74 My Battle to Make the Health Insurers Obey the Law Part 18, Section 1: 31 October 2024
Unpicking The Ombudsman
Email of 5 April 2022
Apart from the sign off
at the end of the email, this is the only indication that the email might have
come from a government agency. The red font
was used in the email.
Sending an email avoided sending anything
on an official letterhead. Except for the
sign off at the end, nothing in this document positively identified it as a
genuine Ombudsman communication. It
could have been typed and sent by HCF using the Ombudsman email address.
Never in my five months of dealing with her
did Ms De Sade send me anything on letterhead.
I do not believe Sarah De Sade actually wrote the email because it has a
completely different tone from all previous emails from Ms De Sade. I am confident it was written by someone else
and sent from Sarah De Sade’s email address.
My guess is that this email was written by Emma Cotterill.
|
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. |
|
Translation ↓ |
|
“We
are completely
sick of having to deal with you and your insistence that HCF obey the
law. We hoped that you would go away
if we made you wait for months. It is
a real pain in the arse that you are still bothering us. |
|
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. |
|
Translation ↓ |
|
“HCF will pay you $8,623.00 as go away
money. HCF will not pay you any more
money – no matter what the law says.” |
The
Ombudsman Recreates History
|
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. |
|
Translation ↓ |
|
Most of the “facts” set out in this
extract are outright lies. Some other “facts” merely blur the truth to
reshape reality. Dividing this extract
into more digestible chunks will clarify what the Ombudsman really said. |
|
You contacted our
Office in December 2021. |
|
↓ |
|
I did “contact” the Ombudsman in December 2021. I emailed a two page letter on 3
December. Attached to my letter to the
Ombudsman was a copy of the four page letter I had emailed to HCF on 3
December. My letter to the Ombudsman
contained few specific details about our situation. My Ombudsman letter did not explicitly say
that Margaret suffered from cancer, although that was a clear implication of
my Ombudsman letter. The few specific
details contained in my Ombudsman letter were in this paragraph. “The total amount of service fees which have
been rejected or ignore in relation to Margaret since 1 January 2021 is
$6,981.00. Given that Margaret is only
one among probably hundreds of cancer patients across Australia who have been
treated in a similar manner by HCF, the issues raised in my letter probably
involved hundreds of thousands of dollars in every calendar year. Apart from the large dollar amounts
involved in these issues, the actions by HCF have been taken in relation to
patients who are extremely vulnerable and – because of their life threatening
illnesses – least able to react in a manner likely to force HCF to change its
behaviour.” By describing my letter as a “contact”, the Ombudsman creates
the possibility that my “contact” was a minor one; it might have been a short
phone call. Vaguely saying my
“contact” occurred in “December” accentuates the ambiguity. This creates the possibility that my
“contact” might have been in late December when the Christmas/ New Year
season results in understaffing of many government agencies. By using this formulation of words, the
Ombudsman ensured there was ambiguity and obscured the truth. |
|
“… to complain
about issues you were having with HCF not paying your wife Margaret’s …
[Lift] invoices …” |
|
Translation ↓ |
|
The choice of words continues the creative ambiguity
process. I did not complain about
“issues” but about the failure of HCF to pay for medical services provided to
Margaret and to other cancer patients who had also been provided with medical
services by Lift. This choice of words
deliberately minimises the breadth of the matters that I had asked the
Ombudsman to investigate. |
Did I Say My Wife Had “Cancer”
|
You explained your wife has cancer … |
|
↓ |
|
In my letter to the
Ombudsman, I did NOT say that Margaret had cancer. Nor did I say that Margaret had been
attending Lift since January 2021.
This information was only in the letter to HCF. It was easy for the Ombudsman to be accurate,
but it prefers to blur the truth – presumably to minimise its own inaction. My Ombudsman letter contained
very little detail; it did not say that Margaret had cancer, although this
was the implication. Information that Margaret
had cancer was in my HCF letter dated 3 December 2021 where I said. “My
wife Margaret was diagnosed in July 2020 with what may well prove to be
incurable ampullar cancer …. My
understanding is that the ampullar is a junction point just outside the
pancreas where the bile duct and the pancreatic duct meet in a T
junction. The growth of the cancer in
this location is likely to result in the failure of the digestive
system. If Margaret’s digestive system
fails, she will die.” In this sentence, the
Ombudsman confirms it had read the 4 December 2021 letter to HCF, but despite
this, the Ombudsman minimised the danger Margaret faced. All cancers are dreadful and many are
fatal, but some cancers can be survived.
By using the generic word “cancer” rather than referring to Margaret’s
specific cancer, the Ombudsman created ambiguity. According to the Ombudsman, Margaret
suffered from “cancer” rather than from deadly “ampullar cancer”. |
****
Margaret in Alaska on 14 September 2016.
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