38: The Battle to Make the Health Insurers Obey the Law - Part 1: 5 October 2024

In March 2021, the cat scans gave us the astonishing news that Margaret’s course of chemotherapy and radiotherapy had been wildly and unexpectedly successful.  Before the grueling 6 weeks of treatment started in December 2020 (it finished on 20 January 2021), the oncologist had warned us that the likely most optimistic outcome would be an extension of Margaret’s life by perhaps another 2 or 3 months to perhaps April or May 2021 

I have already described the barbecue we held on 26 January 2021 to in effect jointly say goodbye to our friends.  That was the barbecue which was used as an excuse by Anne Ryan and most of our other friends to vastly reduce contact with Margaret and to completely eliminate all contact with me.

After the barbecue, none of our invited guests ever came to our house again.  In the wake of the cancellation, I became so ill that I knew death was close on many occasions.  I survived by grim willpower; I refused to abandon Margaret and force her to deal with her deadly cancer by herself.

We were both completely shocked when the March 2021 cat scans revealed that miraculously, the cancer had nearly vanished.  The stunned oncologist had no explanation for what had happened.

Margaret’s apparent cure happened just as my own struggle to live, became a grim daily ordeal to breathe, to eat, to stop coughing and to somehow cope with the agonising pain in my stomach.  My grim struggle to stay alive became a daily feature of my life on 26 January 2021 after the barbecue.  One result of our cancellation was my health collapse.

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Once the chemotherapy and radiotherapy finished on 20 January 2021, the oncologist urged Margaret attend a licensed hospital called Lift Cancer Care Services.  Lift offers one on one supervised exercise – exercise medicine.  To undertake exercise medicine, the patient must be recommended for the treatment by the treating doctor.  Before any exercise therapy session can commence, every patient must be examined by a doctor.  All exercise therapy sessions were conducted as directed by the doctor, in light of the patient’s physical capacity on attendance.

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Australia has both a publicly funded health care system and a privately funded health care system.  The private health care system requires that you have private health insurance.  If you have private health insurance – at least in theory - you do not have to wait months for a specialist appointment and then wait several more months for the public health system to provide give you with potentially life saving treatment.  The insurance – in theory – enables you to get treated before you ever could in the public health system.

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We had full private health insurance.  This meant that if our insurer HCF obeyed the law and paid the money that the law said it was required to pay, the greater part of the cost of Margaret’s treatments at Lift Cancer Care Services would be funded by our health insurer HCF.

In theory, the system operated like this.  When Margaret attended Lift for a treatment, she paid the “gap” between what the government required HCF to pay to Lift Cancer Care Services and the fee actually charged by Lift Cancer Care for the treatments it gave to Margaret.  The gap fee paid by Margaret for her treatments – which were often twice per week in 2021 – averaged $20 per treatment in 2021.

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In the previous paragraphs, I used the words “in theory” to describe the legal obligations of HCF and the other health insurers.  The legal theory differed a great deal from the reality.  The health insurers certainly knew that the government had minimal interest in enforcing its laws against the health insurers. 

I believe that a senior executive (or perhaps more than one senior executive) in the Australian Health Department had been corrupted.  I cannot find any other reasonable explanation for the refusal of the Health Department to enforce the private health insurance legislation.  The possibility of mere incompetence on a massive scale is in my opinion, extremely unlikely.

The “backstop” government regulator of the private health insurance legislation is a government agency called the Commonwealth Ombudsman. 

I believe that a senior executive (or perhaps more than one senior executive) in the Commonwealth Ombudsman had also been corrupted.  I cannot find any other reasonable explanation for the refusal of the Commonwealth Ombudsman to enforce the private health insurance legislation.  Once again, the possibility of mere incompetence on a massive scale by the Ombudsman is in my opinion, extremely unlikely.

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In October 2021 we were told by Lift Cancer Care Services that our health insurer HCF and two other health insurers - Teachers’ Health and NIB - had for multiple consecutive months, refused to make the insurance payments to Lift Cancer Care Services that the private health insurance laws theoretically obligated them to pay.

As From 1 December 2021, we would have to pay the full fee for the services provided to Margaret by Lift and we would then have to have our own argument with HCF to extract payment from HCF of the money that the law in theory said HCF was obliged to pay.  Patients at Lift who were insured with HCF, Teachers’ Health and NIB would also have to pay in full on the day and then try and force their health insurers to pay what the legislation said they had to pay.

Lift Cancer Care Services did NOT ask its patients to pay the money that the health insurers had refused to pay in the past.  Lift Cancer Care was prepared to somehow find the “missing" money out of its own pocket

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The news from Lift Cancer Care signaled the beginning of what became a desperate battle by me to force the three health insurers to obey the law.  It became very clear to me at the beginning of this struggle that the continuation of Margaret’s life depended on me refusing to allow the health insurers to continue to defy the law.

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By July 2021 my own battle to stay alive had been successfully completed when my lung specialist worked out that my health issues had been caused by my own immune system.  Once I commenced injections every 4 weeks in mid July 2021, my health stabilized and I have had no significant health issues since then.

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Within two weeks of my final stay in hospital, Margaret’s cat scan revealed that her cancer was back with a vengeance and that it had now spread into her lymph nodes.

My understanding of the lymph node system – as given to me my Margaret – is that it circulates fluids within the body.  It is similar to the blood circulatory system but different in that the one fluid it does not carry, is blood.  Once cancer has made its way into the lymph nodes, it has a super highway to every part of the body.  If it gets into the lymph nodes, the cancer is guaranteed the ability to spread everywhere throughout the body and kill.

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The presence of the cancer in Margaret’s lymph nodes was confirmed by two “look see” operations and by a PET scan in August 2021.  We did our best to prepare for Margaret’s death.

On the second of the “look see” operation where the surgeon physically saw the cancer in Margaret’s lymph nodes, he took some tissue samples.  The oncologist looked stunned when he told us the result of the testing of the lymph node tissue samples.

Margaret’s cancer was still there, but she had made it disappear from her lymph nodes.  I have the written report setting out this unbelievable finding.

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Although the cancer had been driven out of Margret’s lymph nodes, she still had the cancer; it most definitely had not gone away.

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The surgeon decided to have another “look see” operation on 1 December 2021.  This was the date that the new payment arrangements were to commence at Lift Cancer Care Services.  This was the new payment system which became necessary because of the refusal of our insurer HCH, Teachers’ Health and NIB to make the insurance payments that the law most definitely required them to make to patients who attended Lift Cancer Care Services.

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Margaret had her surgical procedure on 1 December 2021.

The result could not have been more depressing.  The cancer had spread and she needed to prepare for an early death.  Despite this, the surgeon wanted to have another “look see” operation on 3 December, so Margaret stayed in hospital.

Margaret told me on 2 December that when we had finished our coffee, she would visit Palliative Care on the hospital grounds to see what help it could offer in the final days of her life.

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I did not know it on 2 December 2021, but I was about to start a grim struggle to keep Margaret alive.  My struggle was to ensure that Margaret and the other patients at Lift Cancer Care Services got what the law said they were supposed to get – payment of their treatment costs by their health insurers.

My grim struggle with the health insurers lasted until July 2022.  I kept it up because I knew that so long as I kept trying to force the health insurers to obey the law, Margaret would continue to live.  I knew that Margaret’s life – quite literally - depended on how I acted towards the health insurers.  If I let the insurers get away with their bad behaviour, she was doomed.  This meant – of course - there was never any possibility that I would let the health insurers continue to break the law. 

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This is a photo of Margaret on Thursday 2 January 2020 while we were in New Zealand.  Before she became so desperately ill, Margaret always insisted on lighting a cigarette whenever I tried to take a photo of her.  Margaret lost 20 kilograms during the 9 days that we were in New Zealand.

 

This is a photo of one of the women Margaret wrongly believed was one of her close friends.  This is Sue Chapman; she holidayed in New Zealand with us immediately after Christman 2019.  This photo was taken on Thursday 2 January 2020.

Anne Ryan also holidayed with us in New Zealand just after Christmas 2019.  This photo of Anne Ryan and Sue Chapman was taken on Monday 6 January 2020 in Christchurch.  Anne and Sue were close friends.

 

Margaret and I visited Croagh Patrick with Sue Chapman and Anne Ryan on Monday 16 September 2019.  They walked with me up the lowest slopes of Croagh Patrick on that day.  Margaret stayed in the café at the foot of Croagh Patrick.

 

This is Margaret on Monday 23 September 2019.  We stayed in Killashee House to celebrate the 10^th anniversary of our marriage in Killashee House on 30 July 2009.  Margaret did her best to stop me taking this photo.