“He said/she said” dispute with insurance company costs family $34,500 — now what?

puertoCarla Baker’s 85-year-old father was seriously injured while vacationing in Puerto Vallarta, Mexico. Good thing he’d bought an insurance policy through Access America, which covered his hospitalization and medical evacuation.

Actually, not so good. Access America didn’t pay all of his bills, leaving the family tens of thousands of dollars poorer.

What now?

Baker picks up the story after his accident on June 8:

After he was taken to the hospital, both my step-mother and Dr. Alejandro Rios, a physician at San Javiar Hospital, called Access America. My step-mother could not reach a human, only a recording. Dr. Rios spoke to an Access America representative and waited for a day and a half for Access America to make arrangements and advance the funding for an air ambulance trip back to the States.

The family waited at the hospital until late June 8th and well into the afternoon of June 9th waiting for Access America to get back to Dr. Rios. At that time, it was determined that my father needed to be air ambulanced back home due to intense pain and the need for surgery. The family had to scrape together the $34,500 to pay upfront for the flight.

Baker filed a claim with Access America and were reimbursed $10,200 for their canceled flights. But they denied the remaining $24,500, insisting that there was no record of the Bakers contacting Access America after the accident.

I really don’t know what we could have done differently given the circumstances. The reason that this appeal is occurring so late after the accident is that it took six months to get a denial of coverage letter from Medi-Care and then we had to go through his secondary insurance to get another denial.

We feel that Access America was negligent in this case for not providing timely service and that my father should be reimbursed. Any help that you can provide in reaching a fair resolution would be appreciated.

I contacted Access America on Baker’s behalf. Here’s its response:

We have thoroughly checked our records and cannot find any record of Mr. Baker, his family, his doctor or a hospital contacting us for help on his behalf.

Our phone lines are staffed 24/7/365 and we do not utilize any sort of answering machine or answering service.

Callers to our main number are prompted to push “9” if the caller is traveling and needs help. Those calls are routed to our assistance group which is staffed 24/7/365. Our assistance group has no record of being

I am very sorry that Mr. Baker has been ill and I wish him and his family the best. I’m also very sorry that we have not been able to assist him further. As was described in our letter to Carla Baker, we did make a significant consideration in reimbursing him for $10,200 in transportation expenses.

True enough, a $10,200 reimbursement is nothing to sneeze at. But Baker’s insurance policy promised full coverage, and that’s not what he got. I ran the response by Baker.

It sounds like this has turned into a “he said/she said” situation. I don’t understand why they don’t have any record of two calls being placed to them.

At this point in time, even if I could get a Spanish interpreter to contact Dr. Rios at the hospital, I don’t know if he would remember the situation. It sounds like Access America would not take his word either since they don’t have a record of his call.

Access America seems to be insinuating that the ten family members and a physician who were involved in waiting word from Access America are lying. I am so frustrated. Any ideas?

I have a few thoughts on this case.

A polite appeal to Access America, containing a letter from Dr. Rios that corroborates Baker’s account, might be helpful. But chances are, she will have to take Access America to court in order to recover her money.

This also underscores the importance of asking for names, extensions and reference numbers when you call an insurance company. First, get the name of the person you’re talking to. Ask for an extension. And before you get off the phone, ask for a reference number or case number — and make a record of it — so that you know that they know you made the call.

I’m troubled by the discrepancies between the Bakers’ account and Access America. Unfortunately, it may be up to a judge to decide who’s right.

(Photo of Puerto Vallarta, Mexico by Stewart Leiwakabessy/Flickr Creative Commons)

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