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 recognise 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 finalising 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 | 
It seems like they only felt like the problem was between Lift and HCF, thus thought they were no longer required to take action. This 'reimbursement' felt more like a bribe.
ReplyDeleteI think the Ombudsman was running a "Protection Racket" for the health insurers. The payment had nothing to do with law enforcement and it completely ignored the only issue that had any importance - were the health insurers acting lawfully or unlawfully? The Ombudsman was in effect saying the health insurers were acting lawfully when it had ample information given to it be me to tell it the health insurers were acting unlawfully. I think this amounts to a Protection Racket and that someone at a senior level at the Ombudsman was corrupt.
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