Bay Area Woman Wins $10,000 Battle with Anthem After Using AI-Powered Appeal Tool
SAN FRANCISCO, CA – A Bay Area woman has successfully overturned a $10,000 health insurance claim denial thanks to a free, AI-powered platform designed to fight back against insurance companies. The victory highlights a growing trend of insurance denials and the challenges patients face in navigating complex appeals processes.
Maria Gonzalves, a social worker, had been battling Anthem for years over the charges when she discovered Counterforce Health, a platform that utilizes artificial intelligence to build cases for appealing denied claims.
“Family members had told me, ‘Just pay the bill, just move on.’ And that’s just not who I am,” Gonzalves said. “I’m a social worker. I was going to advocate for myself. I was absolutely not going to give Anthem money that I did not owe them.”
According to Counterforce Health founder, Dr. Karan Shah, the average person spends five to ten hours researching and compiling evidence for an appeal, a process many find too daunting. “Ninety-nine percent of denied claims are never appealed,” Shah told CBS News Bay Area. “So, people just say I’ll either go without that or I’ll pay out of pocket. Of the 1% that are appealed, 50% of people win at baseline. Just goes to show you two things: that denials are unfair, and then people are not bothering to fight back.”
Shah created Counterforce Health after personally experiencing the frustration of navigating insurance denials while his wife underwent cancer treatment. “It’s at the darkest time of your life…you now have to dedicate a lot of your energy to fighting the insurance company,” he explained. He noted that increasingly, initial denials are issued by AI systems, requiring significant effort to challenge. “So now it’s like OK,we’ll build AI and empower people to fight back in a second.”
Using the tools provided by counterforce Health, also known as Agent Maxwell, Gonzalves filed another appeal to Anthem. In early August, the insurance company dropped all of her charges.
Gonzalves believes insurance companies are exploiting patient exhaustion for profit. ”Insurance companies are supposed to support us and help us make sure that we get healthcare. But instead, they’re going after us, and they’re essentially trying to wear us down to earn money off of people’s exhaustion, and it’s not right.”
CBS News Bay Area has reached out to Anthem for comment.
Shah also runs CAREYAYA, a caregiving platform connecting college students with older adults, partnering with students at UC Berkeley and Stanford. His focus remains on empowering individuals to navigate the healthcare system. “Having people feel empowered, that they have some agency in this journey,” he said.
