Eleventh Circuit Affirms Dismissal of ERISA Benefits Claim for Failure to Plausibly Allege Primary Coverage, but Remands to Permit Amendment

In Mendoza v. Aetna Life Insurance Company, No. 23-13674, 2026 WL 775293 (11th Cir. Mar. 19, 2026), the Eleventh Circuit affirmed dismissal of an ERISA § 502(a) claim where the plaintiff failed to plausibly allege that the defendant insurer was responsible as the primary payor under a coordination of benefits provision—but held that the plaintiff should be given an opportunity to amend.

The case arose after the plaintiff sought coverage for over $420,000 in medical expenses related to her newborn twins’ extended NICU stay. The insurer denied the claim, asserting it was the secondary carrier and that another plan—held by the children’s father—was primary.

The plaintiff alleged that the father’s plan did not cover the children because they were never enrolled, and therefore her plan should be primary. But the Eleventh Circuit agreed with the district court that these allegations were insufficient to state a plausible claim for benefits. The court emphasized that the plan’s coordination of benefits provision turned on the existence of coverage—not enrollment—and included the “birthday rule,” under which the parent with the earlier birthday provides primary coverage.

Critically, the complaint failed to allege key facts necessary to establish that the insurer’s denial was wrongful. The plaintiff did not plead facts showing that the father’s plan did not provide coverage for the newborns, nor did she allege that the birthday rule would make her plan primary. Without such factual allegations, the claim did not rise above speculation.

The Eleventh Circuit rejected the plaintiff’s arguments that her allegations were sufficient, that the coordination of benefits provision did not apply to newborn coverage, and that the district court improperly resolved factual issues at the pleading stage. Instead, the court held that the complaint lacked the factual content necessary to plausibly establish entitlement to benefits.

However, the court reversed in part and remanded, holding that dismissal with prejudice was improper. Because the missing facts—such as the father’s birthdate and the terms of his insurance plan—were readily available to the plaintiff and could potentially cure the deficiencies, the plaintiff should be given an opportunity to amend her complaint in good faith.