the adequacy of a claim decision is limited to determining whether the decision was “arbitrary and capricious” or “an abuse of discretion.” Id. However, the Second Circuit has noted that even where a plan grants such discretionary authority, Department of Labor regulations “impose[ ] minimum requirements for benefit claims procedures, and ... clarif[y] that, when a plan fails to comply with those minimum requirements, the plan’s decision denying a claim should not be entitled to deference in court.” Halo v. Yale Health Plan, 819 F.3d 42, 51 (2d Cir. 2016); see also 65 Fed. Reg. at 70,255 (“The Department’s intentions in including this provision in the proposal were to clarify that the procedural minimums of the regulation are essential to procedural fairness and that a decision made in the absence of the mandated procedural protections should not be entitled to any judicial deference,”). The Halo court held that:

When denying a claim for benefits, a plan’s failure to comply with the Department of Labor’s claims-procedure, regulation, 29 C.F.R. § 2560.503-1, will result in that claim béing reviewéd de novo in federal court, unless the plan has otherwise established procedures in full conformity with the regulation and can show that its failure to comply with the claims-procedure regulation in the processing of a particular claim was inadvertent and harmless.

Halo, 819 F.3d at 58.

IV. DISCUSSION

Plaintiffs assert three causes of action: (1) under ERISA § 502(a)(1)(B) to recover full benefits due; (2) under ERISA § 502(a)(3) to remedy alleged breaches of fiduciary duty and claims procedure; and (3) under ERISA § 502(a)(1)(A) for the Plan Administrator’s alleged failure to supply plan information within 30 days. As a preliminary matter, the Court considers whether Plaintiffs have exhausted their administrative remedies.

A. Exhaustion of Administrative Remedies

Defendants argue that they are entitled to summary judgment because Plaintiffs “failed to exhaust available administrative remedies and cannot show that an appeal would have been futile.” (Dkt. No. 41-23, p. 9; Dkt. No. 42-15, p. 14). In ERISA cases, “[a] failure to exhaust administrative remedies provides grounds for dismissal or summary judgment in favor of the opposing party.” Zarringhalam v. United Food & Commercial Workers Int’l Union Local 1500, 906 F.Supp.2d 140, 152 (E.D.N.Y. 2012); see also Klotz v. Xerox Corp., 332 Fed.Appx. 668, 669 (2d Cir. 2009).

1) Relevant Law

The Second Circuit has “recognized the firmly established federal policy favoring exhaustion of administrative remedies in ERISA cases.” Halo, 819 F.3d at 55 (quoting Kennedy v. Empire Blue Cross & Blue Shield, 989 F.2d 588, 594 (2d Cir. 1993)). However, the Circuit has also “explained that there is a balance to be struck” and that “ERISA requires both that employee benefit plans have reasonable claims procedures in place, and that plan participants avail themselves of these procedures before turning to litigation.” Id. at 55-56 (second quotation from Eastman Kodak Co. v. STWB, Inc., 452 F.3d 215, 219 (2d Cir. 2006)). Essential to the Halo decision was an ERISA regulatory provision, which notes:

In the case of the failure of a plan to establish or follow claims procedures consistent with the requirements of this section, a claimant shall be deemed to have exhausted the administrative remedies available under the plan and shall be entitled to pursue any available remedies under section 502(a) of the Act on the basis that the plan has failed to provide a reasonable claims procedure that would yield a decision on the merits of the claim.

29 C.F.R. § 2560.503-1(1). Construing this provision, the Halo court rejected the “substantial compliance” standard that courts had frequently applied on the basis that it was “flatly inconsistent” with the ERISA regulations promulgated in 2000. Halo, 819 F.3d at 56.

The ERISA regulatory framework provides “minimum requirements for employee benefit plan procedures pertaining to claims for benefits by participants and beneficiaries” and obligates the plans to “establish and maintain reasonable procedures governing the filing of benefit claims, notification of benefit determinations, and appeal of adverse benefit determinations.” 29 C.F.R. § 2560.503-1(a)-(b), One such minimum requirement for a reasonable claims procedure is:

In the case of a post-service claim, the plan administrator shall notify the claimant, in accordance with paragraph (g) of this section, of the plan’s adverse benefit determination within a reasonable period of time, but not later than 30 days after receipt of the claim. This period may be extended one time by the plan for up to 15 days, provided that the plan administrator both determines that such an extension is necessary due to matters beyond the control of the plan and notifies the claimant, prior to the expiration of the initial 30-day period, of the circumstances requiring the extension of time and the date by which the plan expects to render a decision. If such an extension is necessary due to a failure of the claimant to submit the information necessary to decide the claim, the notice of extension shall specifically describe the required information, and the claimant shall be afforded at least 45 days from receipt of the notice within which to provide the specified information.

29 C.F.R. § 2560.503—1(f)(2)(iii)(B). As the Ninth Circuit has stated and the Second Circuit has agreed, “In simple English, what this regulation calls for is a meaningful dialogue between ERISA plan administrators and their beneficiaries.” See Booton v. Lockheed Medical Benefit Plan, 110 F.3d 1461, 1463 (9th Cir. 1997); Juliano v. HMO of N.J., Inc., 221 F.3d 279, 287 (2d Cir. 2000); see also Magee v. Metro. Life Ins. Co., 632 F.Supp.2d 308, 318-19 (S.D.N.Y. 2009) (quoting Juliano and noting that “ERISA requires an administrator to inform plan participants of the information it seeks and the criteria to be applied”).

2) General Reasonableness of the Claims Process

As noted above, Plaintiffs allege that they received only two written replies from Excellus in response to submissions of benefits claims in February, May, June, August, and October 2014. Excellus asserts that it sent additional replies, but that there are no copies of these replies in the record because, as a general practice, it does not retain copies after sending them. (Dkt. No. 42-1, p. 7 nn. 2, 4). Of the two responses in the record, the first, dated March 4, 2014, noted that “a valid procedure code and/or detailed description of service” as well as a “valid diagnosis code and/or detailed description of illness” were “missing or invalid;” however, it omitted any mention of an itemized invoice. (Dkt. No. 43-7, p. 41). The second reply, dated June 30, 2014, noted that Excellus needed “To and From dates of service” on an “itemized statement;” however, it failed to specify which claim it referred to and did not request procedure or diagnosis codes. (Id. at p. 42). It has adduced no evidence that the purported additional responses were consistent with each other or otherwise procedurally valid.

Plaintiffs fared no better in telephone communications with Excellus. When Plaintiffs’ counsel’s office called Excellus on May 8, 2014, the Excellus representative did not indicate that there were any deficiencies with Plaintiffs’ benefits claims. (Id. at pp. 7-9). During a subsequent call on May 28, 2014, Plaintiffs requested “something in writing such as a denial” so they could pursue an appeal; however, Excellus never responded to this request. (Dkt. No. 43-3, ¶¶ 31-33; Dkt. No. 47-1, ¶¶ 31-33; Dkt. No. 48-1, ¶¶ 31-33; Dkt. No. 61).

These written and telephonic interactions do not constitute a “meaningful dialogue” like that which the ERISA regulations envision. Excellus’ inconsistencies and failures to respond, particularly after Plaintiffs sought to carry forward their claims to the appeals process, are significant procedural deficiencies that caused legitimate harm to Plaintiffs, who were left to believe that they could not appeal to Excellus and faced significant economic hardship as they paid for B.E.’s treatment out-of-pocket. These problems, along with Excellus’ failure to keep records of claim return notifications, support a finding that it did not “maintain reasonable procedures governing the filing of benefit claims” as required.

3) Requirements under 29 C.F.R. § 2560.503-1(f)—Notice of Extension

Additionally, Excellus failed to meet .the requirements of 29 C.F.R. § 2560.503—1(f). As noted above, where a group health plan claimant for post-service benefits submits a claim that lacks necessary information, the plan must respond within 30 days with either an adverse benefit determination or a “notice of extension” that (1) “notifies the claimant ... of the circumstances requiring the extension .., and [ (2) ] the date by which the plan expects to render a decision,” (3) “specifically describes the required information,” and (4) affords the claimant “at least 45 days from receipt of the notice within which to provide the specified information.” See 29 C.F.R. § 2560.503—1(f)(2)(iii)(B). After providing a notice of extension, the requirement to issue an adverse benefit determination is tolled until “claimant responds to the request for additional information.” 29 C.F.R. § 2560.503-1(f)(4). An interpretative FAQs page on the Department of Labor’s website notes that the tolling provision has broader meaning, such that

[t]he time period for making the decision is suspended (tolled) from the date of the notification to the claimant to the earlier of:

• The date on which a response from the claimant is received by the plant, or]

• The date established by the plan for the furnishing of the requested information (at least 45 days)[.]

Dep’t of Labor, Benefit Claims Procedure Regulation FAQs, (Nov. 14, 2016, 11:11am), https://www.dol.gov/agencies/ ebsa/about-ebsa/our-activities/resource-center/faqs/benefit-claims-procedure-regulation, C-3. Here, Excellus did not issue a timely adverse benefit determination and also failed on at least two occasions to meet the procedural requirements for its notices of extension.

a. Failure to Issue a Timely Adverse Benefit Determination

Even after Plaintiffs’ May 28, 2014 phone call, Excellus never issued an adverse benefit determination for Plaintiffs’ February claims submission. Consequently, Excellus violated subsection (f). An adverse benefit determination means any of the following:

A denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit, including any such denial, reduction, termination, or failure to provide or make payment that is based on a determination of a participant’s or beneficiary’s eligibility to participate in a plan, and including, with respect to group health plans, a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit resulting from the application of any utilization review, as well as a failure to cover an item or service for .which benefits are otherwise provided because it is determined to be experimental or investigational or not medically necessary or appropriate.

29 C.F.R. § 2560.503-1(m)(4). Under subsection (g), any adverse benefit determination must notify the claimant of the specific plan provision upon which the determination is based, the plan’s review procedures, time limits, and other information. 29 C.F.R. § 2560.503-1(g). Plans are permitted to issue an adverse benefit determination denying claims “at any point in the administrative process on the basis that it does not have sufficient information.” Benefit Claims Procedure Regulation FAQs, C-21. However, as discussed above, plans may also afford claimants additional time to submit information before issuing an adverse benefit determination, in accordance with subsection (f) of the regulations. Thus, a notification to a participant requesting additional information can, but does not necessarily, constitute an adverse benefit determination.

Thus, while the ERISA regulatory scheme would allow Excellus to deny Plaintiffs’ claims for lack of sufficient information, it requires Excellus to include information about the appeals process, and comport with the formalities of subsection (g) when issuing such an adverse benefit determination. Excellus did not issue a denial, as required by the PPO Contract. (Dkt. No. 41-6, p. 42). Its responses lacked information about further administrative review, did not reference specific plan provisions that Plaintiffs violated, and did not make clear “in a manner calculated to be understood by the claimant” that it was issuing an initial denial. See 29 C.F.R. § 2560.503-1(g). In fact, Excellus’ communications to Plaintiffs did not suggest that it had denied Plaintiffs’ claims or terminated their benefits, but rather stated that it had not processed Plaintiffs’ claims at all. (See Dkt. No. 43-7, pp. 41-42). Thus, on these facts, the Court finds that the Excel-lus responses in the record did not constitute adverse benefit determinations.

Plaintiffs’ May 28, 2014 phone call to Excellus, in which they requested a written denial so that they “can move forward and appeal if possible” (Dkt. No. 61), constitutes a response to the prior Excellus communications, which had notified Plaintiffs that they needed to submit additional information. Thus, even if that notice was sufficient to toll the time limit within which Excellus needed to issue an adverse benefit determination in connection with the February claim for benefits, that tolling ceased on May 28, 2014, giving Excellus 15 days to issue an adverse benefit determination. See 29 C.F.R. § 2560.503-1(f)(2)(iii)(B), (f)(4). Excellus failed to do so, thereby violating the ERISA regulations.

Excellus argues that the regulatory timing provisions do not apply, however, because Plaintiffs’ failure to provide additional information “precluded Excellus from conducting an initial review of the claims and from making an initial determination.” (Dkt. No. 47, p. 15). This argument is unavailing. The ERISA regulations state that adverse benefit determinations must be made “within a reasonable period of time” regardless of whether the claimant has submitted all necessary information. 29 C.F.R. § 2560.503—1(f)(2)(iii)(B), (f)(4). These provisions also permit plans to limit the amount of time afforded claimants to provide necessary information; id. therefore, it follows that plans may deny claims if claimants do not meet the time limitation. The Department of Labor FAQs add further support to this interpretation, noting that “[t]he time for making an initial claims decision begins to run when the claim is filed in accordance with a plan’s reasonable filing procedures, regardless of whether the plan has all of the information necessary to decide the claim at the time of the filing” and that, even when missing necessary information, “the plan may nevertheless have to make a decision on the claim before receiving such information.” Benefit Claims Procedure Regulation FAQs, C-1-C-2 (emphasis added). Excellus has therefore violated the timing provisions in subsection (f).

b. Requirements of a “Notice of Extension”

As stated, the parties dispute the number of responses Excellus issued in response to Plaintiffs’ claims for benefits. None of Excellus’ written or telephonic communications in the record include “the date by which the plan expects to render a decision” or a “date established by the plan for the furnishing of the requested information.” See 29 C.F.R. § 2560.503-1(f)(2)(iii)(B); Benefit Claims Procedure Regulation FAQs, C-3. Furthermore, Ex-cellus has adduced no evidence that the purported additional responses contained such information. Thus, even construing the evidence in a light most favorable to the Defendants, Excellus has failed to abide by requirements for issuing a sufficient “notice of extension” under subsection (f). See Linder v. BYK-Chemie USA, Inc., 313 F.Supp.2d 88, 93 n.4 (D. Conn. 2004) (“Moreover, because the letter inviting Linder to provide additional information nowhere states that an extension of time was necessary, and nowhere provides a date by which the plan expected to render a decision, it does not meet the regulation’s requirements for notice of an extension of time to process a claim.”).

4) Exeellus’ Argument that the ERISA Regulations at Issue Do Not Apply

Excellus also argues that because it did not technically deny Plaintiffs’ claims for benefits, ERISA § 503, which refers specifically to denials, and 29 C.F.R. § 2560.503-1, which “flows from” that statutory section, are inapplicable. (Dkt. No. 47, p. 16). Excellus cites Tolle v. Carroll Touch, Inc., 23 F.3d 174, 180 (7th Cir. 1994), for the proposition that absent a denial of a benefits claim, “plans are not require[d] to comply with the conditions under § 503 and related regulations.” (Dkt. No. 47, p. 17). This argument is unavailing. The holding in Tolle, decided in 1994, was based upon a previous version of the ERISA regulations. Unlike the current codification, the 1994 regulations did not specify that they derived authority from both ERISA § 503 (referring specifically to notice and review “to any participant whose claim for benefits ... has been denied”) and ERISA § 505 (broadly authorizing the promulgation of regulations “necessary or appropriate to carry out the provisions of this title”). Compare 29 C.F.R. § 2560.503-1(a)(1) (1994) (not specifying its source of authority) with 29 C.F.R. § 2560.503-1(a)(1) (2016) (noting its promulgation “[i]n accordance with the authority of sections 503 and 505”); see also 29 U.S.C. §§ 1133, 1135.

Furthermore, the 1994 codification did not contain the provision now found at 29 C.F.R. § 2560.503—1(f)(2)(iii)(B), which specifically regulates plan procedures in cases where an extension of time to determine a claim is needed “due to a failure of the claimant to submit the information necessary.” 29 C.F.R. § 2560.503-1 (1994). Applying this earlier version, the Tolle court reasoned that the plan at issue “was not required to comply with the procedural requirements of § 503 [in rejecting the claim]” because the plan had provided notice that it “could not process [the] claim because the claim form was not completed in all of its parts.” Tolle, 23 F.3d at 180. Post-Tolle updates to the regulatory scheme plainly require additional notice procedures, which Defendants in this case have failed to meet. As a result, Exeellus’ argument that the regulations are inapplicable in this case must fail.

5) Conclusion

Construing the facts in the light most favorable to Defendants, resolving all ambiguities in their favor, and drawing all reasonable inferences against Plaintiffs, the Court finds that Defendants violated the procedural requirements of the ERISA regulations as promulgated at 29 C.F.R. § 2560.503-1. As noted above, the burden is on Defendants to show that these procedural failings were “inadvertent and harmless.” Halo, 819 F.3d at 58. Here, however, the record shows that the procedural deficiencies left Plaintiffs believing that they could not pursue further administrative appeal. While it is true that Plaintiffs are not blameless in the miscommunications among the parties to this litigation, it is undisputed that Plaintiffs attempted to pursue administrative remedies following the Exeellus responses to their February submission of benefits claims by requesting that Exeellus issue a written decision so that they could appeal. Exeellus, however, did not issue a decision, and because it did not provide Plaintiffs with information regarding the appeals process, it delayed final adjudication of Plaintiffs’ claims and prevented further development of the administrative record. Thus, Plaintiffs reasonably believed that their sole remaining option was to seek redress from the courts and, as a result, unquestionably suffered harm. The Court therefore finds that Plaintiffs have exhausted administrative remedies and that Defendants are not entitled to summary judgment on that ground. The Court turns to the issue of whether Plaintiffs may assert a claim to recover benefits against Excellus.

B. ERISA § 502(a)(1)(B) Claims

ERISA § 502(a)(1)(B) permits civil actions by a participant or beneficiary “to recover benefits due to him under the terms of his plan, to enforce his rights under the terms of the plan, or to clarify his rights to future benefits under the terms of the plan.” 29 U.S.C. § 1132(a)(1)(B). Plaintiffs seek de novo review of their mental health claims and a judgment that they are entitled to reimbursement for mental health benefit costs incurred. (Dkt. No. 27, p. 14).

1) Plaintiffs’ Claim to Recover Full Benefits Due as Against Excellus

Excellus argues that it is entitled to summary judgment with respect to the Plaintiffs’ claim under § 502(a)(1)(B) because, as a claims administrator, it is not a proper defendant. The Second Circuit has stated held that “[i]n a recovery of benefits claim, only the plan and the administrators and trustees of the plan in their capacity as such may be held liable.” Chapman v. ChoiceCare Long Island Term Disability Plan, 288 F.3d 506, 509-10 (2d Cir. 2002); see also Delprado v. Sedgwick Claims Mgmt. Servs., Inc., No. 1:12-CV-00673, 2015 WL 1780883, at *38, 2015 U.S. Dist. LEXIS 51263 (N.D.N.Y. Apr. 20, 2015). However, in New York State Psychiatric Ass’n v. UnitedHealth Group, the Second Circuit held that “where the claims administrator has sole and absolute discretion to deny benefits and makes final and binding decisions as to appeals of those denials,” it “is an appropriate defendant in a § 502(1)(B) action for benefits.” 798 F.3d 125, 132 (2d Cir. 2015). The New York State Psychiatric Ass’n court noted that § 502(a)(1)(B) does not, “by is plain terms ... preclude suits against claims administrators” and noted that “since Leonelli [v. Pennwalt Corp., 887 F.2d 1195 (2d Cir. 1989) ], we have not held or even suggested that a claims administrator is an improper defendant under § 502(a)(1)(B).” Id. at 132-33.

Here, Excellus is a claims administrator but does not have sole and absolute discretion to deny benefits,” and it does not make final and binding decisions as to appeals. Plan participants can appeal Ex-cellus’ determinations to CMC, which can then make a final determination on claims for benefits that binds Excellus. (Dkt. No. 45-1, ¶ 9; Dkt. No. 46-1, ¶¶ 9-11). The Second Circuit holding in New York State Psychiatric Ass’n did not address these facts, and prior to its holding, the longstanding rule in the Second Circuit was that only a plan administrator or fiduciary could be held liable under § 502(a)(1)(B). See Levi v. McGladrey LLP, No. 12-CV-8787, 2016 WL 1822442, at *4-5, 2016 U.S. Dist. LEXIS 44617, at *12-13 (S.D.N.Y. Mar. 31, 2016) (citing Crocco v. Xerox Corp., 137 F.3d 105, 107-08 (2d Cir. 1998); Gates v. United Health Grp,, No. 11 Civ. 3487, 2012 WL 2953050, at *10, 2012 U.S. Dist. LEXIS 100831, at *31 (S.D.N.Y. 2012) (noting that “discretion or control over certain administrative functions doe's not make a party a de-facto plan administrator” and that, as a result, “plaintiff cannot maintain her Section 502(a)(1)(B) claim against UHIC”). Since there is no governing precedent for holding a claims administrator with less than total control responsible, the Court, finds that Excellus is not hable under Count I of the Second Amended Complaint, and that Count is therefore dismissed as against Excellus,

2) Judicial Review and the Administrative Record

For Plaintiffs’ § 502(a)(1)(B) claim against the CMC Defendants, it remains for the Court to determine the standard of judicial review. Generally, when courts consider an ERISA claim alleging improper denial of benefits, “a de novo standard of review will apply to the plan administrator’s determination, unless the plan grants authority to the administrator to use his or her discretion to construe the terms of the plan and determine eligibility for plan benefits.” Wilson v. Aetna Life Ins. Co., No. 8:15-CV-752, 2016 WL 5717370, at *5, 2016 U.S. Dist. LEXIS 135396, at *13 (N.D.N.Y. 2016) (citing Firestone Tire and Rubber Co., 489 U.S. at 115, 109 S.Ct. 948). While the Plan grants CMC such discretionary authority, the extent to which Excellus exercises discretion is unclear. Nevertheless, procedural deficiencies in the claims process mean that, under Halo and 29 C.F.R. §. 2560.503-1(1), the Court must apply a de novo standard.

a. Evidence under Review

When conducting de novo review of administrative decisions on ERISA claims, “district courts typically limit their review to the administrative record before the plan at the time it denied the claim.” Halo, 819 F.3d at 60. The Second Circuit, however, has recognized that “the decision whether to admit additional evidence is one which is discretionary -with the district court, but which discretion ought not to be exercised in the absence of good cause.” Id. (quoting DeFelice v. Am. Int’l Life Assurance Co., 112 F.3d 61, 66-67 (2d Cir. 1997)). “[G]ood cause to admit additional evidence may exist if the plan’s failure to comply with the claims-procedure regulation adversely affected the development of the administrative record.” Id. (emphasis added). “The decision whether to consider information outside the administrative record is a discretionary one even where there is ‘good cause,’ ” Locher v. UNUM Life Ins. Co. of Am., 389 F.3d 288, 295 (2d Cir. 2004) (citing Critchlow v. First UNUM Life Ins. Co. of Am., 340 F.3d 130 n.2 (2d Cir. 2003) (withdrawn and vacated on reconsideration on other grounds, 378 F.3d 246 (2d Cir. 2004)).

While the facts of this case might establish good cause to look beyond the administrative record, the Court, in its discretion, declines to do so. Although supplementing an administrative record may be appropriate under different facts, the situation here would essentially require the Court to create the administrative record db initio. It is not the role of the district courts to serve as substitute claims administrators. Novick v. Metro. Life Ins. Co., 914 F.Supp.2d 507, 528 (S.D.N.Y. 2012) (citing Miller v. United Welfare Fund, 72 F.3d 1066, 1071 (2d Cir. 1995)). Although Defendants’ procedural violations hindered development of the administrative record, their failures are balanced against: (1) Plaintiffs’ failure to provide the additional information that Excellus requested; (2) the absence of any suggestion that Defendants have a conflict of interest or would otherwise render a biased or unfair determination of Plaintiffs’ claims if provided the requested information; (3) Defendants’ relative expertise in creating an administrative record and determining medical necessity; and (4) the Court’s interest in judicial economy. Therefore, the Court will not look beyond the administrative record upon its exercise of de novo review.

Here, the administrative record contains only the documentation that Excellus had before it when reviewing Plaintiffs’ claims. That consists of all relevant documents describing rights and obligations under the Plan, Plaintiffs’ claims submissions pertaining to Maple Lake, which included Maple Lake invoices, and records of communication among Plaintiffs, Excellus, and CMC.

b. Application of Judicial Review

“When applying the de novo standard of review, the Court reviews ‘all aspects of the denial of an ERISA claim.’ ” McDonnell v. First Unum Life Ins. Co., No. 10-CV-8140, 2013 WL 3975941, at *11, 2013 U.S. Dist. LEXIS 110361, at *37-38 (S.D.N.Y. Aug. 5, 2013) (citing Kinstler v. First Reliance Std. Life Ins. Co., 181 F.3d 243, 245 (2d Cir. 1999)). The Court gives no deference to the administrative interpretation of the plan documents or its conclusion regarding the merits of the claim, but rather “reaches its own conclusion about whether the plaintiff has shown, by a preponderance of the evidence, ... entitlement] to benefits under the plan.” McDonnell, 2013 WL 3975941, at *12, 2013 U.S. Dist. LEXIS 110361, at *39. As always at the summary judgment stage, a genuine issue of material fact would prevent the Court from awarding judgment as a matter of law.

Here, the ASC “expressly approves the terms and conditions set forth in the [PPO Contract]” and provides that “[b]enefits will be provided only if all of the terms and conditions set forth in [the PPO Contract] are satisfied.” (Dkt. No. 43-4, ¶ 5.1(a)). One relevant condition is that the Plan “provide[s] coverage ... for the covered benefits described ... as long as the hospitalization, care, service, technology, test, treatment, drug, or supply (collectively, “Service”) is Medically Necessary.” (Dkt. No. 41-6, p. 10). The Claims Administrator (Excellus) “decide[s] whether care was Medically Necessary ... base[d] ... in part on a review of [ ] medical records ... [and] medical opinions.” (Id. at p. 10). Services are Medically Necessary only if:

A. they are appropriate and consistent with the diagnosis and treatment of your medical condition;

B. they are required for the direct care and treatment or management of that condition;

C. if not provided, your condition would be adversely af