My insurance company says my husband’s ambulance ride wasn’t medically necessary

I was standing in the kitchen with the phone pressed to my ear, listening to some woman at the insurance company tell me for the third time that the ambulance ride wasn’t covered because it wasn’t “medically necessary.” My husband was in the bedroom, still groggy from the surgery, and I could hear the ice machine humming. The bill on the counter said $2,847. I remember thinking, I don’t have time for this. But I also knew I wasn’t going to let it go.

My name is Denise Kowalski. I’m fifty-eight. I work part-time at a dental office in Erie, Pennsylvania, doing billing and scheduling. My husband, Ray, drives a delivery truck for a bakery. We’re not rich. We’re careful. We have a mortgage, a used Honda, and a savings account that took a hit when Ray’s gallbladder went bad in March.

It started on a Tuesday. Ray came home from his route looking gray. He said he felt like he’d been kicked in the ribs. By midnight he was sweating through his shirt, and I drove him to the ER at Saint Vincent. They did an ultrasound and said the gallbladder was infected. They admitted him. Two days later, they took it out. The surgeon said it was a mess in there. Fine. We got through it.

Then the bills started. The hospital stay was mostly covered. The surgeon was in-network. But the ambulance ride from the ER to the surgical center across town—that was the problem. The insurance company, a big national outfit, said it wasn’t an emergency transport because Ray was already stable. They said he could have been driven in a private car.

I called them on my lunch break. I sat in the break room with my tuna sandwich and a notepad. The woman on the phone was polite but firm. She said, “I understand your frustration, ma’am, but the claim was reviewed and denied. You can appeal.”

So I appealed. I wrote a letter. I included the discharge summary from the ER, which said “patient requires monitored transport.” I faxed it from the dental office because we still had a fax machine. I made copies of everything. I kept a folder in the kitchen drawer next to the takeout menus.

A month later, I got a form letter saying the appeal was denied. The reason was the same: not medically necessary. I called again. This time I got a man named Greg. He said, “Ma’am, the decision is final unless you want to request an external review.”

I said, “What’s that?”

He explained it. I wrote it down. External review. Independent third party. I said, “Okay, how do I do that?”

He said he’d send the forms. I waited two weeks. Nothing came. I called back. They said they had no record of my request. I asked to speak to a supervisor. The supervisor, a woman named Carla, said she’d “look into it.” I never heard from her again.

By then it was June. Ray was back at work, but he was still tired. I was spending my evenings on the phone, on hold, listening to the same hold music. My daughter, Melissa, told me to just pay it. She said, “Mom, it’s not worth your health.” But I couldn’t. It wasn’t the money, exactly. It was the principle. They were treating us like we were trying to cheat them.

One night I was sitting at the kitchen table, going through the folder for the tenth time, and I noticed something. The ambulance bill had a code on it. I didn’t know what it meant, but I looked it up online. It was a code for advanced life support. That meant there was a paramedic on board, not just a driver. I called the ambulance company. A woman in billing said, “Oh, yeah, that’s standard for post-surgical transfers. They need monitoring.”

I said, “Can you send me something that says that?”

She said, “Sure, honey. I’ll email it right now.”

That email was the turning point. I printed it out. I wrote another letter. This time I sent it to the state insurance department. I didn’t know if they’d do anything, but I was tired of talking to the insurance company. I sent copies of everything: the denial letters, the discharge summary, the ambulance code, the email from the billing woman.

Three weeks later, I got a call from a woman at the state insurance department. She said they were opening an investigation. She asked me a few questions. I answered. She said, “We’ll be in touch.”

I didn’t hear anything for two months. I figured it was over. Then, in September, I got a letter from the insurance company. It said they had reversed their decision. The ambulance ride was covered. They were sending a check for $2,847 to the ambulance company. And they were refunding our copay of $350.

I sat at the kitchen table and read the letter twice. Ray came in and asked what was wrong. I said, “Nothing. They finally paid it.”

He said, “Good. Now can we go out to dinner?”

We went to the diner down the street. I had a meatloaf sandwich. Ray had the turkey platter. We didn’t talk about the insurance company. We talked about Melissa’s new apartment and whether we should get the gutters cleaned before winter.

I still have the folder. It’s in the basement now, in a box with the tax returns. I don’t know why I kept it. Maybe just to remind myself that sometimes you have to be a pain in the ass to get what you’re owed. It took six months and a lot of phone calls, but I won. It didn’t feel like winning, exactly. It felt more like being the last one standing in a game nobody wanted to play.