Court Opinion

ID: 9350958
Source: CourtListenerOpinion
Date Created: 2022-12-28 21:01:57.063579+00
Date Added: 2024-06-11T16:57:53.171648
License: Public Domain

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                                                 PUBLISHED

                                   UNITED STATES COURT OF APPEALS
                                       FOR THE FOURTH CIRCUIT

                                                  No. 21-2375

        NEIL BASTA

                       Plaintiff - Appellant

        v.

        NOVANT HEALTH INCORPORATED; NOVANT HEALTH SOUTHERN
        PIEDMONT REGION, LLC; THE PRESBYTERIAN HOSPITAL, d/b/a Novant
        Health Huntersville Medical Center

                       Defendants - Appellees

        ------------------------------

        UNITED STATES OF AMERICA

                       Amicus Supporting Appellant.

        Appeal from the United States District Court for the Western District of North Carolina, at
        Charlotte. Robert J. Conrad, Jr., District Judge. (3:19−cv−00064−RJC−DSC)

        Argued: October 28, 2022                                      Decided: December 27, 2022

        Before WILKINSON and NIEMEYER, Circuit Judges, and TRAXLER, Senior Circuit
        Judge.

        Reversed and remanded by published opinion. Judge Wilkinson wrote the opinion, in
        which Judge Niemeyer and Senior Judge Traxler joined.
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        ARGUED: David John Hommel, Jr., EISENBERG & BAUM, LLP, New York, New
        York, for Appellant. David E. Stevens, JOHNSTON, ALLISON & HORD, P.A.,
        Charlotte, North Carolina, for Appellees. Noah Benjamin Bokat-Lindell, UNITED
        STATES DEPARTMENT OF JUSTICE, Washington, D.C., for Amicus United States.
        ON BRIEF: Andrew Rozynski, EISENBERG & BAUM, LLP, New York, New York, for
        Appellant. Patrick E. Kelly, JOHNSTON, ALLISON & HORD, P.A., Charlotte, North
        Carolina, for Appellees. Kristen Clarke, Assistant Attorney General, Tovah R. Calderon,
        Christopher C. Wang, Civil Rights Division, UNITED STATES DEPARTMENT OF
        JUSTICE, Washington, D.C., for Amicus United States.

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        WILKINSON, Circuit Judge:

               Neil Basta, a deaf man, sought an interpreter to communicate with Novant Health

        Huntersville Medical Center during his wife’s childbirth there. After Novant Health failed

        to provide him with a live interpreter or a functioning Video Remote Interpreting device,

        Basta filed this disability discrimination lawsuit. The district court dismissed his claim.

        Because the court applied an incorrect standard of law, we must reverse its judgment and

        remand for further proceedings. We believe that under the proper standard, the plaintiff has

        plausibly pled enough under the Rehabilitation Act to survive a Fed. R. Civ. P. 12(b)(6)

        dismissal motion.

                                                     I.

                                                    A.

               Neil Basta sought medical care for his pregnant wife at Novant Health Huntersville

        Medical Center (Novant Health) from June 2, 2017 to June 4, 2017. Am. Compl. ¶ 5. Basta

        is a “profoundly deaf individual,” with “limited proficiency in written English,” whose

        chosen form of communication is American Sign Language (ASL). Am. Compl. ¶¶ 13–14.

        Because of these limitations, Basta “requires auxiliary aids and services to communicate

        effectively in a medical setting.” Am. Compl. ¶ 14.

               Mrs. Basta, who is not deaf, had experienced life-threatening complications that

        caused her to become unconscious during her first childbirth. Am. Compl. ¶ 32. When she

        was again expecting, Mr. Basta sought to act as her healthcare proxy. In that capacity, he

        would communicate with the hospital during Mrs. Basta’s second childbirth in the event

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        that his wife could no longer advocate for herself. See Am. Compl. ¶¶ 30–33. Novant

        Health has a section on its website entitled “Interpretive Services,” which states that:

               If you or your family have special communication needs, we offer free interpreter
               services, which include: Foreign language interpreters for those with limited English
               proficiency, Sign language interpreters, Oral interpreters, TTY and other services
               for deaf or hard-of-hearing individuals. When you arrive at one of our Novant
               locations, if you or your family need assistance from an interpreter, let our staff
               know.

        Am. Compl. ¶ 10.

               Prior to June 2, 2017, Basta contacted Novant Health to request that he be provided

        with a qualified ASL interpreter when the couple arrived for the birth. Am. Compl. ¶ 16.

        According to the complaint, a Novant Health staffer assured him that there would be an in-

        person ASL interpreter if Basta contacted the hospital when they were on their way to the

        facility. Am. Compl. ¶ 17.

               When Mrs. Basta went into labor, Mr. Basta contacted Novant Health to advise them

        that he was bringing his wife into the hospital. Am. Compl. ¶ 18. At that time, he repeated

        his request for an interpreter. Id. However, the staff member Mr. Basta spoke to said that

        he had to wait until the time of arrival at the hospital to request an interpreter. Id. Upon

        arriving at the hospital, Basta and his wife reiterated their requests. Am. Compl. ¶ 19.

        Novant Health staff advised them that they were “working on it.” Id.

               Novant Health staff then provided Mr. Basta with a Video Remote Interpreting

        device (VRI), which allows deaf people to communicate with an interpreter via streamed

        video over the internet. Am. Compl. ¶ 20. Federal regulations require that VRI services

        have a high-speed internet connection to deliver the high-quality images that enable deaf

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        users to see the sign language properly. 28 C.F.R. § 36.303(f). According to the complaint,

        this VRI device malfunctioned. It was “blurry, choppy, and did not have a clear enough

        picture” for Basta to communicate with a remote interpreter. Am. Compl. ¶ 20. Hospital

        staff then brought a second VRI device into the room. Am. Compl. ¶ 21. However, this

        device malfunctioned in the same manner. Id. Further, the hospital staff plugged the device

        into an electrical outlet away from his wife’s hospital bed, which required Basta to leave

        his wife’s bedside to use it. Id.

               After the second VRI device malfunctioned, Novant Health did not provide a live

        in-person interpreter or any other auxiliary devices for Basta for the rest of the stay. Am.

        Compl. ¶ 22. He made repeated requests for interpreters during this time, but none were

        provided. Am. Compl. ¶ 26. Instead, Novant Health required Basta to communicate with

        doctors and staff via lip-reading, a method of communication which Basta is unable to fully

        understand. See Am. Compl. ¶ 2. Basta claims he was thus unable to comprehend what was

        happening throughout the delivery process and was unable to ask questions to hospital

        staff. Am. Compl. ¶ 23.

                                                    B.

               After his stay at Novant Health, Basta filed the instant lawsuit, alleging violations

        of (1) Section 504 of the Rehabilitation Act (RA), 29 U.S.C. § 794, (2) Section 1557 of the

        Patient Protection and Affordable Care Act (ACA), 42 U.S.C. § 18116, and (3) Title III of

        the Americans with Disabilities Act (ADA), 42 U.S.C. § 12181. He sought declaratory and

        injunctive relief under the ADA and compensatory damages under the RA and the ACA.

        Novant Health filed a motion to dismiss pursuant to Fed. R. Civ. Pro. 12(b)(1) and 12(b)(6),

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        contending that Basta (1) lacked standing for injunctive relief under the ADA, and (2)

        failed to state a claim under both the RA and the ACA. The case was initially assigned to

        a magistrate judge, who advised that Novant’s motion should be granted in its entirety.

        Basta then objected to the magistrate’s recommendation as to the RA and ACA claims,

        arguing that he sufficiently pled a prima facie violation of these statutes. However, he

        conceded that he lacked standing for injunctive relief under Title III of the ADA. See Joint

        App’x (J.A.) 53.

               The district court adopted the magistrate’s recommendation and dismissed Basta’s

        complaint. Basta v. Novant Health, Inc., No. 3:19-cv-64-RJC-DSC, 2021 WL 5326367

        (W.D.N.C. Nov. 16, 2021). It first dismissed the ADA claim, adopting the magistrate’s

        reasoning that Basta lacked standing for injunctive relief. Id. at *2. As for the RA claim for

        compensatory damages, the district court focused on the narrow issue of whether Basta

        plausibly pled that Novant Health “‘intentionally discriminated’” against him. Id. at *3

        (quoting Pandazides v. Va. Bd. of Educ., 13 F.3d 823, 830 n.9 (4th Cir. 1994)). Noting a

        lack of precedent from this court regarding the standard for intentional discrimination, the

        district court defined it as one of “deliberate indifference,” which occurs when “‘the

        defendant knew that harm to a federally protected right was substantially likely

        and . . . failed to act on that likelihood.’” Id. (quoting Liese v. Indian River Cty. Hosp. Dist.,

        701 F.3d 334, 344 (11th Cir. 2012)).

               The court found that “[f]or an entity like Novant, deliberate indifference cannot be

        shown by failing to provide ASL-fluent interpreters alone…[n]or can [it] be shown when,

        through no fault of its own, one of its electronic devices malfunctions.” Id. Instead, Basta

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        had to have alleged “systemic and pervasive problems, rather than an isolated incident”

        related to malfunctioning VRI devices to plausibly plead a claim under the RA. Id. Since

        Basta alleged only an isolated occurrence of malfunctioning VRI devices relating to his

        single three-day stay at Novant Health, the court found he failed to make out a prima facie

        claim entitling him to compensatory damages under the RA. Id. at *4.

               Lastly, the district court dismissed Basta’s compensatory damages claims under

        Section 1557 of the ACA on the grounds that “the ACA claim fails for the same reason as

        the RA claim.” Id. Since Basta had not alleged facts showing that Novant intentionally

        discriminated against him under a deliberate indifference standard, necessary for the ACA

        claim to survive, the court dismissed that claim as well. Id.

                                                     II.

               Basta timely appealed the district court’s order. He argues that his complaint

        plausibly alleged claims under Section 504 of the RA and Section 1557 of the ACA.

        According to Basta, intentional discrimination via deliberate indifference can be proven by

        the fact that Novant provided only two malfunctioning VRI devices on the first day of a

        three-day stay and failed to provide any other interpretive services or auxiliary aids despite

        repeated requests. He argues that he was thus entitled to proceed to discovery on these

        claims.

               We hold that Basta plausibly pled a claim of compensatory damages under the RA.

        Basta waived his appeal rights for the ADA injunctive relief claim by failing to object to

        the magistrate’s recommendation, see Wright v. Collins, 766 F.2d 841, 845–46 (4th Cir.

        1985), so we focus only on his RA and ACA claims. We agree with the district court that

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        these claims rise and fall together. Under the ACA, “an individual shall not, on the ground

        prohibited under…section 794 of title 29 [section 504 of the RA]; be excluded from

        participation in, be denied the benefits of, or be subjected to discrimination under, any

        health program or activity[.]” 42 U.S.C. § 18116(a); see also Francois v. Our Lady of the

        Lake Hosp., Inc., 8 F.4th 370, 378 (5th Cir. 2021) (“For disability-discrimination claims,

        the ACA incorporates the substantive analytical framework of the RA.”); Doe v. BlueCross

        BlueShield of Tenn., 926 F.3d 235, 239 (6th Cir. 2019) (noting that “the Affordable Care

        Act picks up the standard of care for showing a violation of § 504”) (emphasis omitted);

        Doe v. CVS Pharmacy, Inc., 982 F.3d 1204, 1210 (9th Cir. 2020) (“[T]o state a claim for a

        Section 1557 violation, [plaintiffs] must allege facts adequate to state a claim under Section

        504 of the Rehabilitation Act.”). Accordingly, we focus on the standard for compensatory

        damages under the RA, as this is a threshold determination as to whether Basta plausibly

        pled a claim under the ACA.

                                                     A.

               Section 504 of the Rehabilitation Act provides that “[n]o otherwise qualified

        individual with a disability in the United States …shall, solely by reason of her or his

        disability, be excluded from 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). Therefore, to establish a prima facie violation of the RA against a private

        entity which receives federal funds, a plaintiff must show that he or she is: (1) a “disabled

        individual” as defined in the RA; (2) “otherwise qualified” to participate in the offered

        activity or to enjoy its benefits; (3) excluded from such participation or enjoyment solely

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        by reason of his or her handicap; and (4) that the program administering the activity

        receives federal financial assistance. See Halpern v. Wake Forest Univ. Health Sciences,

        669 F.3d 454, 461–62 (4th Cir. 2012); see also Koon v. North Carolina, 50 F.4th 398, 405

        (4th Cir. 2022). One way to prove this third prong is by showing that a hospital failed to

        adequately accommodate a hearing-impaired individual by providing ineffective auxiliary

        aids under the RA. Liese, 701 F.3d at 343–44.

              Novant does not deny that it receives federal funding, nor does it contest that Basta

        has a disability within the meaning of the RA. Moreover, Novant agrees that Basta, as a

        healthcare proxy for his wife, was entitled to auxiliary aids to ensure effective

        communication with hospital staff. See 28 C.F.R. §§ 35.160(a)(1)–(2). The parties agree

        that the only element in dispute is whether Novant failed to adequately accommodate Basta

        by providing him malfunctioning auxiliary aids on the first day of his three-day stay at

        Novant.

               The general meaning of an adequate accommodation has been well-explained. In

        passing the RA, Congress sought to target a type of “thoughtless[] and indifferent[]”

        discrimination, which arises not out of “invidious animus” but rather out “of benign

        neglect.” Alexander v. Choate, 469 U.S. 287, 295 (1985). Thus, recipients of federal funds

        must ensure that “otherwise qualified handicapped individual[s]” are “provided with

        meaningful access to the benefit that the grantee offers.” Id. at 301. Pursuant to

        congressional delegation, see 29 U.S.C. § 794(a), the Department of Health and Human

        Services has issued regulations which further define what meaningful access requires in a

        hospital setting. These regulations “warrant respect” by this court. A Helping Hand, LLC

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        v. Baltimore Cty., 515 F.3d 356, 362 (4th Cir. 2008) (internal quotations omitted); see also

        Nat’l Fed. of the Blind v. Lamone, 813 F.3d 494, 506 (4th Cir. 2016).

               The regulations prohibit a recipient of federal funds from providing a disabled

        individual “an opportunity to participate in or benefit from the aid, benefit or service that

        is not equal to that offered nonhandicapped persons” or “that is not as effective as . . . the

        benefits or services provided to others.” 45 C.F.R. § 84.52(a)(2)– (3). Although “aids,

        benefits and services, to be equally effective, are not required to produce the identical result

        or level of achievement for handicapped and nonhandicapped persons,” they “must afford

        handicapped persons equal opportunity to obtain the same result . . . .” Id. § 84.4(b)(2).

               Important here, a recipient of federal funds with more than fifteen employees must

        “provide appropriate auxiliary aids to persons with impaired sensory . . . skills, where

        necessary to afford such persons an equal opportunity to benefit from the service in

        question.” Id. § 84.52(d)(1). These auxiliary aids may include interpreters or other services

        for hearing-impaired individuals. Id. § 84.52(d)(3). Both the statute and the regulations

        thus make clear that the RA focuses on “the equal opportunity to participate in obtaining

        and utilizing services” in hospital settings. Silva v. Baptist Health S. Fla., Inc., 856 F.3d

        824, 834 (11th Cir. 2017) (emphasis in original).

               Although, as noted, Basta waived his ADA claim here, the regulations interpreting

        the ADA can still be helpful in understanding the RA’s requirements. This court interprets

        the ADA and the RA in lockstep, see Koon, 50 F.4th at 403 n.2, and the ADA’s regulations

        further elucidate the requirements governing auxiliary aids. ADA regulations provide that

        “[a] public accommodation shall furnish appropriate auxiliary aids and services where

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        necessary to ensure effective communication with individuals with disabilities.” 28 C.F.R.

        § 36.303(c)(1) (emphasis added). Notably, regarding VRI, an entity that chooses to provide

        interpretive services in this manner must ensure that it meets certain performance

        standards. See id. § 36.303(f). These include “[r]eal-time, full-motion video” over a

        sufficiently strong wireless network “that delivers high-quality video images that do not

        produce lags, choppy, blurry or grainy images, or irregular pauses in communication” and

        “[a]dequate training to users of the technology…so that they may quickly and efficiently

        set up and operate the VRI,” among others. Id., § 36.303(f)(1)–(4). A VRI system that does

        not meet these standards is not “an effective method[] of making aurally delivered materials

        available to individuals with hearing impairments”– meaning a non-compliant VRI system

        is not an appropriate auxiliary aid. 42 U.S.C. § 12103(1)(A).

               A plaintiff who proves a prima facie violation of the RA may seek the remedies

        available under Title VI of the Civil Rights Act, including damages. See 29 U.S.C. §

        794a(2); see also Pandazides, 13 F.3d at 829–30. However, in order to receive

        compensatory damages, a plaintiff must prove not only that a defendant-entity failed to

        provide appropriate auxiliary aids, but also that it acted with an intent to discriminate. See

        Pandazides, 13 F.3d at 830–32 & n.9; see also Koon, 50 F.4th at 405. This standard, of

        course, must be more than negligence, but this court has not yet articulated the precise

        manner of proving discriminatory intent under the RA. The parties in this case both

        proceeded under a “deliberate indifference” standard, and the district court also considered

        it the appropriate standard. Most of our sister circuits have also found that intentional

        discrimination can be proven via deliberate indifference. See Liese, 701 F.3d at 345; S.H.

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        ex rel. Durrell v. Lower Merion Sch. Dist., 729 F.3d 248, 262–65 (3d Cir. 2013); Loeffler

        v. Staten Island Univ. Hosp., 582 F.3d 268, 275–276 (2d Cir. 2009); Barber ex rel. Barber

        v. Colo. Dep’t of Revenue, 562 F.3d 1222, 1228–29 (10th Cir. 2009); Duvall v. Cty. of

        Kitsap, 260 F.3d 1124, 1138–39 (9th Cir. 2001).

               Because there is a substantial interest in preserving a uniform approach to this

        question, we too will proceed under that standard. See Koon, 50 F.4th at 404 (assuming a

        deliberate indifference standard applies in a case presenting ADA and RA claims for

        compensatory damages). We emphasize, however, that this requires much more than a

        showing of pure negligence. As the Supreme Court has said in the Eighth Amendment

        context, deliberate indifference lies “somewhere between the poles of negligence at one

        end and purpose or knowledge at the other.” Farmer v. Brennan, 511 U.S. 825, 836 (1994).

                                                      B.

               Accordingly, under Section 504 of the Rehabilitation Act, we must determine

        whether Novant acted with deliberate indifference to Basta’s federal rights. This standard

        requires a plaintiff to plausibly plead that a defendant (1) knew that harm to a federally

        protected right was substantially likely and (2) failed to act on that likelihood. Koon, 50

        F.4th at 405. In the context of failing to provide an effective auxiliary aid, a plaintiff “must

        show that the defendants knew there was a substantial likelihood that they would be unable

        to communicate effectively with [a deaf patient or companion] but still made a deliberate

        choice not to provide one.” McCullum v. Orlando Reg’l Healthcare Sys., Inc., 768 F.3d

        1135, 1147–48 (11th Cir. 2014) (internal quotations omitted).

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               One thing a deliberate indifference standard does not require in this context,

        however, is some obvious pattern of mechanical failure in auxiliary aids provided by the

        hospital. The district court reasoned that “systemic and pervasive problems, rather than an

        isolated incident” in the provided VRI services “must exist to succeed in showing

        intentional discrimination through deliberate indifference.” Basta, 2022 WL 5326367 at

        *3.

               We disagree. Requiring plaintiffs to make this showing improperly shifts the

        emphasis under the Rehabilitation Act from the violation of an individual right at a discrete

        point in time to widespread violations, spanning across multiple people or multiple visits.

        It is well-known that civil rights statutes exist, among other reasons, to protect a single

        individual from a statutory violation without the invariable need to prove a “systemic and

        pervasive problem[],” as the district court held. The RA, like other civil rights statutes,

        seeks to “provide individual citizens effective protection against [discriminatory]

        practices.” Cannon v. Univ. of Chicago, 441 U.S. 677, 704 (1979) (emphasis added).

        Requiring plaintiffs who suffered a violation of the RA to show a longstanding pattern of

        similar violations defeats this goal. While a history of violations is relevant evidence to

        proving deliberate indifference, it cannot be equated with the standard itself. See Farmer,

        511 U.S. at 842 (“longstanding, pervasive, [and] well-documented” rights violations can

        be circumstantial evidence that defendants “had been exposed to information concerning

        the risk and thus must have known about it”); see also Silva v. Baptist Health S. Fla., Inc.,

        838 Fed. App’x 376, 382 (11th Cir. 2020) (finding evidence that several plaintiffs

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        “routinely” experiencing malfunctioning VRI was enough of a showing of deliberate

        indifference to survive summary judgment).

               Instead, “[d]eliberate indifference is, at bottom, an actual-notice standard.” Koon,

        50 F.4th at 406. In the context of this case, “the simple failure to provide an [in-person]

        interpreter on request is not necessarily deliberately indifferent to an individual’s rights

        under the RA.” Liese, 701 F.3d at 343. But demonstrating that a hospital had notice of a

        patient’s need for auxiliary aids and failed to provide them despite knowledge that the

        patient could not effectively communicate without such aids supports a finding of

        deliberate indifference. See Duvall, 260 F.3d at 1140.

                                                     III.

               With these standards in mind, Basta sufficiently pled intentional discrimination

        under the Rehabilitation Act to survive a motion to dismiss. We review the district court’s

        dismissal order de novo. Wilcox v. Brown, 877 F.3d 161, 166 (4th Cir. 2017). “To survive

        a motion to dismiss, a complaint must contain sufficient factual matter, accepted as true, to

        state a claim to relief that is plausible on its face.” Carey v. Throwe, 957 F.3d 468, 474 (4th

        Cir. 2020) (internal quotations omitted). This procedural posture requires us to assume the

        truth of all well-pled facts and draw reasonable inferences in favor of Basta. Id.

                                                      A.

               The complaint made a showing that Novant Health staffers both knew of a

        substantial likelihood that Basta would be unable to communicate without an appropriate

        auxiliary aid, yet still made a conscious choice not to provide one. See McCullum, 768 F.3d

        at 1147–48. Although hospital staff provided some auxiliary aids in the form of two VRI

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        machines, its failure to address the substantial shortcomings of these devices over a three-

        day period despite repeated requests for an interpreter gives rise to a plausible inference of

        deliberate indifference. See, e.g., Crane v. Lifemark Hosp., 898 F.3d 1130, 1133, 1136

        (11th Cir. 2018); Loeffler, 582 F.3d at 276–77.

                   The facts show that Basta is a “profoundly deaf” individual who requires “auxiliary

        aids and services to communicate effectively in a medical setting.” Am. Compl. ¶¶ 3-4.

        Basta alleged that he alerted Novant Health of his need for an interpreter well in-advance

        of his arrival, pursuant to its policy of providing free interpreter services to the hearing-

        impaired. Am. Compl. ¶¶ 10, 16. Hospital staff allegedly stated it would comply with that

        request. Am. Compl. ¶ 17. Basta then again told Novant Health of his need for an

        interpreter on his way to the hospital. Am. Compl. ¶ 18. This was sufficient to put Novant

        Health on notice that Basta was a hearing-impaired individual who was entitled under

        Section 504 to an accommodation in the form of an auxiliary aid. See Koon, 50 F.4th at

        407; see also Duvall, 260 F.3d at 1139 (“When the plaintiff has alerted the public entity to

        his need for accommodation…, the public entity is on notice that an accommodation is

        required, and the plaintiff has satisfied the first element of the deliberate indifference

        test.”).

                   The complaint goes on to allege that Novant provided two malfunctioning VRI

        devices. Am. Compl. ¶¶ 20–21. These devices would have satisfied Novant’s Section 504

        obligations had they functioned correctly. Indeed, “the proper inquiry [under Section 504]

        is whether the auxiliary aid that a hospital provided to [a] hearing-impaired [individual]

        gave that [individual] an equal opportunity to benefit from the hospital’s treatment.” Liese,

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        701 F.3d at 343. The RA’s regulations are clear that “other aids for persons with impaired

        hearing” besides interpreters may satisfy the auxiliary aid requirement. 45 C.F.R.

        § 84.52(d)(3). Therefore, a failure to provide an in-person interpreter need not beget a

        finding of deliberate indifference. See, e.g., Liese, 701 F.3d at 343. However, the “other

        aids” must work. The machines here malfunctioned. Basta’s complaint alleged that both

        machines were “blurry, choppy, and did not have a clear enough picture” for him to

        understand what the remote interpreter was conveying. See Am. Compl., ¶¶ 20–21. Further,

        the second VRI device was plugged far away from Mrs. Basta’s bed, forcing Basta to leave

        her in order to understand what was going on. Am. Compl. ¶ 23.

               Had the malfunctioning VRI been the only issue, this might have been a case where

        “good-faith efforts to remedy the plaintiff’s problems…prevent finding deliberate

        indifference.” Koon, 50 F.4th at 407. Indeed, Novant Health insists that it had no way of

        knowing that the VRI would malfunction. See Resp. Br. at 13–15. The crux of Basta’s

        claim, however, is not the malfunctioning VRI on the first day of his stay: it is that despite

        repeated requests for another auxiliary aid, such as an in-person interpreter, Novant Health

        did nothing to ensure that Basta could communicate with its staff for the rest of his three

        days at the hospital. The complaint alleges that Basta “made repeated requests for

        interpreters” from June 2 to June 4, 2017. Am. Compl. ¶ 26. Further, the complaint alleges

        that “Basta was unable to understand what was happening throughout the delivery process”

        and he “was not given the opportunity to ask any questions concerning his wife’s treatment

        and was thus unaware if she had any medical concerns.” Am. Compl. ¶ 23.

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               After the VRI devices malfunctioned, Basta repeatedly requested an interpreter.

        Defendant’s staff requested in turn that he sign a form regarding the malfunctioning VRI

        machine, which raises a plausible inference that they knew of its inefficacy and of his need

        for continued interpretive services. See Am. Compl. ¶ 24. Instead, Novant required Basta

        to communicate via lip-reading, which Basta alleges he could not understand. Am. Compl.

        ¶ 3. The important issue again is that Novant did nothing to remedy this situation despite

        having ample time to do so. Therefore, Basta pled a sort of “apath[y]” that shows Novant’s

        “indifference to [Basta’s] rights may have been so pervasive as to amount to a choice.”

        Loeffler, 582 F.3d at 277.

                                                     B.

               We emphasize that finding deliberate indifference via failure to provide effective

        auxiliary aids under the RA varies from case to case. Plaintiffs are entitled to have their

        disability effectively accommodated, but what such effective accommodation requires is

        based on the abilities of the individual, the nature and complexity of the information

        exchanged, and the overall context of the situation. See, e.g., 28 C.F.R. § 36.303(c)(1)(ii).

        In sum, “[t]he task of determining whether an entity subject to the RA has provided

        appropriate auxiliary aids where necessary is inherently-fact intensive[.]” Crane, 898 F.3d

        at 1135. Here more factual development is needed. The district court erred in dismissing

        Basta’s RA claim at the motion to dismiss stage.

                                                    IV.

               It matters not that plaintiff Basta was not himself the patient. Regulations, in this

        case under the ADA, create “an obligation to provide effective communication to

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        companions” with disabilities. 28 C.F.R. § 36.03(c)(1). Given the often-interlocking nature

        of the disability statutes in this case, it is easy to see why that guidance would be applicable

        here. Patients often arrive at hospitals in pain, unconscious, or feeling intense stress. In

        these situations, which can be not only confusing but overwhelming, a patient’s

        companion, often a spouse or a family member, may be the only advocate available. To

        have that single advocate barred from communication with a hospital and its staff is to

        leave the patient stranded. Basta, a hearing-impaired individual, was unable to

        communicate his wife’s complicated medical history to her doctors during childbirth,

        despite repeated requests for some effective means of doing so. The situation was a high-

        risk one for the couple, and the medical event one of the highest urgency and meaning.

               Accordingly, we must reverse the district court’s judgment dismissing Basta’s

        Rehabilitation Act claim. We remand this case for further proceedings consistent with this

        opinion. Since Basta’s Affordable Care Act claim is predicated on the plausibility of his

        Rehabilitation Act claim, we reverse the district court’s judgment dismissing that claim as

        well, and remand for such other and further proceedings as may be appropriate.

                                                                     REVERSED AND REMANDED

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