Ellen Gentile was lying on the operating table with a hospital gown and an IV in her arm when her family told them they learned that the neck surgery they believed was approved might not actually be covered.
The Millburn, New Jersey, mother was living with excruciating pain from a ruptured disc that left her partially paralyzed and unable to move her arms or hands. Expecting long-awaited relief, the woman arrived at the hospital ready for the procedure after being told to come the night before.
“They had called me the night before and said come in,” Ellen told the ABC. 7 On Your Side consumer reporter Nina Pineda (1). “You know, we assumed everything was approved.”
The surgery was ultimately successful as his condition worsened and his mobility was at risk. But when the bills were later counted, Gentile and her husband, Matthew, faced nearly $126,000 in medical expenses.
But what Ellen experienced is not unusual. A 2024 study by the Commonwealth Fund found that nearly half of insured Americans faced unexpected medical expenses (2). Here’s how the situation occurs and what patients can do if they lose insurance coverage.
When Pineda later sat down with the couple and investigated where the malfunction might have occurred, he asked if anyone had warned them that this might not be covered by the procedure.
“The business manager said it usually worked,” Matthew recalled.
The couple was denied insurance coverage after submitting claims totaling six figures and including nearly $37,000 for the artificial spine device and nearly $9,000 in anesthesia costs. They appealed the decision twice, but both attempts were unsuccessful.
When 7 On Your Side The insurance company then contacted Independence Blue Cross and provided letters of medical necessity from Gentile’s doctor. The insurance company maintained its position, arguing that the device was not approved by the US Food and Drug Administration and the surgery was not officially authorized. Still, the exchange revealed one option remained: The couple could conduct a final review through an independent third party.
For many Americans, dealing with medical bills and coverage disputes can feel overwhelming. Data from the Kaiser Family Foundation shows that approximately 44% of U.S. adults say it is very or somewhat difficult to afford health care costs (3). Financial distress is especially evident among the uninsured; Roughly 82% of uninsured adults under age 65 have difficulty paying for care, compared with 42% of those with health insurance.
Ellen’s experience reflects a broader truth: Insurance denials can affect patients at all income levels, including those who understand the healthcare system. In a separate case discussed earlier in terms of money in novemberNicole Hughes, MD, director of the University of Colorado Farley Center for Health Policy, initially faced a hospital bill of nearly $64,000 after surgery for a broken ankle.
His insurer acknowledged that the procedure itself was medically necessary but denied the cost of an overnight hospital stay, explaining that the services were billed together in a lump sum claim. The technical distinction ultimately shaped what insurers were willing to pay. Hughes later said in terms of money In the immediate aftermath of trauma, patients are rarely in a position to think strategically about insurance approvals or network status.
“Even as a physician working in health policy, it was never on my mind at that moment to ask about my level of care and/or call my insurance company,” Hughes said.
Although the details of the two cases are different, they both share one thing in common: Neither patient accepted the initial rejection. Appealing coverage decisions can make a difference, but many Americans never take this step. The Commonwealth Fund reported that 45% of insured adults reported receiving a bill for care they believed should be covered, while almost a fifth said they were denied coverage for a service recommended by doctors (4).
Even so, less than half of those who encountered billing errors or denials formally challenged them, mostly because they were unaware they had a right to appeal.
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In the end, Ellen said she was grateful for that. 7 On Your Side helped guide the family to a final review option.
“What I mean is, you were able to give us a more convenient route and it was approved,” Matthew said.
The rejection was overturned through an independent third-party review and the $126,680.25 bill was honored. Still, unexpected medical bills can happen to almost anyone. Sara Collins, senior fellow and vice president of healthcare coverage and access at the Commonwealth Fund, told CBS MoneyWatch that confusion around the billing process often leaves patients unsure of how to respond (5).
“Many people with insurance face unexpected bills and denial of care recommended by doctors,” he said. “And a lot of them don’t know what to do about it; people are confused about the healthcare process itself, both in the way it’s billed and who’s responsible for it.”
In Hughes’ experience, he said it’s important to document everything and ask the right questions when faced with a rejection.
Requesting a written explanation of the denial may also help clarify whether the issue relates to prior authorization, medical necessity standards, network availability, or billing codes. Patients can work with their provider’s billing office to resubmit their claims with updated documentation or corrected coding.
If concerns persist, consumers can file a formal appeal with their insurance company or request an external review through their state’s insurance department; This is an important step that proves decisive in Ellen’s case.
Even if a rejection is ultimately valid, options may still be available. Some hospitals offer financial assistance programs, often referred to as “charity care (6).” The Internal Revenue Service defines charity care as free or discounted health services provided to individuals who meet an agency’s eligibility criteria and are unable to pay for all or part of their treatment.
State insurance departments and patient advocacy groups can also provide guidance, helping patients better understand their rights and resolve complex billing disputes. Ellen’s experience is a reminder that the first answer from an insurer is not always the last answer.
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ABC7 (1); Commonwealth Fund (2, 4); Kaiser Family Foundation (3); CBS News (5); IRS (6)
This article provides information only and should not be construed as advice. It is provided without any warranty.
