April Fool’s Day Turns Serious for Dowers
For many, April Fool’s Day is just a bit of fun. But for Angela and Andrew Dower in Ocotillo Wells in 2023, it turned into a nightmare.
“I remember waking you up and asking you what happened next,” Andrew recalled, clearly affected. “And it just feels so bad, knowing everything that happened to me.”
What Andrew doesn’t remember is experiencing multiple seizures or being flown to the hospital by emergency helicopter. As someone with epilepsy, seizures aren’t a shock for him, but the sheer number he had that night was alarming.
“He just kept convulsing. It was 3, 4, 5, 6 times. I knew something wasn’t right,” Angela shared with NBC 7.
After Angela called 911, park rangers and medical personnel verified her concerns. Andrew needed to get to the emergency room urgently, but an ambulance would take too long. So, first responders called for a helicopter to speed things up.
He was transported to the University of California, San Diego in La Jolla, where doctors managed to stabilize him and diagnosed him with an aggressive brain tumor. Angela described a troubling incident where she was held at knifepoint just weeks earlier.
Insurance Denial Adds to Their Ordeal
Just months later, they received a shocking letter from Blue Shield, their health insurance provider.
“When I first opened that denial, it felt like a weight on my chest,” Angela expressed. “It was infuriating to know we had been diligent with our insurance, going to the doctor, getting referrals, only to be let down during such a critical moment.”
The letter stated that the air ambulance ride was not covered because it wasn’t deemed “medically necessary.” This left the Dowers facing a bill of about $64,000.
“If that flight hadn’t happened, he might not be here today,” Angela said, clearly shaken. “Hearing that from the insurance company, it really makes you question everything. Why am I paying these bills? Why are we doing everything right?”
“Especially knowing doctors said I was having a status attack, I was on the verge of death,” Andrew added.
Blue Shield claimed coverage was denied in part because the air ambulance didn’t pick him up at the site of his injury. However, the Dowers argued that their campsite was too rough for the helicopter to land. A ground ambulance had to rush Andrew to a more accessible airstrip before transferring him to the helicopter.
“All the doctors said we did the right thing, but hearing we could have lost him was just hard to absorb,” Andrew reflected.
The Dowers shared documentation with NBC 7, showing that the flight crew deemed an air ambulance necessary and took him to the most appropriate facility.
Increasing Denials in the Healthcare System
Caitlin Donovan, senior director of the Patient Advocacy Foundation, noted this troubling trend, indicating that urgent situations should lead to easier approvals. “It’s disturbing to see a complete denial in such cases,” she pointed out.
Donovan mentioned that since the No Surprises Act of 2022 came into effect, insurance companies have looked for other ways to deny claims rather than handle out-of-network charges more transparently.
Investigating the Insurance Response
After two denied appeals from Blue Shield, the Dowers pursued an independent medical review, but the process dragged out for nine months. That’s when they turned to NBC 7 for help.
“Reaching out to you was my last hope,” Angela said.
After NBC 7 contacted Blue Shield, the company made an unexpected turnaround, agreeing to cover Andrew’s air ambulance ride less than two weeks later.
“I cried when they told us that,” Angela expressed. “It felt like a weight lifted from my heart. I’m so grateful; it’s thanks to you all that we could finally resolve this.”
Andrew chimed in, “We owe NBC.” Yet, lingering stress remained as they reflected on the ordeal.
“I spent countless hours on the phone, trying to get answers,” Angela recounted. “Every time it was, ‘Sorry, they’re not available,’ or ‘That’s how it is.’ It’s disheartening it had to be that complicated.”
Blue Shield opted not to comment due to privacy regulations. NBC 7 has previously negotiated with insurers after obtaining privacy waivers. Despite multiple requests, Blue Shield declined to issue one.
Angela desires more than mere reimbursement. “I would like an apology for all the stress, for the hardship it caused our family. Why does it have to be such a struggle?” she questioned.
Donovan noted, “It’s surprising given the gravity of their situation that the insurance company was so clearly in the wrong. Unfortunately, it’s evident that patient care is often denied to save costs.”
What To Do If Your Claim Gets Denied
If you feel your health insurance claim is unjustly denied, the Patient Advocate Foundation can assist. Their resources include templates for appeal letters.
While the state didn’t comment on Andrew’s case, there is a possibility of overturning the denial. Since 2017, the California Independent Medical Review program has evaluated emergency transportation cases, with a significant number resulting in decisions favoring patients.
