Published: 9 August 2019
On Wednesday 31 July, ABC’s 7.30 Report aired a segment on why people are quitting health insurance. Teachers Health was mentioned in this story and inexplicably, we were not invited to provide comment.
The story on the 7.30 Report did not correctly present the facts of the situation – in fact the portrayal of the member’s events and its coverage was grossly false and misleading.
Had we been given the opportunity, we could have responded to many of the inaccuracies reported, and we are in the process of requesting a correction and clarification from the ABC.
Teachers Health is in the business of paying claims for its members – that is why it exists. Unlike for profit insurers who have shareholders’ interests to consider, at Teachers Health as a not-for-profit health fund, there is no motivation for them to not pay claims.
Teachers Health’s response to claims made in the broadcast and online:
- Included in the coverage was a Teachers Health member who spoke about her experience after being diagnosed with breast cancer, and coverage for breast reconstruction following a double mastectomy.
- The article refers to Teachers Health Mid-level cover, which has always covered medically necessary breast surgery, reconstruction and chemotherapy. The health fund does not determine what is cosmetic and what is medical – this is determined by the surgeon’s medical coding.
- In relation to the mastectomy and breast reconstructive surgery all applicable hospital charges have been paid in accordance with the product benefits and hospital contract. At no stage did the member have to ‘complain’ or ‘fight’ with the fund for payment of these hospital costs.
- In accordance with standard operating procedure, payments are made as soon as the normal checks and balances are completed. Teachers Health follows standard claims processes to ensure it is compliant with private health insurance legislation. For some treatments, including breast surgery, they are required to collect additional documentation to pay a claim. They can’t pay a claim without it, and it may mean that some claims payments are delayed.
- All medical accounts (specialists and other doctor fees) for the inpatient medical services in question have been paid in accordance with Medicare billing requirements and access gap arrangements.
- Teachers Health cannot control the fees surgeons charge – this is where members may encounter a gap. In this member’s case, the significant out of pockets costs incurred resulted from the surgeon and other treating doctors’ fees greatly exceeding the Medicare benefit and the benefit the fund is allowed to pay under the legislation in these circumstances.
- Teachers Health offers varying levels of cover – including Basic, Mid Hospital (Basic Plus), Mid Classic (Silver Plus) and Top cover (Gold) options. Each of these hospital products provides varying coverage, so it’s always important for members to understand if their cover is right for them.
- Teachers Health has always covered medically necessary breast surgery, breast reconstruction, chemotherapy, radiotherapy and immunotherapy for cancer under our Top Hospital (Gold), Mid Classic (Silver Plus) and Mid Hospital (Basic Plus) covers. The Private Health Insurance Reforms did not change this. Teachers Health covers all hospital associated costs including theatre fees, accommodation, pathology and prostheses with contracted hospitals.
- Teachers Health cannot control the fees that specialists charge or visibility around what they charge – this is where members may encounter a gap, or out-of-pocket expenses. This last point is one of the most concerning. While the media is placing pressure on the private health insurance industry about gap fees, the attention is being diverted from the actual cause of the problem – a lack of visibility around specialist fees.