73 My Battle to Make the Health Insurers Obey the Law Part 18, Section 1: 30 October 2024

 

The Ombudsman Tells Me to Bugger Off – 5 April 2022

This is an email that I finally received from the Ombudsman on 5 April 2022.  It told me very clearly that I should bugger off and stop bothering the Ombudsman.  I reproduce the email without alteration.  In later blogs, I will tease out the crimes that I believe the Ombudsman may may have committed by sending me this email.  

 

Tue 5/04/2022 2:37 PM Sarah De Sade Sarah.DeSade@ombudsman.gov.au Commonwealth Ombudsman complaint - Hankin - Ref PHI-2021-101690 [SEC=OFFICIAL] To: John Hankin   OFFICIAL   Dear Mr Hankin   Thank you for contacting the Commonwealth Ombudsman about the issues you are experiencing with HCF and Lift Cancer Care (LCC). I appreciate your patience while our Office investigated your complaint.  I would like to advise that HCF have offered to reimburse you $8,623.00 to cover claims for services at Lift Cancer Care between January 2021 and February 2022.  They will not, however, be honoring any further claims until such a time as their dispute with Lift Cancer Care has been resolved.    Our Understanding of your situation: You contacted our Office in December 2021 to complain about issues you were having with HCF not paying your wife Margaret’s LCC invoices.  You explained your wife has cancer and had been attending LCC since January 2021.  You explained that the LCC claims were not being declined by HCF, but being rejected due to lack of information.  This had resulted in a build-up of unpaid claims with LCC, and as a result in December 2021 LCC stopped lodging claims directly with HCF.  You were asked to pay for services up front and then claim directly with your insurer.   This was administratively taxing because claims required additional paperwork signed off by Margaret’s doctors each time a claim was submitted.  In January 2022 you paid LCC approximately $6,000 to cover the cost of treatment undertaken by Margaret for the previous 12 months because HCF had still not provided benefits to LCC for the claims submitted.  You advised our Office that HCF were now no longer accepting any claims from LCC.  Our Investigation Investigation revealed that due to claiming issues with various insurers LCC had applied to the Department of Health to have their ‘Tier 2’ hospital status removed.  Removal of this status allowed LCC to bill patients for services directly rather than having to submit claims directly with a patients insurer.  This application was approved, and explains why you were required to pay upfront for services and then claim directly from your insurer from December 2021 onwards.  It is important to note that the primary function of the Office is to assist consumers with their private health insurance problems.  When administrative disputes between health funds and hospitals are brought to our attention, our main role is to assess the reasonableness of the response from both parties.   In this case, we are of the view that HCF’s request for additional information to support individual LCC claims is reasonable under the current framework.  We are also of the view that LCC have demonstrated they have made every effort to convince HCF to pay benefits for their services.  Despite this effort HCF remain unconvinced LCC is eligible to claim.   In these sort of circumstances, we expect that both parties work together to come to an agreement without the patient suffering any financial detriment.  It is not the role of this Office to make determinations for hospitals and insurers with regard to the correct interpretation of specific rules.  Our role is to help people resolve complaints about their private health insurance as quickly as possible. This Office makes sure an insurer’s decisions are consistent with legislation, policy terms and conditions and their own internal procedures and rules. We are independent and impartial.    Outcome In this case, although the dispute between HCF and LCC remains unresolved to date, HCF has agreed to reimburse you $8,623.00* to cover claims for services incurred at Lift Cancer Care between January 2021 and February 2022.   I am of the view this a reasonable outcome, and that HCF have acted in accordance with the expectations of the Office to resolve your individual complaint.    Going forward we would not expect HCF to continue paying claims from LCC until the dispute is resolved at a higher level. I realise that this is not the outcome you were hoping for.  Unfortunately the Office is unable to intervene further with the broader issues being experienced by LCC.  I will request that HCF contact you directly with regard to your financial reimbursement of $8,623.00.  As there is no further remedy this Office can provide you in relation to your complaint, I will be inalizing our file on this matter.   Your complaint will remain in our system as we report on issues of concern to consumers and your complaint may be used in this regard. Please feel free to contact me if you have any questions.   Kind regards Sarah de Sade   Complaints Officer  Private Health Insurance COMMONWEALTH OMBUDSMAN phone 1300 362 072 email phi@ombudsman.gov.au website www.ombudsman.gov.au

* I insisted that Lift give me an invoice for all of the treatments that HCF had refused to pay.  The invoice came to $8,623.00 and I paid this invoice to prevent the Ombudsman from dismissing our complaints on the spurious basis that we had not suffered any financial loss and that Lift had suffered the loss and not us.  In this email, the Ombudsman did a variation on this swindle trick.  It told HCF to pay the $8,623.00 and then told us to bugger off because we no longer suffered any financial loss. 

****

Apart from the probability that a number of crimes were committed when the Ombudsman sent this email to me, the email is completely full of false statements – and the Ombudsman conclusively knew these statements were false because I had already given it full information.

I was astonished and outraged that a government agency felt it could behave in such an appalling manner.

In future blogs, I will dissect this email and highlight the many false claims made by the Ombudsman and the crimes that I believe were committed by the Ombudsman in sending this email to me.

It was irrelevant to the Ombudsman that Margaret’s life was threatened by cancer. 

It was irrelevant that the lives of all the other patients at Lift Cancer Care Services were also threatened by cancer.

It was irrelevant to the Ombudsman that it was ignoring multiple breaches of the very legislation that it was theoretically established to enforce.

The Sarah De Sades of this world really do walk amongst us and we pay them fat salaries – to do nothing when we ask them to do their jobs.  I hope you are reading this and squirming Sarah.

This was Margaret on 16 February 2021.  We escaped to Port Lincoln for a few days.  This is one of the patients that the Ombudsman believed did not matter – some one who hopefully would die quickly so that we would no longer be a nuisance.