54 My Battle to Make the Health Insurers Obey the Law Part 10: 14 October 2024

During my phone conversation with the Ombudsman on Friday 18 February 2022, Sarah De Sade asserted that HCF was entitled to refuse to pay the claims for Margaret’s treatments because Lift Cancer Care Services had been asked by HCF to provide more information about the claims, but had failed to provide the requested additional information.  I am certain she made this assertion without having ever seen the documents submitted to HCF by Lift, and without having ever examined the relevant legislative provisions.  Later, on 18 February, Lift gave me copies of ALL documentation connected with all of the treatments submitted to HCF, both paid and unpaid, by Lift.  The documentation included all documents created by Lift for every treatment provided to Margaret, plus copies of all correspondence received by Lift in relation to those treatments.

As at 18 February 2021, there were 35 unpaid HCF claims for Margaret’s treatments.  There were only 14 HCF responses for the 35 separate unpaid claims.  Each of the responses was a single page letter telling Lift that HCF would not pay the claim.  The HCF rejection letters did not enable me to identify the specific dates of the treatments for which HCF was refusing to pay. 

The sending of the 14 rejection letters to Lift but not to us, meant there had been a minimum of fourteen unlawful acts by HCF.  When a claim is made to a health insurer, the insurer must register receipt of the claim and it must record the fate of the claim –whether it is accepted (and paid) or whether it is rejected (and not paid).  If the patient has paid in full for the treatment, the health insurance policy holder must be told in writing whether the claim has been accepted or rejected.  When the patient has paid only the insurance “gap”, the claim is submitted to the insurer by the health provider.  In these cases, both the insurance holder and the health service provider must be informed in writing whether the claim has been accepted or rejected.

Although HCF had sent 14 rejection letters to Lift Cancer Care Services, we had not been informed about any of the 14 rejections.  I believe even if the rejections were lawful, this means HCF committed a minimum of 14 offences even– and the rejections were definitely unlawful.

The paperwork also told me that HCF had broken the law far more often than on the 14 occasions that it had sent rejection letters to Lift.  Because there were 35 unpaid claims, HCF should have written at least 35 rejection letters both to Lift and to us – meaning there should have been a total of 70 rejection letters, not 14.  Failure to advise the fate of the claims meant there were 35 separate offences in relation to not telling us about the claims, plus an additional 21 offences in relation to not telling Lift about the fate of the claims.  Even if the claims had been lawfully rejected, HCF had clearly broken the law on at least 56 occasions.

HCF had obviously ignored the law, but for some reason the Ombudsman thought the conduct of HCF was appropriate.

I was horrified by what I unearthed in the rejection letters, but there was a lot more to come.

The fourteen rejection letters differed from each other only in minor details.  Not one of the rejection letters identified any additional information that HCF claimed it needed to enable the claims to be paid. 

The rejection letters expressed clear contempt towards Lift Cancer Services as the treatment provider, Margaret as a patient with incurable cancer and me as a HCF policy holder.  All rejection letters displayed lack of professionalism and a lack of sympathy for a patient whom the doctors had diagnosed as dying.

These are dates of the 14 rejection letters. 

February 2021	March 2021	April 2021	May 2021
25 February 2021	* 26 March 2021 * 26 March 2021 * 26 March 2021	21 April 2021	4 May 2021 18 May 2021
June 2021	July 2021	August 2021
2 June 2021	* 10 July 2021 * 10 July 2021 * 10 July 2021 * 10 July 2021	* 14 August 2021 * 14 August 2021

 

* These letters were all separate letters even though they had an identical date as other letters.

A very important question remained apart from the misleading nature of the 14 rejection letters.  What had happened to the 21 claims which had not officially been rejected?  By inference, the answer was very clear.  They had not been processed in any way.  HCF had made them “disappear”.  They had gone straight into the HCF “Deleted” box.

If HCF was “processing” our claims in this cavalier manner, it was obviously doing exactly the same thing to all of the other Lift patients who were insured with HCF.  I presumed that the other recalcitrant health insurers – Teachers Health and NIB – were also acting the same way.

In my attempt to force HCF to obey the law and pay for Margaret’s treatments, I had uncovered serious criminal behaviour – and it appeared that this behaviour was not confined to HCF.  Even worse, the Ombudsman seemed to be well aware that the health insurers were breaking the law – and seemed to be actively helping them to do this.