Blog No. 163 - HCF Explains Its Refusal to Pay lift Treatment Claims – Part 2: 31 January 2025

Margaret in Alaska (Arctic Circle trip), Wednesday the 7th of September 2016.  It was cold!

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Margaret and I enroute to the Arctic Circle, Wednesday 7 September 2016.

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This blog continues the dissection of the lies told by the CEO of HCF in her letter dated 6th of May 2022.

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Yet More Really Big Lies

HCF rejected the majority of claims lodged in relation to Margaret's treatment at Lift because the Type C certificates accompanying the claims did not include the reasons why the medical consultations were required to be provided at a hospital (as required by rule 7 of the Private Health Insurance (Benefit Requirements) Rules 2011).

Translation ↓ (1)

The theory of Bulls**t Baffles Brains Theory is on full display here.  Sheena Jack is pretending to refer to clause 7 of Part 3, Schedule 3 of the Private Health Insurance (Benefit Requirements) Rules 2011. Clause 7 DOES NOT require the Type C certificate to “include the reasons why the medical consultations were required to be provided at a hospital”.  Sheena Jack has invented a legislative requirement to avoid admitting HCF has broken the law.  This claim is complete rubbish; it is nonsensical. **** Sheena Jack is telling Another Really Big Lie.

Translation ↓ (2)

In putting forward this specific lie, Sheena Jack did not notice that she was contradicting what HCF had claimed to the Ombudsman.  According to the Ombudsman, HCF had sought further information about the Lift claims and this further information had not been provided.  The Ombudsman thought this was an excellent excuse for the refusal to pay the claims. **** If HCF rejected the Lift claims because the Type C certificate did not “include the reasons why the medical consultations were required to be provided at a hospital”, why didn’t HCF claim this to the Ombudsman? Perhaps HCF thought that even the Ombudsman would find it too difficult to swallow this particular lie. **** This was yet Another Really Big Lie.

Translation ↓ (3)

Sheena Jack asserts “HCF rejected the majority of claims lodged in relation to Margaret's treatment at Lift”.   This is more Bulls**t Baffles Brains. Most of Margaret’s Lift claims were NEVER rejected.  If they had been rejected, the Health Department and the Ombudsman might have felt more pressured to carry out their jobs.  HCF did not reject most claims - HCF made them “disappear”.  Because they never appeared in the official claims’ history, there was no need to reject them.  This gave the Health Department and the Ombudsman the excuse they needed to not ask questions about the reasons for rejection. This was yet Another Really Big Lie.

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Meaningless Words Plus Yet Another Really Big Lie

While HCF does not challenge the clinical assessment of any practitioners at Lift that the nature of Margaret's medical condition means she requires supervision during her exercise sessions, the exercise session is not the Type C procedure.

Translation ↓

Sheena Jack claims she “does not challenge the assessment of any practitioners that the nature of Margaret's medical condition that she be supervised during her exercise sessions”, but she also asserts “the exercise session is not the Type C procedure”.  Because HCF says the “exercise session” is not a Type C procedure”, it will not pay for Margaret’s admission to hospital to receive the exercise therapy.   If this seem to make no sense, this is because it makes no sense. **** Although the medical practitioner who examined Margaret when she attended every therapy session at Lift thought that - for the reasons set out in the certificate completed by that doctor after that examination - Margaret could not have exercise therapy except in a hospital, HCF refused to pay for the hospital admission because while Margaret  was in hospital, she received an “exercise session”. **** This part of the Sheena Jack letter translates into this. HCF accepted Margaret could not safely receive her treatment except in a hospital, but it refused to pay for her admission to hospital because it disapproved of ANYONE having an “exercise session” in hospital.  HCF – an insurance company – claimed to knows more about the proper treatment of Margaret’s (or anyone else’s) cancer than her treating doctors did.  How utterly arrogant and stupid.   No one in HCF studied medicine.   No one in HCF asked for any information about Margaret’s cancer.   Despite this, HCF obviously thought it knew more about how to treat cancer than any of the doctors who referred patients to Lift. **** HCF dis not dispute the opinions of Margaret’s doctors because those opinions were irrelevant to HCF. **** Here, Sheena Jack resorts to meaningless words and combines them with yet Another Really Big Lie.

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Bulls**t Baffles Brains – Yet Again! 

The exercise session does not have an MBS item number and is not recognised by Medicare.

Translation ↓

Bulls**t Baffles Brains is on full display here. The “exercise session” does not have an MBS number because HCF was never asked to pay Anything for the “exercise session”. The payment that HCF and the other insurers refused to pay was the legislated payment for admission to a hospital. The law says that to be entitled to receive this legislated payment, a “Type C” certificate must be provided to the health insurer in the format set out in the legislation. All certificate submitted for the services provided by Lift Cancer Care Services fully complied with the legislation. Bulls**t Baffles Brains! Yet Again!

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Even More Bulls**t Baffles Brains!

Rather, the GP consultation is the Type C procedure with an MBS item number.

Translation ↓

Next time Sheena Jack visits her general practitioner, she should ask her doctor whether she is having a medical examination or a Type C procedure. The general practitioner will not know what she is talking about and the GP will probably be so stupid that the GP will think he/ she is conducting a medical examination! Bulls**t Baffles Brains! Again!

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Somehow, Sheena Jack convinced the Board of HCF that she knew so much about health insurance that she ought to be appointed as the Chief Executive Officer of HCF.

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Mickey the Mouse probably knows nothing about the law affecting health insurance in Australia.

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Mickey the Mouse probably knows more about the law affecting health insurance in Australia that Sheena Jack

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To be continued …

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Unfortunately, there is even more to come.

Blog NO.162 - HCF Explains Its Refusal to Pay lift Treatment Claims – Part 1: 30 January 2025

 

Me climbing the bottom of Croagh Patrick 16th of September 2019.

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View from Louisburgh Ferry, Ireland 16th of September 2019.

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The purpose of Sheena Jack’s letter of 6th of May 2022 was simple – implement Bulls**t Baffles Brains.

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This is the first part of my dissection of the letter.

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You Were Supposed to Go Away

Dear Mr Hankin, Re: Treatment of claims for services provided by Lift Cancer Care Services  Thank you for your comprehensive and heartfelt letter. I appreciate you informing me of your frustrating experience with HCF in recent months and of the details of your claims history in relation to Margaret's treatment at Lift Cancer Care Services (Lift).

Translation ↓

You wrote to all company Directors.  I did not expect this; you have given me multiple headaches.  I have to protect myself from the fallout.  How can I shut you up?

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You Didn’t Go Away

Firstly, I would like to express my sincerest thoughts of sympathy to you and Margaret for the difficult period you have both faced since Margaret's diagnosis with ampullar cancer in July 2020. This must have been, and would be continuing to be, a very emotional and uncertain experience for both of you, which I understand would not have been made easier from claims rejections and unsatisfactory communication from HCF.

Translation ↓

I must pretend to be sorry for what we did to you and Margaret.  Why didn’t you go away?

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I Must Pretend We Made a Mistake

I would also like to apologise for the stress HCF may have caused through the communication and correspondence that you have received from us in relation to your claims. It appears that the information you have received from the complaints resolution and customer service teams at HCF has been inconsistent and at times, incorrect, and your experience as a member throughout this complaint process has been below that which we expect and aim to achieve for our members.

Translation ↓

If you had gone away, I wouldn’t have to pretend this has been a mistake.  Now I must pretend to be nice while also denying we broke the law by refusing to pay the Lift claims. **** I had nothing to do with what happened.  It was all a cock up by the “complaints resolution and customer service teams”.

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I Have to Lie (1)

Based on your interactions with HCF to date, I appreciate that you have formed the view that HCF is intentionally banning any claims for hospital benefits that have been made for services provided by Lift. I set out below an explanation of HCF's approach to the claims made by Lift in relation to its provision of services. I hope this explanation provides some clarity for the reasons why we rejected claims submitted by Lift (although as you are aware, we have paid claims on an ex-gratia basis, including reimbursement for claims paid by Margaret, to remove out of pocket costs for members).

Translation ↓

We did ban payment of claims to Lift Cancer Care.  That is why we never paid Lift except when our staff disobeyed instructions. I hope to divert you from our illegal actions in “intentionally banning any claims for hospital benefits that have been made for services provided by Lift”. We broke the law but we are really nice.  We did you a favour when you complained about us breaking the law.  We paid some claims and told you we would not pay any future claims.

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I Have to Lie (2)

In relation to your experience in making a complaint to and communicating with HCF, I have set out in this letter how we will respond.

Translation ↓

Now I have to come up with something.

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Meaningless, Misleading Words

Reasons for rejecting claims made by Lift As you have described in your letter, Margaret attends Lift to undertake supervised exercise sessions that are appropriate for her physical condition.

Translation ↓

I must give the impression I am saying something although I am really saying nothing.  This waffle gives the impression Lift is an ordinary gym and not a registered hospital.

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Sheena Jack Comes Up With a Really Big Lie

Reasons for rejecting claims made by Lift … She also receives a medical examination by a doctor prior to commencing this exercise, which would constitute a consultation with a general practitioner and be categorised as MBS* item 37 or 47 (the Type C procedure). * MBS = Medicare Benefits Schedule

Translation ↓

The admission that Margaret’s “medical examination by a doctor prior to commencing this exercise … would constitute a consultation with a general practitioner and be categorised as MBS item 37 or 47” contradicts the claim made by HCF Marion where Rachael Harwood claimed there is no Medicare Item 37. **** By claiming Medicare Items 37 and 47 constitute “the Type C procedure”, Sheena tells  Really Big Lie.  They are not.  The law requires payment by Medicare – not health insurers - of a stipulated fee for listed medical services such as medical examinations.  When the patient directly pays the medical practitioner for the examination, Medicare makes the payment to the patient.   If the medical practitioner sends a medical examination bill directly to Medicare, the required payment is made to the medical practitioner. **** Payment for any Item 37 or 47 medical examination never involves HCF.  It is a matter between Medicare and the patient or Medicare and the doctor. **** Sheena asserts that the medical examination is the “Type C procedure”.  This is bulls**t and as HCF CEO, Sheena must have known this. **** A “Type C procedure” is any medical procedure described in clause 7 of Part 3, Schedule 3 of the Private Health Insurance (Benefit Requirements) Rules 2011. **** Any medical procedure which cannot safely be administered outside of a hospital is a Type C procedure, even if hospital admission is not needed for other patients who are not gravely ill. **** A medical procedure is any procedure thought appropriate by a medical practitioner. **** ALL patients who attend Lift have cancer.  All been referred to Lift by their treating doctors.  Their doctors say none of them can safely receive Lift treatments unless they are in hospital. Margaret was referred to Lift by her radiologist Dr Palumbo. ****  No claim was ever made for the cost of the treatments Margaret received from Lift. **** The law says that when a patient is admitted to a hospital, a minimum payment must be paid by the private health insurer to cover the cost of the hospital admission.  HCF and other health insurers refused to pay the fee required by law for the admission of cancer patients to a hospital.  The health insurers were NEVER asked to pay for the treatments administered while patients were in the hospital. **** Sheena Jack was Chief Executive of HCF.  She must have known what she said in this part of her letter was a Really Big Lie.

I will dissect the rest of Sheena Jack’s letter in the following blogs.

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