75 My Battle to Make the Health Insurers Obey the Law Part 18, Section 3: 31 October 2024

 

Unpicking The Ombudsman Email of 5 April 2022 (2)

Did Margaret Simply “Attend” Lift Cancer Care?

”…  and had been attending [Lift] since January 2021.”

Translation ↓

These words were selected to minimise what the law required the Ombudsman to investigate.  Margaret had attended Lift since January 2021, but only because her oncologist had recommended it.  The careful selection of words here creates the possibility Margaret decided to undertake the Lift program on her own initiative – something the Ombudsman knew was untrue.  My 3 December 2021 HCF letter said this. “Margaret commenced chemotherapy and radiotherapy in December 2020 and this treatment continued through January 2021.  The cancer went into remission in March 2021 but it surged back into renewed life in September 2021.  As I write this letter of complaint, Margaret is an in patient in hospital receiving treatment.* Part of the treatment program recommended by Margaret’s treating oncologist was attendance at a registered day hospital called Lift Cancer Care Services.  My understanding is that when she attends Lift, she is admitted as a patient and given treatment by registered professionals.  Each treatment consists of an initial medical examination by qualified medical personnel who then recommend an exercise program which is then undertaken on the premises of Lift.  The exercise program is closely supervised by Lift personnel and adjusted on an ongoing basis during each treatment session.  As I understand it, the aim of the programs provided by Lift is to increase the physical strength of cancer patients so that their ability to survive and gain benefit from the specific cancer treatments recommended by their medical practitioners, is enhanced.  To be eligible to undertake the services provided by Lift, participants in the Lift program must have received a formal diagnosis of cancer and, in addition, their treating medical practitioners must decide that the cancer treatment regime is likely to be enhanced if participants take part in the Lift program. Margaret began to take part in the Lift program in January 2021.  She has found the program to be of great benefit to her physical and mental health while she is in the midst of an extreme threat to her ongoing physical existence.” * Margaret and I expected Margaret would die in the very near future when I wrote this on 3 December 2021.

 

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From this point on the Ombudsman “summary” of relevant facts stops being ambiguous and becomes a complete work of fiction.

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Outright Lying by Ombudsman (1)

You explained that the LCC claims were not being declined by HCF, but being rejected due to lack of information.

Translation ↓

This was an outright lie.  I did no such thing.  In my 3 December 2021 letter to HCF (which I copied to the Ombudsman), I said this. “Lift has now advised Margaret and me that contrary to what we had believed to be the case, HCF has, for the most part, either responded with spurious and legally incompetent reasons for rejecting claims, or completely ignored the claims and not bothered to provide any response at all.”

 

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Outright Lying by Ombudsman (2)

“This had resulted in a build-up of unpaid claims with [Lift], and as a result in December 2021 LCC stopped lodging claims directly with HCF.”

Translation ↓

This was another outright lie.  After the passage quoted above, my 3 December letter to HCF said this. “Because of the callous disregard by HCF of its legal obligations under the policy of private health insurance between it and ourselves (and other cancer patients who have attended Lift), Lift has not been paid for multiple treatments provided to its patients.  In Margaret’s specific case, as at the date of this letter, HCF has either refused to pay or completely ignored thirty (30) separate claims made by Margaret under our policy of private health insurance.”

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Ombudsman Fudges the Truth Instead of Lying Outright

“You were asked to pay for services up front and then claim directly with your insurer.”

Translation ↓

In this sentence, the Ombudsman did not actually lie but it once again – almost certainly deliberately - understated the what I was complaining about.  Immediately after the passage quoted above, my 3 December HCF letter to HCF said this. “Because of the callous and cavalier attitude displayed by HCF, Lift is now able to provide services only if patients pay for their treatment on the day of service and then seek reimbursement individually from HCH.”

 

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Outright Lying by Ombudsman (3)

“This was administratively taxing because claims required additional paperwork signed off by Margaret’s doctors each time a claim was submitted.”

Translation ↓

In this sentence, the Ombudsman not only lied, it resorted to fanciful lies that bore no relationship at all to my complaints.  My 3 December HCF letter which I copied to the Ombudsman went on to say this. “I am utterly disgusted by the actions of HCF and under cover of this letter, I am now making 30 separate complaints to HCF about its failure to respond to its legal obligations under our health insurance policy. I attach as Table 1, a complete listing as at the date of this letter of all claims that have either been refused or ignored by HCF.  This Table includes the dates of the treatments, the Lift invoice numbers, the item claim numbers submitted by Lift and – where a formal refusal of the claim has occurred- a statement of the reasons asserted by HCF as justifying the refusal.” I was not in any way bothered by the “administratively taxing” nature of us having to pay for the health services provided to Margaret and then lodge a claim with HCF for payment of the insurance benefits the law entitled us to.  My complaint was motivated by the refusal of HCF to obey the law.

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The Ombudsman Can’t Read

In January 2022 you paid 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.

Translation ↓

In this passage, the Ombudsman demonstrated a complete lack of interest in the detail of our complaint.  This lack meant the Ombudsman was unable to accurately state how much I paid to Lift nor the month I paid it.  On 21 February 2022, I had told the Ombudsman what we had paid and when. “Because there is a legally binding contract between Margaret and Lift Cancer Care Services, and because HCF has refused to honour its contractual and legislative obligations to Margaret and me, as at 18 February 2022, our (legally enforceable) debt to Lift Cancer Care Services amounted to $6,978.00.  This debt was owed for services provide to Margaret up to the end of November 2021.  As stated earlier, all service fees from 1 December 2021 onwards were paid on the date of receipt of the services. Lift Cancer Care Services provided us with an invoice for the outstanding fees on 18 February 2022.  That invoice was paid by direct electronic transfer on 20 February 2022.”

Margaret gives birthday present to Anne Ryan 15 January 2020