3 May 2022 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). 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. 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. 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). 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. 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. 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). 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). 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. The exercise session does not have an MBS item number and is not recognised by Medicare. Rather, the GP consultation is the Type C procedure with an MBS item number. In order for Lift to claim hospital level benefits for attending Lift for exercise classes, the doctors must certify that the GP consultation must be undertaken in hospital (as opposed to the exercise sessions). Lift's doctors have not certified this. Handling of your complaint While I have explained above that HCF has rejected Margaret's claims for hospital benefits on the basis that the claims have not complied with the relevant regulatory requirements, there is a separate issue relating to the handling of your complaints when making these claims and seeking information from HCF. HCF will undertake a thorough investigation into the way your complaints have been handled which will assist us to improve our complaints handling procedures and ensure that the correct information is consistently conveyed to our members. HCF will investigate each of the allegations you have made in your letter, including in relation to the claims that are missing from HCF's claims history record for you and Margaret and your interactions with Ms Lindsay and Ms Harwood. While contact was maintained during the investigation of your complaint, HCF was advised by the Ombudsman on 2 February 2022, that you remained dissatisfied with the outcome and the complaint was escalated within the Ombudsman’s service for their investigation. As part of that escalation, the Ombudsman requested that HCF did not correspond with you about this matter while they conducted their investigations, our apologies for any frustration this may have caused. I trust this letter clarifies HCF's position on the claims made by Lift, HCF will continue to engage with the Department of Health on the payment of hospital benefits for Type C procedures. In closing I would like to apologise again if HCF failed to provide clarity in its communications on this issue and the time and energy you and Margaret have spent seeking answers. Yours faithfully, Sheena Jack CEO & Managing Director Copy to: Mr Mark Johnson, HCF Chairman | 
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