Washington County resident Mary Johnson (not her real name) had suffered through a scary early diagnosis, batteries of painful tests, an outpatient surgical procedure and a lengthy, uncomfortable recovery. But the outcome was good, and she prepared to continue a life interrupted, thinking the worst was over. Then the bills started to arrive marked, “Unpaid, insurance claim denied.”

As is often the case in such matters, Mary didn’t receive just one bill. She received bills from her doctor, the specialist to whom she had been referred, the laboratory that conducted the tests, the radiologist who interpreted images, and the hospital in which the surgical procedure had been conducted. The bills totaled well over $3,500. Stunned because she had assumed her medical insurance, for which she paid more than $600 a month, would cover her expenses, Mrs. Johnson called her insurance company.

The insurance company representative told Mary coldly that the medical procedure she had undergone was classified as “experimental” and was, therefore, not covered under her policy, and that she would have to discuss the matter with the various healthcare providers. She began calling all involved, her doctor’s office, the hospital, the radiology group, the laboratory, and the specialist, in an attempt to find out why she was not covered for what most agreed was a fairly common procedure.

All said there must have been a mistake, and agreed to resubmit the claim. But when the next billing cycle came, Mrs. Johnson received another round of bills saying the claims were still denied. She again contacted the insurance company, which stood fast on the denials. Mary soon began to receive collection notices. The automatic billing systems had kicked in and her “debts” had been referred to collection agencies. Mrs. Johnson was now a victim of an impersonal, computerized system that deals in bytes and numbers rather than names and humans. It was only then that Mary Johnson contacted COMBAT for help.

The COMBAT mediation volunteer assigned to Mary’s case immediately suspected a coding error. Somewhere in the system, our volunteer was almost certain, someone had entered the wrong code for the diagnosis or procedure, triggering the denials. COMBAT collected copies of Mrs. Johnson’s original bills, then called the doctor, specialist, hospital, radiology group and laboratory asking for the appropriate code numbers. We then compared the codes provided with both the original bills and the second billing. All matched up. But in the denial from the insurance company, there were three errors in coding.

Why the insurance company had not corrected the error, especially after the second round of claims sent by the medical offices, we can only imagine. And when COMBAT contacted the company, rather than just checking previous claims for errors, they insisted on yet another round of claims from the healthcare providers. We called the various offices, monitored the insurance company’s review, and when they agreed there had been mistakes, requested that they notify Mrs. Johnson that she owed nothing. Mrs. Johnson was overjoyed when she received confirmation that all $3,500 had been paid.

Consumers often believe that insurance companies are benefactors interested in protecting policyholders. But in fact, insurance companies will often use any convenient excuse to NOT pay a claim. They may not like that we say this, but if they are unhappy, it will not ruin our day.

What does Mrs. Johnson’s experience teach us? Check with your healthcare providers and review your policy BEFOREHAND to make sure you are covered. And if you believe you have been unfairly denied a claim, ask questions and CHALLENGE. Don’t just assume that your insurance company is operating in your best interests.

Consumer Forum is a collaboration of the Bangor Daily News and Northeast COMBAT/The Maine Center for the Public Interest, Maine’s membership-funded nonprofit consumer organization. For help or to request individual or business membership information write: Consumer Forum, Bangor Daily News, PO Box 1329, Bangor 04402-1329.