COMBAT gets stubborn insurance company to cover claim

Melinda Price, formerly of Columbia Falls, wasn’t looking forward to happy holidays when she contacted Northeast COMBAT. She had been self-paying health insurance premiums to a Nebraska company for years without a claim when she was told she needed major surgery for a life-threatening condition.

Worrying almost as much about the cost as the condition, Melinda asked her doctor to review her policy before the surgery. She was relieved when her physician said he was certain she was covered.

After a successful surgery, Melinda’s doctor even went so far as to have his office staff help her file a claim as she recovered. But within three weeks, the insurance company responded by refusing to pay the bill, claiming that Melinda had a pre-existing condition and the surgery was not covered.

When Melinda showed her doctor the letter of refusal, he strongly disagreed with the insurance company’s decision and promised to support her claim 100 percent. But despite Melinda’s and her doctor’s repeated attempts over the next six months, the company was unyielding, unresponsive, sometimes insulting, and refused to reconsider. It was then that Melinda contacted COMBAT.

The COMBAT caseworker working with Melinda obtained a copy of the letter from Melinda’s physician asserting that she did not have a pre-existing condition and her claim was therefore valid. COMBAT then wrote the company on her behalf.

Within 10 days, the company responded, saying a letter from the physician was not enough, they needed a complete medical report. COMBAT responded immediately, reminding the company that Melinda’s physician had already sent a full report with the initial claim. But, to facilitate matters, we sent another copy of the report and demanded that the company honor the claim within the next 21 days or COMBAT would be forced to refer the matter to Maine’s Insurance Commission.

Within three days, COMBAT received a telephone call from a vice president of the company, assuring us the case was being reviewed and there would be no need to get government agencies involved. For a consumer organization, the smell of fear coming from an arrogant and unresponsive out-of-state corporation is a sweet fragrance with which we are quite familiar.

Two weeks later, the company notified COMBAT that Melinda’s claim had been accepted and that they appreciated our persistence in correcting “this clerical mistake.” Well, if that’s what they needed to say to save face, we’ll give them that one.

Barely a week later, Melinda called to say that her $5,679 in medical bills had been paid by the insurer. “Thank you so much COMBAT,” she wrote, “without you, I honestly don’t think I would have received satisfaction from my insurance company and that would have made for a pretty lousy Christmas.”

For COMBAT, this was just one example of many insurance-related complaints we have received over the past 33 years. Big national companies often make consumers jump through hoops in hopes they will just give up. Unfortunately, many people do just that – quit because they feel alone and without the means to fight back. But there is strength in numbers, and while it’s easy for out-of-state companies to ignore an individual, they often respond differently when contacted by an organization that represents thousands of supporters.

Melinda shared her Christmas surprise by sending COMBAT a $250 donation. Then her doctor sent $100 with a note saying, “You guys do good work.” Those generous gestures, in addition to the fact that we had backed down an out-of-state company that was playing the “hoops game,” gave us even more reason to say, “If you think we Mainahs give up without a fight … ho, ho, ho!”

Consumer Forum is a collaboration of the Bangor Daily News and Northeast COMBAT-Maine Center for the Public Interest, Maine’s membership-funded non-profit consumer organization. Individual membership $25, business rates start at $125 (0-10 employees). For help and information write: Consumer Forum, Bangor Daily News, PO Box 1329, Bangor 04402-1329.