Hankin Redden Blog

39: The Battle to Make the Health Insurers Obey the Law - Part 2: 6 October 2024

To recap, Margaret had a surgical procedure on Wednesday 1 December 2021 and the operation revealed that cancer had spread and death was close. Despite what he saw, the surgeon scheduled another “look see” operation for about 6.00 pm on Friday 3 December. Margaret stayed in hospital. If she had gone home, the covid restrictions would have prevented her from being readmitted to the hospital for the follow up operation.

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Throughout Friday 3 December 2021, I worked frantically on letters of complaint to our health insurer HCF and to the Commonwealth Ombudsman. In theory, the Ombudsman was the government agency which, in conjunction with the Australian Health Department, enforced the laws governing private health insurance.

At about 4.30 in the afternoon, I emailed this letter of complaint to HCF.

Dear HCF,

My name is John Hankin and I write to lodge a serious complaint about what seems to be a systemic refusal by HCF to respond to claims for reimbursement of medical expenses which are clearly covered by the policy of private health insurance which my wife and I have had with HCF since 2014. My membership number is xxx and the policy covers both myself and my wife Margaret Redden.

My wife Margaret was diagnosed in July 2020 with what may well prove to be incurable ampullar cancer of her ampullar. My understanding is that the ampullar is a junction point just outside the pancreas where the bile duct and the pancreatic duct meet in a T junction. The growth of the cancer in this location is likely to result in the failure of the digestive system. If Margaret’s digestive system fails, she will die.

Margaret commenced chemotherapy and radiotherapy in December 2020 and this treatment continued through January 2021. The cancer went into remission in March 2021 but it surged back into renewed life in September 2021. As I write this letter of complaint, Margaret is an in patient in hospital receiving treatment.

Part of the treatment program recommended by Margaret’s treating oncologist was attendance at a registered day hospital called Lift Cancer Care Services. My understanding is that when she attends Lift, she is admitted as a patient and given treatment by registered professionals. Each treatment consists of an initial medical examination by qualified medical personnel who then recommend an exercise program which is then undertaken on the premises of Lift. The exercise program is closely supervised by Lift personnel and adjusted on an ongoing basis during each treatment session. As I understand it, the aim of the programs provided by Lift is to increase the physical strength of cancer patients so that their ability to survive and gain benefit from the specific cancer treatments recommended by their medical practitioners, is enhanced. To be eligible to undertake the services provided by Lift, participants in the Lift program must have received a formal diagnosis of cancer and, in addition, their treating medical practitioners must decide that the cancer treatment regime is likely to be enhanced if participants take part in the Lift program.

Margaret began to take part in the Lift program in January 2021. She has found the program to be of great benefit to her physical and mental health while she is in the midst of an extreme threat to her ongoing physical existence.

The relevant legal relationship between Margaret and Lift is that Lift provides services to Margaret and in return for the provision of those services, Margaret has a legal obligation to pay the agreed amount for those services. In order to make the process as easy as possible for Margaret and for the other participants in its program, Lift acts as agent for Margaret and submits claims to HCF on Margaret’s behalf after the conclusion of each therapy program that Margaret attends at Lift. If and when HCH accept the claims made by Lift on Margaret’s behalf, Lift accepts the insurance reimbursement provided by HCF as full payment by Margaret for the services it has provided to her.

As a matter of law, when Lift submits a claim to HCF under Margaret’s private health insurance policy with HCF, it is Margaret – or if you like, me as the official policy holder – who is making the claim under the health insurance policy. Lift is not making any claim on its own behalf. It acts purely as an agent to assist its program participants – every one of whom has been diagnosed with a life threatening illness. All actions taken by HCF in relation to claims made by Lift are actions taken not in relation to Lift but in relation to each and every patient on whose behalf Lift has submitted a claim.

Lift has now advised Margaret and me that contrary to what we had believed to be the case, HCF has, for the most part, either responded with spurious and legally incompetent reasons for rejecting claims, or completely ignored the claims and not bothered to provide any response at all. Because of the callous disregard by HCF of its legal obligations under the policy of private health insurance between it and ourselves (and other cancer patients who have attended Lift), Lift has not been paid for multiple treatments provided to its patients. In Margaret’s specific case, as at the date of this letter, HCF has either refused to pay or completely ignored thirty (30) separate claims made by Margaret under our policy of private health insurance. Because of the callous and cavalier attitude displayed by HCF, Lift is now able to provide services only if patients pay for their treatment on the day of service and then seek reimbursement individually from HCF.

I am utterly disgusted by the actions of HCF and under cover of this letter, I am now making 30 separate complaints to HCF about its failure to respond to its legal obligations under our health insurance policy.

I attach as Table 1, a complete listing as at the date of this letter of all claims that have either been refused or ignored by HCF. This Table includes the dates of the treatments, the Lift invoice numbers, the item claim numbers submitted by Lift and – where a formal refusal of the claim has occurred- a statement of the reasons asserted by HCF as justifying the refusal.

I also attach as Table 2, a complete listing as at the date of this letter of the seven (7) occasions on which claims have been accepted by HCF. I note that on six of the occasions when claims were paid by HCF, the item number in question attached to the claims was Item 37. All of the claims which have been rejected or ignored by HCF have Item 37 attached to the claims. On some occasions, HCF asserts – falsely – that Item 37 is not a valid item number, while on other occasions HCF has actually paid claims under this item number.

The specific action that we require to satisfy the 30 complaints itemised in Table 1 is payment in full to Lift of the complete amount payable under our policy of private health insurance either to us for on payment to Lift, or payment by HCF directly to Lift as our agent. I stress that we reject completely any assertion by HCF that the claims in question are not payable because of the reasons set out in Table 1, viz –

• Item number 37 is not a valid item number on HC21 claim form;

• Outpatient services are not payable by HCF;

• Please note that Item 37 is not valid;

• Please provide valid item number for Hospital admission billed as it cannot be billed as Item 37.

On each occasion that Margaret has attended Lift, she has been admitted as a patient, not as an outpatient. If item 37 is not technically correct, HCF has a legal duty to advise the item number that HCF asserts should be cited in the claim.

We look forward to the speedy rectification of the matters raised in this letter.

Simultaneously with sending this formal letter itemising our 30 separate complaints regarding the actions of HCF - and often failure to act - I have made 30 separate formal complaints to the Commonwealth Ombudsman. I have asked the Ombudsman to commence formal investigation of the complaints made to the Ombudsman once a period of fourteen (14) days has expired from the date of this letter. Unless we receive full satisfaction of all of the complaints set out in Table 1 attached to this letter by no later than close of business on 27 December 2021, action by the Ombudsman will commence.

In the final paragraph of my letter to the Ombudsman, I have said the following:

“Notwithstanding the fact that I have given HCF 14 days in which to respond to Margaret’s specific matters, the matters raised in my letter to HCF are of significant importance to all cancer patients. I understand that other providers of services similar to those available at Lift – and their cancer patients – have been treated in a cavalier manner similar to that in which Margaret has been treated. Because of the general importance of this issue to multiple numbers of cancer patients, it is probably appropriate that the Ombudsman investigate this matter because of the community wide nature of the issues raised in my letter to HCF, because of its general importance to the Australian community as a whole. In my view, because of the community wide nature of the issues raised in my letter to HCF, immediate intervention by the Ombudsman is appropriate.”

Margaret and I look forward to seeing a speedy resolution of her unpaid insurance claims. In addition, we hope that intervention by the Commonwealth Ombudsman will lead to a more general cessation by HCF of the reprehensible way in which it has treated other cancer patients in addition to Margaret.

My letter to HCF was completely ignored apart from a formal “yes, we got your letter and we are giving it a thorough investigation” response.

I expect companies such as HCF to treat complaints in a cavalier manner. If government agencies such as the Health Department and the Ombudsman are known to refuse to enforce the law, companies such as HCF will routinely ignore the law. HCF acted in exactly the way I expect big companies to act; insurance companies routinely reject claims that should not be rejected.

My letter to the Ombudsman was also completely ignored. I received no communication of substance from the Ombudsman until a I got a phone call in very late January 2022. The phone call told me that this was a very complex matter and that the Ombudsman would get back to me.

Unlike the health insurers, the Ombudsman was legally obliged to enforce the law, but it was obviously known to the health insurers that it rarely if ever did. In my opinion, the relevant senior officers employed at the Ombudsman were almost certainly corrupt. Incompetence makes no sense as an excuse. The health insurers knew that neither the Health Department nor the Ombudsman would do anything of substance to enforce the law. HCF ignored my letter because it knew it could ignore it and there would be no legal consequences.

My beautiful wife Margaret might well die if she was unable to access the treatments provided by Lift Cancer Care, but that was irrelevant to HCF. In a competition to make more money or spend a little to save a life, HCF was always going to go for the money.

My letters were addressed to one company that was greedy and held the law in contempt and to a government agency that did not give a damn about doing its job.

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But neither HCF nor the Ombudsman had the incentive to keep going in this struggle that I had.

At about 7.30 pm in the evening of Friday 3 December 2021, I received a phone call from Margaret.

Despite zero treatment since Wednesday 1 December 2021, the surgeon had the astounding news that the cancer had again retreated. He told Margaret that he had never seen her cancer so small.

Margaret was free to come home that night and I made sure she did just that.

Margaret slept at home that night and her cancer had once again done something unheard of.

I had written letters demanding justice for Margaret and for all cancer patients.

My reward was another extension of Margaret’s life.

If keeping Margaret alive meant an all out battle with the health insurers, I would gladly accept the battle.

I would never willingly allow Margaret to die if there was anything at all I could do to keep her alive.

If the health insurers had been able to read my mind that night, they would have known there was no possibility that they would ever win. I was unbeatable for one simple reason – Margaret’s continued life – and the lives of many other cancer patients – depended on me forcing the health insurers to obey the law.

The end result was never in doubt after Margaret told me I could bring her home. The only unclear aspect was the exact road which would lead to the insurers obeying the law.