Health Fund Refusing Claim - over Two Years Late

Lwongcr on 05/05/2021 - 12:00

My health fund, Teachers Federation Health, is refusing to pay my childs orthodontic treatment. Normally this is capped at $2500.
I've gone through their complaints process.

The next step would be the PHIO ombudsman

My wife stuffed up and thought the payment had to claimed within 2 years of the LAST payment.

However, the fund says that they wont pay since it you have to claim within 2 years of the TREATMENT which they consider as the date of the invoice, so effectively won't pay for any of the claims.

My childs orthodontic was about 2 years, and the orthodontist made us pay by installment i.e. $300 per month after an initial deposit of $2500 so this was over a long period of time. It cost us $8800 overall, so I don't think this is really value for money…

Any suggestions for helping me resolve this?

Health & Beauty

Comments

  • brendanm on 05/05/2021 - 12:02
    +21

    Make claims in accordance with the rules given by your health fund in future.

  • Quantumcat on 05/05/2021 - 12:03
    +1

    If it is capped at $2500 won't you have reached that already with the remaining payment after the deposit? Each $300 invoice will have a later and later date won't it?

    • original15 on 05/05/2021 - 19:13
      +2

      Maybe never claimed any of it? And now after two years trying to claim total of $2500 cap? Really unsure this is going to go well for OP

  • GourmetFoodie on 05/05/2021 - 12:06
    +13

    Totally confused? Why on earth were you not claiming every $300 Installment? You had 2 years to claim. You haven’t met the terms and conditions of your contract. They have every right to refuse payment. The ombudsman won’t be able to do anything because the insurer has not done anything wrong here and there is no grey area.

    • Jono05 on 06/05/2021 - 12:28
      +1

      This. When my daughter and son were going through their treatment I was claiming after every bill. Better in my pocket then theirs. Before you know it you reach your claim limit, then no more claiming. Don’t know why you’d wait 2 years to claim.

  • Hithere on 05/05/2021 - 12:10
    +7

    I can't see how you think that you have a case against the fund.

    Can't see what the Ombudsman can do to help.

    My wife stuffed up

    I doubt if that's a strong basis for a dispute.

    Put it down to an expensive life lesson "always read the rules in a contract"

  • Drakesy on 05/05/2021 - 12:16
    +1

    Karens be Karenning

  • Baysew on 05/05/2021 - 12:24
    +5

    My health fund, Teachers Federation Health

    Tell them that the dog ate your homework claim.

  • tsunamisurfer on 05/05/2021 - 12:52
    +4

    The real solution here would be to get a new wife.

    • Nugs on 05/05/2021 - 14:19

      quite expensive I hear
      .

      • Sleeqb7 on 05/05/2021 - 16:34

        More or less than the $8800 from insurance?

      • ozbjunkie on 07/05/2021 - 06:27

        When the powers that be release a form of wife insurance, it will be very popular.

  • Seraphin7 on 05/05/2021 - 12:53

    My wife stuffed up

    I wonder if this phrase will find it's way into your PHIO claim?

  • MS Paint on 05/05/2021 - 13:02
    +13

    My wife stuffed up

    Is your wife solely responsible for this?
    Why do you have no input or ownership of an $8500 family expense?
    Blame transfer off the scale on this one IMHO

    • thrillhouse on 06/05/2021 - 08:37
      +4

      Yeah this one frustrates me, too. Accountability is shared as the parents of a child.
      Can only imagine how the conversation went in their loving household.

      "My wife stuffed up" and then "my Childs orthodontic". A lot of possessive pronouns being thrown around but I'm not seeing "my responsibility" anywhere.

    • pegaxs on 05/05/2021 - 13:51
      +4

      hellopam and her scathing reviews… that’ll show ‘em, Pam…

      • screensaver on 05/05/2021 - 13:56
        -2

        see if you can come up with something better, or something at all

        • pegaxs on 05/05/2021 - 18:49
          +2

          Anything would be better than leaving anonymous, passive aggressively worded biased opinions on random review sites.

          • ozbjunkie on 07/05/2021 - 06:28

            @pegaxs: Pam's posts are among the most entertaining posts on the site. How dare you.

    • HelpMeiCantSee on 06/05/2021 - 10:04
      +1

      Another nugget of gold from Pam! God love you!

  • screensaver on 05/05/2021 - 13:07
    -2

    These industry funds are not really value for money. You can make this back by signup bonuses 3 times a year, for instance HCF has a $400 family signup bonus

    • Caped Baldy on 05/05/2021 - 18:10

      Is this something you have experience with?

  • screensaver on 05/05/2021 - 13:13
    -1

    At the moment the fund has an offer of 6 weeks free if you have not been a member for 4 months so you need to do your homework.

    • ensanguined on 06/05/2021 - 13:26

      ????????????????????

      ?

  • holdenmg on 05/05/2021 - 19:41
    +2

    7. Make any claims promptly

    For many services, your hospital, doctor or general treatment provider can claim your health fund benefit and deduct it from your bill. If not, you may have to pay the full bill and claim a refund of some of the bill from your health fund.

    It is safer to make any claims for health fund benefits as soon as possible after receiving treatment. This reduces the risk of misplacing receipts or accounts and your benefit is paid sooner.
    If you are claiming by post it is a good idea to keep a copy of any accounts or receipts you send to your fund.
    Most private health funds won’t pay benefits if you make a claim two years after the health service was provided. If legal action or other unforeseen circumstances are likely to prevent you from making a claim in time, contact your fund. The fund may be able to extend the claim period if you let them know beforehand.

    https://www.ombudsman.gov.au/publications/brochures-and-fact….

  • kfcfatfat on 05/05/2021 - 21:44

    Why did you wait for so long to make your claim?

  • afah0447 on 06/05/2021 - 08:49

    Dentists in this country are criminal in the prices they charge. It's such a protection racket. They even say 'don't go overseas for work' even though many of the o/s dentists went to Western universities, just to protect their profits.

    • md333 on 06/05/2021 - 14:23

      We did much better by going to a dentist instead of an orthodontist, so relatively speaking I don't think dentists are that bad.

  • Bob Svargis on 06/05/2021 - 10:27

    $8K+ is pretty much the going rate for ortho treatment for kids, based on other posts about this in OzB and also my own experience.

    It's easy to say that it's poor value, but at the end of the day, it can take several years and multiple visits to the orthodontist. PLUS, it's not an easy skill to find out there - it requires many years of study.

    It's easy to say "It's a rip off" without detail but that's a cop out.

    My son's orthodontic work went over a roughly 2 year period and I recall at least 20 or more visits to the surgery. All finished but I still have a follow up visit in about 6 months. All included under the $8K+ expenditure.

  • OzHunterNSW on 06/05/2021 - 14:55

    Get a new wife

  • Hirolol on 07/05/2021 - 04:01

    I bet OP didn’t get the response he was looking for…
    Where are you OP?!

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