53 My Battle to Make the Health Insurers Obey the Law Part 9, Section 3 – the Disappearing Ombudsman: 14 October 2024

My next contact from the Ombudsman was a call at 9:43 am on Friday 18 February 2022 while I was driving.  After I stopped driving, I saw that the call was from a “Private Number”.  The Private Number rang back at 10:07 am the same day and I spoke to Sarah De Sade for twenty three minutes.  

My conversation with Sarah De Sade convinced me that:

• The Ombudsman had no intention of making the health insurers obey the law;
• The Ombudsman had no idea what the law was; and
• The Ombudsman had no intention of finding out what the law required.

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Sarah De Sade told me that in March 2021, HCF had requested further information from Lift Cancer Care Services and that Lift did not provide the additional information sought by HCF.  According to Sarah De Sade, this failure to provide “additional information” was a valid reason which entitled HCF to refuse to pay ALL claims lodged with HCF by Lift.  Sarah De Sade made no reference to the copies of the claim documents we had submitted to HCF for the treatment provided to Margaret on 25 January 2022.  These had been sent to her with my email dated 12 February 2022.  It would have been a simple exercise to compare these claim documents to the requirements set out in the legislation – but that would have required her to examine what the legislation said.

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As at 18 February 2022 when this call took place, Margaret had 35 claims for Lift treatments which had been lodged with HCF for payment.  These are the dates of the treatments for which claims had been submitted to HCF, but never paid by HCF.

 

January 2021	February 2021	March 2021	April 2021
18 January 2021 21 January 2021 28 January 2021	3 February 2021 11 February 2021 25 February 2021	3 March 2021 19 March 2021 24 March 2021 31 March 2021	9 April 2021 16 April 2021 19 April 2021
May 2021	June 2021	July 2021	August 2021
10 May 2021 17 May 2021 24 May 2021	2 June 2021 18 June 2021 21 June 2021 28 June 29021	6 July 2021	11 August 2021 23 August 2021
September 2021	October 2021	November 2021	December 2021
1 September 2021 8 September 2021	18 October 2021 25 October 2021	3 November 2021 10 November 2021 18 November 2021	17 December 2021 23 December 2021
January 2022
6 January 2022 18 January 2022 25 January 2022

Even though (at the specific request of the Ombudsman) we had provided written permission for the Ombudsman to obtain all relevant documents from HCF concerning Margaret’s treatments, Sarah De Sade had not:

• Identified the specific dates of the unpaid treatments for which claims had not submitted to HCF; and

·      Obtained copies of the documents relating to those claims.

Perhaps what was even more dismaying was the clear implication that Sarah De Sade had not even identified the relevant legislation and compared the claim documents to the requirements of the legislation.  The investigator appointed by the Ombudsman had not bothered to address the basic question of whether or not the law required HCF to pay the claims.  Common sense told me that a basic requirement of any investigation by the Ombudsman required assessment of the claim documents submitted to HCF against the legislative requirements.

By ignoring the basic requirements of her job as an “investigator”, Sarah De Sade had:

• Accepted that HCF was legally entitled to demand “further information” no matter what the legislation stipulated;
• Accepted that HCF had in fact demanded further information in relation to all 35 unpaid claims for Margaret’s treatments;
• Accepted that in all 35 unpaid claims for Margaret’s treatments, Lift had failed to provide the additional information supposedly asked for by HCF; and
• Accepted that because HCF claimed that Lift had failed to provide the additional information supposedly asked for by HCF, HCF was legally entitled to refuse payment on every one of the 35 unpaid claims.

Did Sarah De Sade truly expect HCF – or any other law breaker – to immediately admit to having broken the law?  If a health insurer claimed it had asked for but not received further information, surely the Ombudsman ought to demand copies of the HCF letters where the additional information was supposedly sought?

Without bothering to ask for or read relevant documents, the Ombudsman had accepted as true, a claim which was an obvious lie – and Sarah De Sade lacked the courage to even say this in writing.

I was extremely disappointed by the attitude of Sarah De Sade on Friday 18 February 2022.  I decided to obtain the detailed information that she had been too lazy to seek out.

Immediately after the phone call, I asked Lift for copies of ALL documentation in its possession relating to Margaret’s treatments and to the HCF claims.  I received those documents later that same day.  The documents enabled me to rapidly establish the falsity of the HCF claims as relayed by Sarah De Sade.  Any assertion by HCF that Lift had failed to provide further information asked for by HCF was a complete lie.

Rather than asking for additional information, HCF had not processed most of the claims in any way.  In most cases, HCF did not even acknowledge receipt of the claims and the claims were neither acknowledged, accepted or rejected.

Most of the claims had completely “disappeared” after being sent to HCF.  Whatever was happening in relation to the refusal of HCF (and other health insurers) to pay for treatments provided by Lift Cancer Care Services was not based on an argument about the legal requirements for payment of the Lift treatment claims – and in some way that was not yet clear, the Ombudsman was a principal player which was actively assisting the health insurers in their refusal to obey the law.