58 My Battle to Make the Health Insurers Obey the Law Part 11 - Section 4: 15 October 2024

Eventually, HCF claimed that it was refusing to pay the Lift claims because of the operation of the Private Health Insurance (Benefit Requirements) Rules, 2011.  The relevant part of the Benefit Rules is clause 7 of “Part 2 Type B procedures”.  Clause 7 appears in the part of the Rules with the heading “Schedule 3, Same-day accommodation: hospitals in all States/ Territories”.

Clause 7 of “Part 2 Type B procedures” in Schedule 3 of the 2011 Rules says this.

7.               Certified Type C procedure Note:   Type C procedures are procedures that do not normally require hospital treatment. (1)        Benefits for day-only accommodation are payable for patients receiving a Type C procedure only if certification under subclause (2) is provided. (2)        Certification must be provided as follows, the medical practitioner providing the professional service must certify in writing that: (a)                    because of the medical condition of the patient specified in the certificate; or (b)                   because of the special circumstances specified in the certificate, it would be contrary to accepted medical practice to provide the procedure to the patient unless the patient is given hospital treatment at the hospital for a period that does not include part of an overnight stay.

 

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Clause 7 defines “Certified Type C procedures” as procedures that do not normally require hospital treatment.

The definition of the procedures contemplated by clause 7 is very different from the definition of procedures in clauses 3 to 6 of Part 2 Type B procedures. 

Under clauses 3 to 6, the insurer has a duty to pay only if the procedure is identified by its Medicare benefit number and is specifically listed in clauses 4, 5 or 6. 

By contrast, the “Certified Type C procedures” identified in clause 7 can be procedure any at all - so long as the required certificate is completed by the medical practitioner.   The required certificate is usually referred to as a Type C certificate.

The payment contemplated by clause 7 is not a payment for the procedure provided to the patient.  Rather, the payment required under clause 7 is a minimum amount the health insurer must pay for hospital accommodation benefits.  The private health insurers must pay on behalf of the patient, the minimum specified amount for hospital accommodation.  The Rules impose no requirement to pay for the “procedure” referred to in the Type C Certificate.

In brief, to invoke the requirement to pay the minimum accommodation benefits, there must be a Type C certificate provided by a medical practitioner and that certificate must comply with the requirements set out in clause 7.

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I eventually discovered that the reason for the refusal to pay by HCF had nothing to do with the legal requirements I have just summarised. 

HCF – and presumably the other health insurers – refused to pay because they did not approve of Margaret’s admission as a patient to Lift Cancer Care Services.  HCF refused to pay because HCF decided that no cancer patients should ever need to be admitted to hospital for the treatments that Margaret was clearly benefitting from as administered to her at Lift.

Our health insurer had decided that it – and not any medical practitioners – would decide what treatments Margaret should receive for her cancer.

The Health Minister Greg Hunt, the Australian Health Department and the Commonwealth Ombudsman all agreed with our health insurer and with Teachers’ Health and with NIB that the health insurers were indeed much better qualified to decide what treatments Margaret ought to receive that her medical practitioners were.  The health insurers decided that no cancer patients should ever need to be admitted to hospital for the treatments that Margaret was clearly benefitting from.

I am still waiting for an apology from HCG+F, from former Health Minister Greg Hunt, from the Australian Health Department and from the Commonwealth Ombudsman.  My best guess is that I will have a very long wait before I ever get my apologies.  Shame on HCF, former Health Minister Greg Hunt, the Australian Health Department and on HCF.  I genuinely believe they were all dishonest on what they did.

That is what the refusal to pay was really about.