75 My Battle to Make the Health Insurers Obey the Law Part 18, Section 3: 31 October 2024

 

Unpicking The Ombudsman Email of 5 April 2022 (2)

Did Margaret Simply “Attend” Lift Cancer Care?

”…  and had been attending [Lift] since January 2021.”

Translation ↓

These words were selected to minimise what the law required the Ombudsman to investigate.  Margaret had attended Lift since January 2021, but only because her oncologist had recommended it.  The careful selection of words here creates the possibility Margaret decided to undertake the Lift program on her own initiative – something the Ombudsman knew was untrue.  My 3 December 2021 HCF letter said this. “Margaret commenced chemotherapy and radiotherapy in December 2020 and this treatment continued through January 2021.  The cancer went into remission in March 2021 but it surged back into renewed life in September 2021.  As I write this letter of complaint, Margaret is an in patient in hospital receiving treatment.* Part of the treatment program recommended by Margaret’s treating oncologist was attendance at a registered day hospital called Lift Cancer Care Services.  My understanding is that when she attends Lift, she is admitted as a patient and given treatment by registered professionals.  Each treatment consists of an initial medical examination by qualified medical personnel who then recommend an exercise program which is then undertaken on the premises of Lift.  The exercise program is closely supervised by Lift personnel and adjusted on an ongoing basis during each treatment session.  As I understand it, the aim of the programs provided by Lift is to increase the physical strength of cancer patients so that their ability to survive and gain benefit from the specific cancer treatments recommended by their medical practitioners, is enhanced.  To be eligible to undertake the services provided by Lift, participants in the Lift program must have received a formal diagnosis of cancer and, in addition, their treating medical practitioners must decide that the cancer treatment regime is likely to be enhanced if participants take part in the Lift program. Margaret began to take part in the Lift program in January 2021.  She has found the program to be of great benefit to her physical and mental health while she is in the midst of an extreme threat to her ongoing physical existence.” * Margaret and I expected Margaret would die in the very near future when I wrote this on 3 December 2021.

 

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From this point on the Ombudsman “summary” of relevant facts stops being ambiguous and becomes a complete work of fiction.

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Outright Lying by Ombudsman (1)

You explained that the LCC claims were not being declined by HCF, but being rejected due to lack of information.

Translation ↓

This was an outright lie.  I did no such thing.  In my 3 December 2021 letter to HCF (which I copied to the Ombudsman), I said this. “Lift has now advised Margaret and me that contrary to what we had believed to be the case, HCF has, for the most part, either responded with spurious and legally incompetent reasons for rejecting claims, or completely ignored the claims and not bothered to provide any response at all.”

 

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Outright Lying by Ombudsman (2)

“This had resulted in a build-up of unpaid claims with [Lift], and as a result in December 2021 LCC stopped lodging claims directly with HCF.”

Translation ↓

This was another outright lie.  After the passage quoted above, my 3 December letter to HCF said this. “Because of the callous disregard by HCF of its legal obligations under the policy of private health insurance between it and ourselves (and other cancer patients who have attended Lift), Lift has not been paid for multiple treatments provided to its patients.  In Margaret’s specific case, as at the date of this letter, HCF has either refused to pay or completely ignored thirty (30) separate claims made by Margaret under our policy of private health insurance.”

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Ombudsman Fudges the Truth Instead of Lying Outright

“You were asked to pay for services up front and then claim directly with your insurer.”

Translation ↓

In this sentence, the Ombudsman did not actually lie but it once again – almost certainly deliberately - understated the what I was complaining about.  Immediately after the passage quoted above, my 3 December HCF letter to HCF said this. “Because of the callous and cavalier attitude displayed by HCF, Lift is now able to provide services only if patients pay for their treatment on the day of service and then seek reimbursement individually from HCH.”

 

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Outright Lying by Ombudsman (3)

“This was administratively taxing because claims required additional paperwork signed off by Margaret’s doctors each time a claim was submitted.”

Translation ↓

In this sentence, the Ombudsman not only lied, it resorted to fanciful lies that bore no relationship at all to my complaints.  My 3 December HCF letter which I copied to the Ombudsman went on to say this. “I am utterly disgusted by the actions of HCF and under cover of this letter, I am now making 30 separate complaints to HCF about its failure to respond to its legal obligations under our health insurance policy. I attach as Table 1, a complete listing as at the date of this letter of all claims that have either been refused or ignored by HCF.  This Table includes the dates of the treatments, the Lift invoice numbers, the item claim numbers submitted by Lift and – where a formal refusal of the claim has occurred- a statement of the reasons asserted by HCF as justifying the refusal.” I was not in any way bothered by the “administratively taxing” nature of us having to pay for the health services provided to Margaret and then lodge a claim with HCF for payment of the insurance benefits the law entitled us to.  My complaint was motivated by the refusal of HCF to obey the law.

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The Ombudsman Can’t Read

In January 2022 you paid 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.

Translation ↓

In this passage, the Ombudsman demonstrated a complete lack of interest in the detail of our complaint.  This lack meant the Ombudsman was unable to accurately state how much I paid to Lift nor the month I paid it.  On 21 February 2022, I had told the Ombudsman what we had paid and when. “Because there is a legally binding contract between Margaret and Lift Cancer Care Services, and because HCF has refused to honour its contractual and legislative obligations to Margaret and me, as at 18 February 2022, our (legally enforceable) debt to Lift Cancer Care Services amounted to $6,978.00.  This debt was owed for services provide to Margaret up to the end of November 2021.  As stated earlier, all service fees from 1 December 2021 onwards were paid on the date of receipt of the services. Lift Cancer Care Services provided us with an invoice for the outstanding fees on 18 February 2022.  That invoice was paid by direct electronic transfer on 20 February 2022.”

Margaret gives birthday present to Anne Ryan 15 January 2020

 74 My Battle to Make the Health Insurers Obey the Law Part 18, Section 1: 31 October 2024

 

Unpicking The Ombudsman Email of 5 April 2022

 

 

The “Official” Stamp

“OFFICIAL”

Apart from the sign off at the end of the email, this is the only indication that the email might have come from a government agency.  The red font was used in the email. 

Sending an email avoided sending anything on an official letterhead.  Except for the sign off at the end, nothing in this document positively identified it as a genuine Ombudsman communication.  It could have been typed and sent by HCF using the Ombudsman email address.

Never in my five months of dealing with her did Ms De Sade send me anything on letterhead.  I do not believe Sarah De Sade actually wrote the email because it has a completely different tone from all previous emails from Ms De Sade.  I am confident it was written by someone else and sent from Sarah De Sade’s email address.  My guess is that this email was written by Emma Cotterill.

 

Thanks for Your Complaint

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.

Translation ↓

“We are completely sick of having to deal with you and your insistence that HCF obey the law.  We hoped that you would go away if we made you wait for months.  It is a real pain in the arse that you are still bothering us.

 

Grab the Money and Go!

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.

Translation ↓

“HCF will pay you $8,623.00 as go away money.  HCF will not pay you any more money – no matter what the law says.”

 

The Ombudsman Recreates History

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.

Translation ↓

Most of the “facts” set out in this extract are outright lies.  Some other “facts” merely blur the truth to reshape reality.  Dividing this extract into more digestible chunks will clarify what the Ombudsman really said.

 

When Is a Letter a “Contact”

You contacted our Office in December 2021.

↓

I did “contact” the Ombudsman in December 2021.  I emailed a two page letter on 3 December.  Attached to my letter to the Ombudsman was a copy of the four page letter I had emailed to HCF on 3 December.  My letter to the Ombudsman contained few specific details about our situation.  My Ombudsman letter did not explicitly say that Margaret suffered from cancer, although that was a clear implication of my Ombudsman letter.  The few specific details contained in my Ombudsman letter were in this paragraph. “The total amount of service fees which have been rejected or ignore in relation to Margaret since 1 January 2021 is $6,981.00.  Given that Margaret is only one among probably hundreds of cancer patients across Australia who have been treated in a similar manner by HCF, the issues raised in my letter probably involved hundreds of thousands of dollars in every calendar year.  Apart from the large dollar amounts involved in these issues, the actions by HCF have been taken in relation to patients who are extremely vulnerable and – because of their life threatening illnesses – least able to react in a manner likely to force HCF to change its behaviour.” By describing my letter as a “contact”, the Ombudsman creates the possibility that my “contact” was a minor one; it might have been a short phone call.  Vaguely saying my “contact” occurred in “December” accentuates the ambiguity.  This creates the possibility that my “contact” might have been in late December when the Christmas/ New Year season results in understaffing of many government agencies.  By using this formulation of words, the Ombudsman ensured there was ambiguity and obscured the truth.

 

Complaining About “Issues”

“… to complain about issues you were having with HCF not paying your wife Margaret’s … [Lift] invoices …”

Translation ↓

The choice of words continues the creative ambiguity process.  I did not complain about “issues” but about the failure of HCF to pay for medical services provided to Margaret and to other cancer patients who had also been provided with medical services by Lift.  This choice of words deliberately minimises the breadth of the matters that I had asked the Ombudsman to investigate.

 

 

Did I Say My Wife Had “Cancer”

You explained your wife has cancer …

↓

In my letter to the Ombudsman, I did NOT say that Margaret had cancer.  Nor did I say that Margaret had been attending Lift since January 2021.  This information was only in the letter to HCF.   It was easy for the Ombudsman to be accurate, but it prefers to blur the truth – presumably to minimise its own inaction. My Ombudsman letter contained very little detail; it did not say that Margaret had cancer, although this was the implication.  Information that Margaret had cancer was in my HCF letter dated 3 December 2021 where I said. “My wife Margaret was diagnosed in July 2020 with what may well prove to be incurable ampullar cancer ….  My understanding is that the ampullar is a junction point just outside the pancreas where the bile duct and the pancreatic duct meet in a T junction.  The growth of the cancer in this location is likely to result in the failure of the digestive system.  If Margaret’s digestive system fails, she will die.” In this sentence, the Ombudsman confirms it had read the 4 December 2021 letter to HCF, but despite this, the Ombudsman minimised the danger Margaret faced.  All cancers are dreadful and many are fatal, but some cancers can be survived.  By using the generic word “cancer” rather than referring to Margaret’s specific cancer, the Ombudsman created ambiguity.  According to the Ombudsman, Margaret suffered from “cancer” rather than from deadly “ampullar cancer”.

 

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Margaret in Alaska on 14 September 2016.

 73 My Battle to Make the Health Insurers Obey the Law Part 18, Section 1: 30 October 2024

 

The Ombudsman Tells Me to Bugger Off – 5 April 2022

This is an email that I finally received from the Ombudsman on 5 April 2022.  It told me very clearly that I should bugger off and stop bothering the Ombudsman.  I reproduce the email without alteration.  In later blogs, I will tease out the crimes that I believe the Ombudsman may may have committed by sending me this email.  

 

Tue 5/04/2022 2:37 PM Sarah De Sade Sarah.DeSade@ombudsman.gov.au Commonwealth Ombudsman complaint - Hankin - Ref PHI-2021-101690 [SEC=OFFICIAL] To: John Hankin   OFFICIAL   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 realise 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 inalizing 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

* I insisted that Lift give me an invoice for all of the treatments that HCF had refused to pay.  The invoice came to $8,623.00 and I paid this invoice to prevent the Ombudsman from dismissing our complaints on the spurious basis that we had not suffered any financial loss and that Lift had suffered the loss and not us.  In this email, the Ombudsman did a variation on this swindle trick.  It told HCF to pay the $8,623.00 and then told us to bugger off because we no longer suffered any financial loss. 

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Apart from the probability that a number of crimes were committed when the Ombudsman sent this email to me, the email is completely full of false statements – and the Ombudsman conclusively knew these statements were false because I had already given it full information.

I was astonished and outraged that a government agency felt it could behave in such an appalling manner.

In future blogs, I will dissect this email and highlight the many false claims made by the Ombudsman and the crimes that I believe were committed by the Ombudsman in sending this email to me.

It was irrelevant to the Ombudsman that Margaret’s life was threatened by cancer. 

It was irrelevant that the lives of all the other patients at Lift Cancer Care Services were also threatened by cancer.

It was irrelevant to the Ombudsman that it was ignoring multiple breaches of the very legislation that it was theoretically established to enforce.

The Sarah De Sades of this world really do walk amongst us and we pay them fat salaries – to do nothing when we ask them to do their jobs.  I hope you are reading this and squirming Sarah.

This was Margaret on 16 February 2021.  We escaped to Port Lincoln for a few days.  This is one of the patients that the Ombudsman believed did not matter – some one who hopefully would die quickly so that we would no longer be a nuisance.