82 The Ombudsman and the Battle to Make the Health Insurers Obey the Law Part 18, Section 5: 5 November 2024

Unpicking The Ombudsman Email of 5 April 2022 (4)

 

The Ombudsman Lies About Its “Mission”

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.

Translation ↓

Here, the Ombudsman lies about its own job description.  Section 20G(1)(a) of the Ombudsman Act is relevant.  It says a complaint can be made about “any matter arising out of or connected with a private health insurance arrangement”.  If a complaint is made, Ombudsman MUST deal with it under the Act.  In this part of the email, the Ombudsman asserts that it has no obligation to try and resolve what it calls “administrative disputes between health funds and hospitals”.  Instead of following the Act, The Ombudsman creates an exception to the Act.  If complaints concern something the Ombudsman labels “administrative disputes”, the Ombudsman refuses to follow the Act and refuses to obey the law.  Here, the Ombudsman lies about the task given to it by Parliament.  The Ombudsman Act does NOT permit the Ombudsman to act like this.  The Ombudsman ignored the rights given to health providers under the Act.  As do patients, health providers have the right to complain to the Ombudsman about health insurers.  The Ombudsman is not given the power to declare a complaint concerns an “administrative dispute” and to then dismiss it.  The Ombudsman Act does not mention anything called an “administrative dispute”.  How can a refusal to pay health insurance benefits which the law says must be paid, ever be classified as an “administrative dispute”?  Surely the only issue in this a case is simple – does the law require the payment to be made or not? Here the Ombudsman says it – and not Parliament – will decide what complaints the Ombudsman will investigate.  This behaviour of the official regulator is unlawful and shameful.

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The Ombudsman Knows HCF Lied – But Doesn’t Care

In this case, we are of the view that HCF’s request for additional information to support individual [Lift] claims is reasonable under the current framework.

Translation ↓

Until this point in the email, the Ombudsman has made no reference to any supposed claim by HCF that it has requested “additional information to support individual claims”.  I had already given the Ombudsman copies of every piece of paper in existence for all of Margaret’s Lift treatments up to 21 February 2022.  The paperwork left np doubt that HCF had NEVER sought any identifiable paperwork and that most claims had been made to disappear.. How could the Ombudsman accept the reasonableness of requests for additional information which had never been made?  Only one logical possibility occurred to me.  HCF had somehow corrupted the Ombudsman?  Was corruption the reason the Ombudsman refused to do its job even when I had already done most of the work for it?  I am still unable to come up with a convincing alternative explanation for the behaviour of the Ombudsman.  I suppose an alternative is possible.

 

The Ombudsman Blows a Kiss at Lift

We are also of the view that [Lift] have demonstrated they have made every effort to convince HCF to pay benefits for their services.  Despite this effort HCF remain unconvinced [Lift] is eligible to claim.

Translation ↓

Here, the Ombudsman casually waves at its obligation to impartially enforce the law.  It showed “impartiality” by pretending to say something positive about Lift.  Lift had gone to great lengths to persuade HCF to obey the law because the welfare of its patients depended on them receiving their treatments..  Every business tries to persuade its debtors to promptly pay their accounts.  They must if they are to survive. Of course, HCF remained “unconvinced” that Lift was “eligible to claim”.  HCF knew the law required it to pay, but it refused to obey the law because the regulator ignored the law. Criminals keep committing crimes when they know the police will do nothing to stop them.

 

The Ombudsman Washes Its Hands of the Complaint

In these sort of circumstances, we expect that both parties work together to come to an agreement without the patient suffering any financial detriment.

Translation ↓

The Ombudsman had learned its lines from Pontius Pilate.  Although saying “I can find no fault with this man”, Pontius Pilate told the High Priests to “Do what you want” with Jesus – thus, initiating the judicial murder of Jesus.  Although claiming it could find no fault with Lift, the Ombudsman also refused to do its duty. In a measure that any lawyer immediately recognisable by all lawyers, the Ombudsman dished out blame to one of the victims of the HCF scam – Lift Cancer Care Services.  According to the Ombudsman, Lift should not to cause financial pain to its patients just because HCF refused to obey the law.  If HCF refused to pay, Lift should swallow the loss – and of course, cease stop trading when it ran out of money! According to the Ombudsman, Lift and not HCF, was at fault in this matter.  Lift had not persuaded HCF to obey the law and no one had complained to the Ombudsman until Lift asked its patients to pay the treatment cost that the health insurers should have paid.  According to the Ombudsman, this was an “administrative dispute” and the Ombudsman was lawfully entitled to ignore “administrative disputes”.  The Ombudsman would never tell health insurers to obey the law.  According to the Ombudsman, HCF should be permitted to do whatever it wanted.  The Ombudsman refused to do the job Parliament had instructed it to do..

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Margaret was gravely ill when she had her 70^th birthday on 29 March 2023.  Somehow, she came to a restaurant to celebrate her continued life.

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Prior to Margaret’s birthday, on Thursday 5 January 2023 David McGregor, Director, Industry Investigations Team, Investigations Branch at the Ombudsman had claimed in a phone call to me that the Ombudsman had been responsible for the health insurers eventually obeying the law.  David McGregor is a liar but he probably told the truth when he claimed he had been a senior communication channel for many years between the Ombudsman and the Health Department and the health insurers. I do not know if David McGregor (David.McGregor@ombudsman.gov.au) was corrupt, but the possibility of this seems real given his phone call and the lies he peddled to me during it.

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On 29 March, Margaret had another 4 months and 23 days to live.  Cheryl Scopazzi was the only “friend” who would come with us and Cheryl cancelled me after we had coffee on Friday 12 January 2024.  Like the other cancellation team members, she has never bothered to tell me why – but she did borrow a lot of money from me on 18 September 2023, just 26 days after Margaret died.  Cheryl is on the right in this photo.