Dina Mendoza v. Aetna Life Insurance Company

── Dina Mendoza v. Aetna Life Insurance Company ── Case No.: 23-13674 Court: Court of Appeals for the Eleventh Circuit Date: March 19, 2026 Category: NEW USCA11 Case: 23-13674 Document: 37-1 Date Filed: 03/19/2026 Page: 1 of 17 NOT FOR PUBLICATION In the United States Court of Appeals For the Eleventh Circuit ____________________ No. 23-13674 ____________________ DINA MENDOZA, Plaintiff-Appellant, versus AETNA LIFE INSURANCE COMPANY, Defendant-Appellee. ____________________ Appeal from the United States District Court for the Southern District of Florida D.C. Docket No. 1:23-cv-22237-RNS ____________________ Before NEWSOM, LAGOA, and KIDD, Circuit Judges. USCA11 Case: 23-13674 Document: 37-1 Date Filed: 03/19/2026 Page: 2 of 17 2 Opinion of the Court 23-13674 LAGOA, Circuit Judge: Plaintiff Dina Mendoza appeals the district court’s dismissal with prejudice of her suit against Defendant Aetna Life Insurance Company for failure to state a claim. Mendoza alleges that Aetna violated the Employment Retirement Income Security Act of 1974 (“ERISA”) by wrongfully denying coverage for medical expenses arising from her newborn twins’ extended hospital stay. The dis- trict court dismissed the complaint on the ground that Mendoza failed to plausibly allege facts establishing that Aetna was the pri- mary insurance carrier responsible for the claimed costs. After careful review, and with the benefit of oral argument, we agree that the complaint, as pleaded, does not state a plausible claim for relief and therefore affirm the dismissal. But we remand this matter to allow Mendoza to amend her complaint, if she can, in good faith, correct the deficiencies identified in this opinion. I. FACTUAL AND PROCEDURAL BACKGROUND Plaintiff Dina Mendoza gave birth to twin daughters at South Miami Hospital on September 13, 2020. Unfortunately, the newborn twins experienced health complications which required an extended hospital stay and treatment in the ICU. In total, the Hospital billed $420,269.00 to Mendoza’s insurance carrier, Aetna, for the costs of the newborns’ medical treatment. Aetna, however, denied coverage, maintaining that it was the secondary insurance carrier and responsible only for payment not covered by the primary insurer. The father of the newborns USCA11 Case: 23-13674 Document: 37-1 Date Filed: 03/19/2026 Page: 3 of 17 23-13674 Opinion of the Court 3 also has an insurance plan, but Mendoza maintains that the new- borns were never enrolled in the father’s plan and that his plan does not provide coverage for the newborns’ medical costs, making Aetna the primary insurer. Mendoza therefore twice appealed Aetna’s denial decision, to no avail. In rejecting Mendoza’s ap- peals, Aetna explained that it “is the secondary carrier [and] [a]nother carrier is the primary insurer for these charges.” As relevant to this determination, Mendoza’s insurance plan includes a coordination of benefits (“COB”) provision. Under that provision, when a dependent child is covered by both her parents’ insurance plans, the plan of the parent whose birthday falls earlier in the calendar year is deemed the primary carrier. This is known as the “birthday rule.” Mendoza does not all