43 The Battle to Make the Health Insurers Obey the Law – Part 5: 8 October 2024

Writing to the Commonwealth Ombudsman was a backup strategy.  I googled complaints about private health insurers and the search said the Commonwealth Ombudsman was the government agency to complain to.  I had never heard of the Ombudsman before.  I got contact details for the Ombudsman from the Ombudsman website. I found the Ombudsman Private Health Insurance Complaint Checklist.  This extract is copied without alteration from that document which is unchanged as I write these words in January 2023.

 

“Step 4 – Contact us: • Online (https://www.ombudsman.gov.au) • Telephone (1300 362 072 option four) between 10:30am to 3:00pm Australian Eastern Standard Time Monday to Friday • Email (phi@ombudsman.gov.au) ; or • Post (GPO Box 442, Canberra ACT 2601) 1. Set out clearly and simply what is wrong and what outcome you are seeking. Focus on the core of the issue and summarise the information as best as you can. We ask that your complaint is a maximum of 500 words. 2. List the key dates such as when the problem occurred and details of the contact you have had with your insurer, hospital or doctor about this issue. 3. Provide us with your contact details. The more contact details you provide us with the easier it will be for us to reach you. An email, phone number and postal address is ideal. 4. Make sure your complaint is complete. Depending on the nature of your complaint, you may need to provide your consent or complete additional forms first: • In most cases, we provide the other party an opportunity to respond to the complaint and reach a resolution with you directly. Make sure you provide consent for us to disclose the details of your complaint or provide copies of the documents you give to us. • If your complaint is on behalf of someone else, they will need to provide permission for you to raise this by completing this form. • If you are complaining about a pre-existing condition and want this Office to review the decision, you will need to complete the form Medical Authority Form for us to gain access to your medical records. 5. We aim to provide an initial response to you within 1-2 business days. Occasionally, it may take us longer to respond. If you have submitted your complaint and you have waited more than a week for a response, please contact us again.”

 

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Because the Ombudsman website made no promises (apart from in item 5), it can perhaps claim it never broke any promises.  In my naivety, I did assume that it would genuinely attempt to process my complaint in accordance with the law.  Surely, government agencies exist to ensure that the law is obeyed.

This Table summarises my communications with the Commonwealth Ombudsman in December 2021.

 

Letter Details	Length of Letter	How Sent*	Date of Response	Length of Response	What Did Response Say?
Letter dated 3 December 2021 addressed to Commonwealth Ombudsman	4 pages	Email to ombudsman@ombudsman.gov.au  sent at 12:54 pm on 3 December 2021	(1) Email received at 9:33 am on Wednesday 8 December 2021 from Karina Low, Complaints Officer                   (2) Incorrectly addressed email received at 11:10 am on Wednesday 15 December 2021 from Sarah De Sade, Complaints Officer	(1) 8 lines plus “sign off”                               (2) 11 lines plus “sign off”	(1) We “will not investigate your complaint at this time.  However, if you receive HCF’s response and remain dissatisfied you are welcome to contact us again.”     (2) After using my incorrect Christian name, the email said “I am giving HCF a final opportunity to resolve the matter directly with you.  I have escalated your complaint to a senior staff member of HCF for further review and response.”
Table 1: Itemisation of 32 Separate Complaints Made by Margaret Redden Regarding Non Payment of Health Insurance Claims	3 pages	Attached to letter dated 3 December 2021   Sent by email to ombudsman@ombudsman.gov.au sent at 12:54 pm on 3 December 2021	Nil	Nil	Nil
Table 2: Itemisation of Claims Accepted by HCF for Identical Services to Those Itemised in Table 1	1 page	Attached to letter dated 3 December 2021   Sent by email to ombudsman@ombudsman.gov.au sent at 12:54 pm on 3 December 2021	Nil	Nil	Nil
Email dated 20 December 2021 to Sarah De Sade	1 page	Email sent at 5:03 pm on Monday 20 December 2021 to  ombudsman@ombudsman.gov.au	Email received from Sarah De Sade at 5:03 pm on Tuesday 21 December 2021	10 lines plus “sign off”	The Ombudsman “will wait until there is an outcome from HCF’s review” before deciding if it will take any action

In effect, the official attitude of the Ombudsman was that it refused to take any action until HCF had finished its bogus “investigation” into what had happened.  The final communication from the Ombudsman on 21 December 2021 told me to “go away”. 

In January 2023, I discovered that the Ombudsman had been aware of the actions of HCF in relation to Lift Cancer Care Services for at least three years in December 2021.  Like the Health Department, the Ombudsman had no intention of doing anything about HCF – or any of the health insurers.  The Ombudsman was “softening me up” as a preliminary to telling me to go away.

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I felt extremely flat after the flurry of activity which had resulted in me writing the letters to HCF and the Ombudsman and compiling the two Tables analysing the Lift claims that had mostly been unpaid but occasionally paid.  Margaret was dying and I had to prepare myself for the imminent funeral.  I tried in vain to think of what I might say at the funeral.  

Although I could not deal with what I might say when that day came, I was able to gather my thoughts about what music I wanted to play at the funeral service.  This is the music list I decided on that evening for the songs I wanted to be played at the funeral.

·       “Blessed We Are”, sung by Peia from the album “Four Great Winds”.

·    “Come Into the Light”, sung by Bliss, from the album “One Hundred Thousand Angels”.

·       “How Can You Mend a Broken Heart”, by the Bee Gees, from the album “Trafalgar”.

·       “Long Time Sun”, sung by Amrit Nam Kaur, from the album “Cradled in Love”.

·       “One Hundred Thousand Angels”, by Bliss, from the album “One Hundred Thousand Angels”.

·       “Time After Time”*, sung by Cyndi Lauper, from the album “She’s So Unusual”.

·       “With You”, sung by Jai Jagdeesh, from the album “I Am Thine”.

* Perhaps unintentionally, “Time After Time” is a song in which the dead lover sings to her living lover, telling him that even though she is dead, she is still watching over him and still cares for him deeply.

 

I stopped trying to think through the details of the funeral at about 6:00 pm when the surgeon was scheduled to commence his surgical list.  I had no idea of Margaret’s position on the list – she might be first or she might be last.  I was physically and mentally exhausted.  I had been awake since 3:00 am and the day was not yet finished.

 42 The Battle to Make the Health Insurers Obey the Law – Part 4: 8 October 2024

These were my thoughts as I wrote my first letter to HCF on 3 December 2021.

Margaret might have been dying, but she would continue receiving the loving care she had been getting from Lift Cancer Care Services while her health permitted.  Why was HCF was refusing to pay for her therapy?  It had to be a mistake and HCF would surely fix it when I pointed it out.

Before writing to HCF on 3December 2121, I googled the HCF contact details and I found nothing on the company website about lodging complaints.  I decided to send the letter to the address from which HCF sent me their “How Wonderful We Are” emails when they did actually pay claims. 

Then I found the HCF Complaint Management Policy.  This is copied without alteration from that Policy on 3 December 2021.

 

GUIDING PRINCIPLES In line with the Standard and HCF’s responsibilities under the Private Health Insurance Code of Conduct, we are committed to the following guiding principles when handling complaints: PEOPLE FOCUS HCF’s complaint handling process is intended to be fair and equitable to all parties. It allows for active involvement by complainants as far as practicable, permitting their views to be heard and taken into account in a balanced, respectful and meaningful way. ACCESSIBLE, VISIBLE AND TRANSPARENT This policy will be available on our website, in our branches and our Head Office. If we discover that you require assistance or support during the process, we will adopt measures to accommodate the assistance and support you require so that you can meaningfully participate in the process. We do not charge a fee for making a complaint. RESPONSIVE We will acknowledge complaints promptly and respond in full in a reasonable timeframe taking into account the urgency of issues raised. We will communicate expected timeframes to you and inform you if we think there may be some delay. OBJECTIVE, FAIR AND EQUITABLE We will review each complaint in an objective and unbiased manner. We will take all reasonable steps to make sure that you are not adversely affected because a complaint was made by you or on your behalf. If a complainant’s behaviour during the process is unreasonable, we will still endeavour to take all reasonable steps to address the valid issues raised in the complaint in a fair and ethical manner.  CONDUCT AND COMMUNICATION We will be helpful, courteous and professional in all our dealings. We will explain the reasons for our decision and any remedy or resolution we consider fair and reasonable in the circumstances. We will provide contact details of the person co-ordinating the response so that you know whom to contact during the process. ACCOUNTABILITY, LEARNING AND PREVENTION There is clear accountability for our complaint management system. We monitor and report information about complaints to gain insight on areas for improvement and issues requiring deeper analysis to prevent recurrence. All staff undertake training on the importance of complaints to HCF and this policy. We undertake periodic reviews and audits of the complaint management system to assess our adherence to this policy, and to evaluate the overall effectiveness and suitability of our complaint management system.

During every aspect of my dealings with HCF over the many months that followed, HCF made no attempt to comply with any aspect of its own Complaint Management Policy.

This Table summarises the correspondence I sent to HCF on Friday 3 December 2021 while Margaret’s life slipped away from her.

 

Letter Details	Length of Letter	How Sent*	Date of Response	Length of Response	What Did Response Say?
Letter dated 3 December 2021 addressed to Customer Support Team HCF	4 pages	Email to service@hcf.com.au sent at 12:51 pm on 3 December 2021	(1) Email received at 5:45 pm on Wednesday 8 December 2021 from Junita Lindsay, Complaint Resolution Officer   (2) Email received at 10:18 am on Monday 13 December 2021 from “The HCF Team”   (3) Email received at 4:10 pm on Monday 20 December 2021 from Junita Lindsay, Complaint Resolution Officer	(1) 7 lines plus “sign off”                   (2) 5 lines plus “sign off”               (3) 7 lines plus “sign off”	(1) We have received your complaint “and we will be investigating this matter further”       (2) A “Complaint Specialist” was investigating my complaint       (3) The Ombudsman has contacted us.  “We are actively investigating this matter”
Table 1: Itemisation of 32 Separate Complaints Made by Margaret Redden Regarding Non Payment of Health Insurance Claims	3 pages	Attached to letter dated 3 December 2021   Sent by email to service@hcf.com.au sent at 12:51 pm on 3 December 2021	No response except for the brief emails responding to my letter	Nil	Nil
Table 2: Itemisation of Claims Accepted by HCF for Identical Services to Those Itemised in Table 1	1 page	Attached to letter dated 3 December 2021   Sent by email to service@hcf.com.au sent at 12:51 pm on 3 December 2021	No response to ME apart from the brief emails sent to me   …  BUT …   HCF took prompt steps to change its systems to prevent any further “accidental” payment of Lift claims	Nil	I had accidentally told HCF it had a “flaw” in its system which sometimes Lift claims to be paid.  HCF acted to stop this

The responses from HCF amounted to asserting “We are investigating”.  This was a deliberate lie.

In reality, HCF knew exactly why the claims had not been paid – HCF had made a deliberate policy decision to ignore the law in relation to Lift Cancer Care Services. 

I am confident there was no investigation carried out at all – apart from a possible inquiry into how some claims had “slipped through the system” and been paid.  Because no further claims were paid until I forced HCF to surrender, I am confident HCF took steps to ensure no claims could be paid in the future.