Insurance satisfaction found with persistence Companies out for profit, not welfare of patients

Even though the law requires simplified insurance policy language, many of us still find it difficult to translate complicated terms and industry jargon. When we face a medical emergency or scary illness, we don’t have time to stop and read our policies. We trust our insurers to be there for us. After all, that’s why we paid premiums for so many years.

But insurance companies are in the business of making a profit. Let’s not kid ourselves into believing the welfare of the client is the first thing insurance company executives think about when they wake up in the morning. They have investors, boards of directors and superiors watching the pulse of their bottom lines as much as the pulse in your wrist.

A reader contacted COMBAT to say she had been diagnosed with a life-threatening condition requiring an operation. Her physician reviewed her insurance policy and said she was covered for the procedure.

After her successful surgery, the physician’s office filed the patient’s claim. But the insurance company balked and would not pay the bill. It maintained the patient had had a related, pre-existing condition within the past year and was not covered.

The client showed her physician the insurance company’s response. The physician strongly disagreed with the insurance company’s decision and said he would support his patient’s claim 100 percent.

Despite her physician’s help with the claim, her attempts to secure payment had been at a standstill for four months. The insurance company was unyielding and unresponsive.

The COMBAT caseworker handling the case told the client to get a letter from her physician verifying she did not have a pre-existing condition and that her claim was valid. We then wrote the insurance company on our client’s behalf, enclosing her physician’s letter.

In 10 days, the insurance company responded that the doctor’s letter was not enough. Instead, the company required a complete medical report. Although her doctor already had sent a full report with the first claim, he was cooperative and sent a duplicate copy of the report to the insurance company at COMBAT’s request.

We followed up with a letter to the insurance company, saying we expected it to honor the claim within the next 21 days and that if it did not, we would contact Maine’s Bureau of Insurance and request its intervention.

A couple of days later we received a telephone call from the vice president of the insurance company, telling us the case was being reviewed and there was no need to get the Bureau of Insurance involved. We were encouraged that the company appeared to be finding religion.

Three weeks later the company notified us that our client’s claim had been accepted. The company said it “appreciated our persistence.” This was kind of like telling the dog you love it because it took its teeth out of your leg, but we accepted the compliment with a righteous grin.

The client later called to say: “Thank you so much. Without you, I honestly don’t think I would have received satisfaction from my insurance company.” We’ll take that a step further and thank the doctor for his tenacity and support of his patient.

COMBAT’s Maine Center for the Public Interest is forming a task force of physicians and other health care professionals who will examine the possibility of creating a voluntary service to help consumers who have encountered reimbursement problems (including Medicare and Medicaid). If you would like to help, write to Consumer Forum.

Consumer Forum is a collaborative effort of the Bangor Daily News and Northeast COMBAT. Send questions to Consumer Forum, Bangor Daily News, P.O. Box 1329, Bangor 04402-1329. COMBAT is a nonprofit organization with annual dues of $10. For membership information, write to the above address.