68 My Battle to Make the Health Insurers Obey the Law Part 17, Section 2: 24 October 2024

 

The Ombudsman Letter Dated 29 March 2022

Unpicking the most obvious insult to Lauren Whiting

The letter is addressed to “Ms Lauren Whiting, Lift Cancer Care Services”.  Lauren is the founder and Chief Executive of Lift and this was certainly well known to the Ombudsman.  I interpret the deliberate omission of her title as Chief Executive as a clear intention to be insulting.

 

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Unpicking the second insult to Lauren Whiting

 

29 March 2022 Ms Lauren Whiting Lift Cancer Care Services By email: admin@xxx

 

Although the letter was sent to “admin@”, says the Ombudsman had been in contact with Lauren Whiting since 2020.  Emma Cotterill, Senior Assistant Ombudsman must have known Lauren Whiting’s direct email address, but decided to ignore it and sent the letter to a general email address.  An intention to be insulting is obviously present in Emma Cotterill doing this.  Did Emma Cotterill intend the letter to be read by more junior staff before Lauren had the opportunity to read it?  I think this is likely.  Emma Cotterill, Senior Assistant Ombudsman being deliberately insulting and demeaning as well as acting as a coward.

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Unpicking The Ombudsman’s Clear Knowledge of the Behaviour of the Health Insurers

 

Disputes regarding claims for claimable Type C services We understand that there is an ongoing dispute between your facility and several private health insurers about the insurers’ denial of claims for claimable Type C services. We first wrote to you about this issue in February 2020.

 

These two sentences date the Ombudsman’s knowledge of the appalling behaviour of the health insurers to a date prior to February 2020 – more than two years before the letter dated 29 March 2020.  Despite knowing about the unlawful behaviour of the health insurers since earlier than February 2020, as at 29 March 2022, the Ombudsman had done nothing.  The Ombudsman had:

·         Not examined the relevant legislation.

·         Not examined any of the documentation submitted in support of the unpaid claims.

·         Not provided any “report” or “recommendations” to the Minister or to the health insurers. 

According to the Ombudsman in this letter dated 29 March 2022, the Ombudsman had done nothing useful for more than twenty five months.

Even though patients suffering from life threatening cancer were entitled to have the regulator clarify their entitlements under their health insurance, the Ombudsman had done nothing for a period in excess of 25 months – as a minimum.

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Unpicking How the Ombudsman Ignored the Facts and the Law

 

We understand that Lift Cancer Care provides treatment, mostly for ‘exercise medicine’, which is carried out as an in-patient procedure. Some insurers have declined claims due to what they consider insufficient details on the Type C Certificate, specifically about the treatment being administered, and questions about whether the service should be provided on an outpatient basis.

 

This paragraph clearly demonstrates the Ombudsman was not impartial but a clear supporter of the health insurers.  The Ombudsman was not interested in the law or the facts.  Sarah De Sade had claimed to me on 18 February that HCF had told the Ombudsman that Lift had not provided sufficient information.  According to Sarah De Sade, this justified the refusal to pay the claims.  In my letter to the Ombudsman dated 21 February 2022, I had provided the Ombudsman with complete information about:

·         All treatments provided to Margaret by Lift up to the date of that letter.

·         Every page of documentation submitted to HCF in support of the claims for payment for Margaret’s Lift treatments.

·         Every piece of correspondence sent by HCF in response to the claims for reimbursement for Margaret’s treatments.

The documentation I gave the Ombudsman on 21 February 2022 proved conclusively that most of the claims submitted for Margaret’s treatments had been ignored by HCF. 

The documentation also proved irrefutably that HCF had lied to the Ombudsman when it claimed it had asked for and never received further information.  To the knowledge of the Ombudsman, every word in this paragraph down to the words “Type C Certificate”, was a complete lie. 

I repeat - this part of the Ombudsman letter was a lie and the Ombudsman certainly knew it was a lie.

 

Unpicking How the Ombudsman Had No Interest in the Law

 

The remaining words of this paragraph I have quoted above show the Ombudsman was not simply a liar.  Read these words carefully.

… specifically about the treatment being administered, and questions about whether the service should be provided on an outpatient basis

The words demonstrate that as far as the Ombudsman was concerned, the law was irrelevant.  The following inferences cannot be avoided when reading the words just quoted. 

As far as the Ombudsman was concerned, the health insurers were entitled to assert a number of unlawful assertions and the Ombudsman fully supported the assertions made by the health insurers no matter what obligations the law imposed on th4e health insurers.

This is what the health insurers were in fact claiming and these are the claims that the Ombudsman clearly thought were acceptable.

·         The health insurers had asserted to the Ombudsman that the treatments provided by Lift should not have been provided at all – presumably because the health insurers knew more about the proper treatment of Lift’s patients that the patients’ doctors knew.

·         The health insurers claimed to the Ombudsman that the Lift treatments should not have been provided and that therefore the health insurers would not pay for the treatments.

·         The health insurers claimed to the Ombudsman that even if the Lift treatments did have any medical justification, they ought to be given as outpatient treatments and not as inpatient treatments.

·         The health insurers claimed to the Ombudsman that because the health insurers thought the Lift treatments should be given as outpatient treatments, the health insurers would not pay for the treatments

·         The health insurers claimed to the Ombudsman that because the Lift treatments were given as inpatient treatments, the health insurers would not pay for the treatments.

The Ombudsman must have been aware of the attitudes of the health insurers I have just summarised and the Ombudsman fully supported the health insurers no matter what the law might require.

Far from fulfilling its intended role as an independent umpire, the Ombudsman had no interest in the law because it had decided to support the health insurers no matter what the law said.  The refusal of the Ombudsman to examine the law makes sense only in the perverse way that the Ombudsman did not want to know what the law said.  Knowing the law might necessitate telling the health insurers they were breaking the law.

An information Circular issued by the Health Department specifically stated that health insurers were forbidden from substituting their own opinions for the opinions of treating medical practitioners.  It is impossible to believe the Ombudsman had no knowledge of the Circular.

The overwhelming impression I got when I read these words was that the Ombudsman was corrupt