Getzes v. Mackereth

Filing 19

MEMORANDUM re MOTION to Dismiss 14 ; (Order to follow as separate docket entry) Signed by Honorable William W. Caldwell on 10/28/13. (ma)

IN THE UNITED STATES DISTRICT COURT
FOR THE MIDDLE DISTRICT OF PENNSYLVANIA
WILLIAM GETZES, by his mother and
next friend, Alice Getzes,
Plaintiff
v.

BEVERLY MACKERETH, in her official
capacity as Secretary of the Department
of Public Welfare of the Commonwealth
of Pennsylvania,
Defendant

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CIVIL NO. 1:13-CV-2067

MEMORANDUM
I.

Introduction
This matter is before the court on the motion to dismiss (Doc. 14) filed by

Defendant Beverly Mackereth, in her official capacity as the Secretary of the Department
of Public Welfare of the Commonwealth of Pennsylvania (“DPW”). Plaintiff William
Getzes opposes the motion. For the reasons that follow, the court will deny the motion.
II.

Background
A.

Procedural History

By complaint filed on August 2, 2013 (Doc. 1), Plaintiff initiated this action
seeking declaratory and injunctive relief stemming from DPW’s refusal to authorize his
claim for reimbursement of expenses associated with the installation of fixed dental
bridges, a type of permanent dental restoration used to replace missing teeth.
Specifically, Plaintiff contends that DPW’s refusal to authorize payment violates his right
to medically necessary dental care pursuant to Title XIX of the Social Security Act, 42

U.S.C. §§ 1396 et seq. (“Medicaid Act”). Plaintiff also claims that DPW’s refusal
constitutes a failure to reasonably accommodate his disabling cerebral palsy and seizure
disorder, in violation of Title II of the Americans with Disability Act (“ADA”), 42 U.S.C. §
12132, and § 504 of the Rehabilitation Act (“RA”), 29 U.S.C. § 794.
On October 7, 2013, DPW filed the instant motion to dismiss and
supporting brief (Docs. 14, 15) seeking dismissal of this action on the grounds that
Plaintiff failed to: (1) exhaust his administrative remedies; or (2) state a plausible claim
for discrimination claim under the ADA or RA. Plaintiff filed a brief in opposition (Doc. 18)
on October 17, 2013, and the matter is ripe for disposition.
B.

Facts1

Plaintiff is a fifty-one-year-old man with cerebral palsy and a seizure
disorder. (Doc. 1 at ¶ 1). He is intellectually disabled, has limited motor skills, and
requires constant supervision. (Id. at ¶ 30). He is enrolled in Pennsylvania’s Medical
Assistance program administered by DPW, which provides medical care to needy
individuals pursuant to the Medicaid Act. (Id. at ¶¶ 4, 14).
Due to an infection, Plaintiff’s dentist removed four of his teeth on May 30,
2013. (Id. at ¶ 36). As a result, only seven teeth remain, and Plaintiff is unable to chew
most solid foods. (Id. at ¶ 37). Plaintiff requires false teeth to consume solid foods and

1

In light of the applicable standard of review, see infra, Part III, the factual
allegations in Plaintiff’s complaint are accepted as true for purposes of ruling on the
pending motion to dismiss.
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receive proper nutrition, but temporary dentures present a significant choking hazard due
to his physical and cognitive limitations. (Id. at ¶¶ 39, 41).
On June 21, 2013, Plaintiff’s dentist submitted a claim to DPW requesting
authorization for payment to provide permanent, fixed dental bridges to Plaintiff in lieu of
dentures. (Id. at ¶ 42). While the Medical Assistance program pays for dentures for
program enrollees such as Plaintiff, DPW denied Plaintiff’s request for fixed dental
bridges as non-compensable under the program. (Id. at ¶¶ 43-44).
III.

Standard of Review
On a motion to dismiss pursuant to Federal Rule of Civil Procedure

12(b)(6), “[w]e accept all factual allegations as true, construe the complaint in the light
most favorable to the plaintiff, and determine whether, under any reasonable reading of
the complaint, the plaintiff may be entitled to relief.” Byers v. Intuit, Inc., 600 F.3d 286,
291 (3d Cir. 2010) (citation and internal quotation marks omitted).
A complaint need only contain “a short and plain statement of the claim,”
Fed. R. Civ. P. 8(a)(2), and detailed factual allegations are not required. Bell Atlantic
Corp. v. Twombly, 550 U.S. 544, 555 (2007). Nonetheless, a complaint has to plead
“enough facts to state a claim to relief that is plausible on its face.” Id. at 570. “The
plausibility standard is not akin to a ‘probability requirement,’ but it asks for more than a
sheer possibility that a defendant has acted unlawfully.” Ashcroft v. Iqbal, 556 U.S. 662,
678 (2009) (quoting Twombly, 550 U.S. at 556). “[L]abels and conclusions” are not

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enough, Twombly, 550 U.S. at 555, and a court “is not bound to accept as true a legal
conclusion couched as a factual allegation.” Id. (citation omitted).
The Third Circuit has described the Rule 12(b)(6) inquiry as a three-step
process:
First, a court must take note of the elements a plaintiff must
plead to state a claim. Second, the court should identify
allegations that, because they are no more than conclusions,
are not entitled to the assumption of truth. Finally, where there
are well-pleaded factual allegations, a court should assume
their veracity and then determine whether they plausibly give
rise to an entitlement for relief.
Connelly v. Steel Valley Sch. Dist., 706 F.3d 209, 212 (3d Cir. 2013) (citation omitted).
IV.

Discussion
DPW seeks dismissal of this action on the grounds that Plaintiff failed to:

(1) exhaust his administrative remedies; or (2) state a plausible discrimination claim
under the ADA or RA. The court will address each issue in turn.
A.

Exhaustion

DPW argues that the court should dismiss this action because Plaintiff
failed to exhaust administrative remedies by not appealing DPW’s denial of payment for
fixed dental bridges to the state board of hearing appeals. (Doc. 15 at 4). Plaintiff, in turn,
contends that administrative exhaustion is not a prerequisite to filing suit under the
Medicaid Act, ADA, or RA. (Doc. 18 at 2). We agree that Plaintiff was not required to
exhaust administrative remedies prior to initiating the instant action.
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With respect to his claim under the RA, “section 504 plaintiffs may proceed
directly to court without pursuing administrative remedies.” Freed v. Consol. Rail Corp.,
201 F.3d 188, 194 (3d Cir. 2000); see also Burkhart v. Widener Univ., Inc., 70 F. App’x
52, 53-54 (3d Cir. 2003) (non-precedential) (“[P]laintiffs need not exhaust their
administrative remedies prior to bringing suit under § 504 of the [RA], which bars both
federal entities and private entities receiving federal funding from discriminating on the
basis of disability in any context.”); N.J. Prot. & Advocacy, Inc. v. N.J. Dep’t of Educ., 563
F. Supp. 2d 474, 491 (D.N.J. 2008) (same).
Similarly, exhaustion of administrative remedies is not a prerequisite to
filing suit under Title II of the ADA. Weidow v. Scranton Sch. Dist., No. 3:08-CV-1978,
2009 WL 2588856, *8, 2009 U.S. Dist. LEXIS 73622, *25-26 (M.D. Pa. Aug. 19, 2009)
(“Although Title I of the ADA requires exhaustion [of administrative remedies], Title II
does not require it.”) (collecting cases); O’Guinn v. Lovelock Corr. Ctr., 502 F.3d 1056,
1061 (9th Cir. 2007) (“We recognize that neither Title II of the ADA nor section 504 of the
[RA] generally requires administrative exhaustion before filing suit.”) (citation omitted);
Elwell v. Okla. ex rel. Bd. of Regents of the Univ. of Okla., 693 F.3d 1303, 1309 (10th Cir.
2012) (“Title II of the ADA lacks the requirement that an otherwise qualified individual
exhaust EEOC administrative remedies before bringing suit.”) (citation and internal
quotation marks omitted).
Plaintiff may likewise proceed on his claim under the Medicaid Act without
first exhausting administrative remedies. See James v. Richman, 547 F.3d 214, 217-18
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(3rd Cir. 2008) (finding that plaintiff was not required to exhaust state administrative
remedies before bringing action to permanently enjoin state agency from denying
Medicaid benefits); Romano v. Greenstein, 721 F.3d 373, 376 (5th Cir. 2013) (stating
that a Medicaid claimant was not required to exhaust administrative remedies before
seeking review of a state agency decision in federal court); Roach v. Morse, 440 F.3d 53,
56-57 (2d Cir. 2006) (noting that “the Medicaid Act does not explicitly or implicitly require
exhaustion of state remedies before a litigant sues under [42 U.S.C. ] § 1983”).
Accordingly, Plaintiff’s purported failure to exhaust administrative remedies
is not grounds for dismissing this matter.2
B.

Failure to State a Claim

DPW also contends that the complaint fails to state a claim under the ADA
or RA because DPW’s refusal to authorize payment for fixed dental bridges was an
eligibility determination, not discrimination. (Doc. 15 at 8). In essence, DPW argues that
its actions were not discriminatory because the Medical Assistance program does not
pay for anyone to receive fixed dental bridges, regardless of whether or not the claimant
is disabled. Plaintiff asserts that even though funding for fixed dental bridges is not
generally available to Medical Assistance participants, DPW’s failure to reasonably
accommodate his disability by deviating from this rule violated the ADA and RA. For the

2

In the alternative, Plaintiff argues that exhaustion of administrative remedies
would have been futile in this instance, or that the attempt he did make to have DPW
reverse its denial of payment qualified as exhaustion. (Doc. 18 at 6-7). The court need
not address these arguments given our finding that exhaustion was not required.
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reasons that follow, the court finds that Plaintiff has stated a plausible discrimination
claim under the ADA and RA.
Title II of the ADA provides in pertinent part that “no qualified individual with
a disability shall, by reason of such disability, be excluded from participation in or be
denied the benefits of the services, programs, or activities of a public entity, or be
subjected to discrimination by any such entity.” 42 U.S.C. § 12132. Similarly, § 504 of the
RA states that “no otherwise qualified individual with a disability . . . shall, solely by
reason of her or his disability, be excluded from the participation in, be denied the
benefits of, or be subjected to discrimination under any program or activity receiving
Federal financial assistance . . . .” 29 U.S.C. § 794(a).
To state a claim under Title II of the ADA, Plaintiff must allege that: (1) he is
a qualified individual with a disability; (2) he was either excluded from participation in or
denied the benefits of some public entity’s services, programs, or activities or was
otherwise discriminated against; and (3) such exclusion, denial of benefits, or
discrimination was by reason of his disability. 42 U.S.C. § 12132; Douris v. New Jersey,
500 F. App’x 98, 100-01 (3d Cir. 2012) (non-precedential). The substantive standards for
determining liability under § 504 of the RA are equivalent to the ADA. McDonald v. Dep’t
of Pub. Welfare, 62 F.3d 92, 94 (3d Cir. 1995).3 Accordingly, claims under both

3

Section 504 of the RA has an additional “[f]ederal financial assistance”
component, see 29 U.S.C. § 794(a), which is satisfied here. Juvelis v. Snider, 68 F.3d
648, 652 (3d Cir. 1995) (“As a recipient of federal financial assistance, DPW is subject
to the requirements of § 504.”).
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provisions are interpreted consistently. Emerson v. Thiel College, 296 F.3d 184, 189 (3d
Cir. 2002).
In its motion to dismiss, DPW challenges the second and third elements of
Plaintiff’s claims under the ADA and RA, contending that it did not deny Plaintiff any
“benefit” of the Medical Assistance program on the basis of his disability because
payment for fixed dental bridges is not a benefit to which anyone is entitled under the
program. This argument, while logical, fails because it too narrowly defines the “benefit”
DPW provides. As the Supreme Court has explained, “the benefit . . . cannot be defined
in a way that effectively denies otherwise qualified handicapped individuals the
meaningful access to which they are entitled; to ensure meaningful access, reasonable
accommodations in the . . . program or benefit may have to be made.” Alexander v.
Choate, 469 U.S. 287, 300 (1985).
Here, the “benefit” DPW provides pursuant to the Medicaid Act is “medical
assistance,” which in this instance include “dental services.” See 42 U.S.C. §
1396a(a)(10)(A). Plaintiff has sufficiently alleged that he was denied the benefit of
medically necessary dental services on the basis of his disability. Specifically, he has
alleged that: (1) he requires restorative dental work; (2) his disability prevents him from
wearing temporary dentures, which are compensable under the Medical Assistance
program; and (3) DPW refuses to reasonably accommodate his inability to wear dentures
by authorizing payment for the alternative–permanent fixed dental bridges. While such
payment would be a deviation from DPW’s program under which fixed dental bridges are
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non-compensable, failure to alter the program or benefit can constitute discrimination
under the ADA and RA.
Ultimately, DPW can avoid liability if it establishes that “accommodating
[Plaintiff] would require a fundamental modification [of the program or benefit] or an
undue burden . . . .” Juvelis v. Snider, 68 F.3d 648, 653 (3d Cir. 1995) (quoting Easley v.
Snider, 36 F.3d 297, 302 (3d Cir. 1994)). The court, however, will resolve the question of
the propriety of Plaintiff’s proposed accommodation at a later stage in this litigation. For
now, Plaintiff has pleaded sufficient facts to state a claim under the ADA and RA.
V.

Conclusion
For the foregoing reasons, we will deny DPW’s motion to dismiss. (Doc.

14). We will issue an appropriate order.

/s/William W. Caldwell
William W. Caldwell
United States District Judge

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