I received this from a Victorian paramedic:
We’ve recently been having a discussion on informed consent. Not, as you would think on treatment consent, rather financial consent.
Our question is: are there any obligations on an ambulance paramedic to provide information to a patient/relative on the financial implications of their transport to hospital?
All ambulance services charge in some form or another, and we believe that it would be an interesting situation for a patient to receive a bill then argue they weren’t adequately informed about the costs of their treatment and transport – and thus refuse to pay. At the extreme this could even been brought further back to the call taker stage – where a number of services now charge for turning up. Should despatchers advise callers that the call out fee for ambulance assessment is $x?
This question is not unreasonable and recently a caller to Sydney radio station complained about receiving an ambulance bill in just these circumstances, though he was given very little support from Ray Hadley – you can hear the phone call at http://www.2gb.com/article/ray-hadley-refusal-pay-ambulance#.VC5K0SmSzBc.
According to the Australian Consumer Law (set out as Schedule 2 to the Competition and Consumer Act 2010 (Cth)) ‘unsolicited services means services supplied to a person without any request made by the person or on his or her behalf’ (s 2). A person must not assert a right to be paid for unsolicited services (s 40). Further a term of a standard contract that is ‘unfair’ is void (s 23).
If a person rings for an ambulance they are clearly making a request for that service, as they would be if someone rings on their behalf, eg when a friend says ‘you’re not well, do you want me to call an ambulance for you’. Often a person will not ring an ambulance for themselves, either they are not capable of doing so or, even if they are competent, someone else rings without their knowledge.
Consider, for example, a shopkeeper who sees an accident outside his or her store and who immediately rings triple zero without the consent or knowledge of the people involved in the accident. A person who was involved in the accident may have some minor injuries including a laceration on the arm. They are approached by a paramedic who asks ‘Are you OK?’ The person says ‘yes’ but the paramedic offers to check them out. They do an examination, perhaps take a BP and pulse and put a bandage on the cut and say ‘You’re OK, no need to go to hospital, we’ll leave you to it’. That person later receives a bill for Emergency attendance fees – no transport $481.00’ (see http://www.ambulance.vic.gov.au/About-Us/Fees.html). In this scenario, they didn’t ring for an ambulance or even ask for the service, but a paramedic was on scene, offered to check them out. Most people would feel some moral pressure to accept what appears to be an offer of concern from a uniformed member of Australia’s most trusted profession. But they may take a different view if they were told ‘Do you want me to check you out, but it will cost $481 if I do?’
Ethically one would have to say there is an obligation to warn a person that the service they are about to engage attracts a fee but there are no doubt difficulties with that. One would not want to discourage a person from receiving care that they actually needed just because they couldn’t afford to pay for it, and one would hope that an ambulance service would not pursue recovery from a truly indigent person who needed their services. Equally there are problems with asking the call taker to advise the caller of ambulance fees, the caller may not be the person who needs the service and one would not want to discourage people calling an ambulance when they need it or when someone else needs it.
Legally, it is unlikely that the Australian Consumer Law would apply. An ambulance service I would suggest, is not engaged in trade or commerce (but see ‘United Firefighters Union of Australia (‘UFU’) v Country Fire Authority (‘CFA’) [2014] FCA 17 (31 January 2014) and the discussion on why the CFA was found to be engaging in ‘trade’ when providing road crash services; it’s certainly not impossible that they are engaged in trade and commerce) and the right to payment is not because of any alleged contract but because of an operation of law. If we limit our discussion to Victoria then the Secretary of the Department of Health may set fees that an ambulance service may charge (Ambulance Services Act 1986 (Vic) s 10(5)) and the ambulance service must comply with the Secretary’s direction (s 10(6)). An ambulance service (remembering Ambulance Service Victoria is a umbrella title covering a number of separate ambulance services; ss 3 and 23, Schedule 1) may charge reasonable fees for the provision of its services (s 16) and by implication what is a reasonable fee is a fee that complies with the Secretary’s direction under s 10. So this is not an issue of contract (and therefore the provision regarding an unfair contract term can’t apply) and the fee is charged because the Act says it may, or even given s 10(6), must be charged.
Although I don’t think the Consumer Law would apply, given the amount involved will be relatively small and well within the jurisdiction of a small claims court or tribunal, I’d suggest to someone seeking advice in the circumstances I’ve described above, that they may like to go before the relevant tribunal (in Canberra that would be the Australian Capital Territory Civil and Administrative Tribunal) and seek an order to the effect the imposition of the fee is ‘unfair’ and should not be enforced. These small tribunals are relatively cheap, act with informality and try to do justice between the parties rather than focus on the letter of the law; a tribunal member may well be attracted to the idea that the fee is unfair and could with some imagination I’m sure, find that they had jurisdiction and authority to refuse to enforce the debt even if an appeal court might say that this was not a correct application of the law. On the other hand, if the person had been in a life threatening situation and the paramedics saved their life, I don’t think any tribunal member would be attracted to the argument that there was any unfairness, particularly if because of the patient’s condition the paramedics couldn’t explain there was a fee even if they wanted to, and no doubt would have provided the service in any event rather than leave the poor patient to die. In those circumstances, if the person really couldn’t pay one would try to negotiate with the ambulance service to reduce or waive the fee, or accept payment by instalments. If the patient had the means to pay but simply didn’t want to then I think Ray Hadley’s approach, above, is probably appropriate.
Australian Emergency Law 
I have been concerned about this issue for some time. In my experience, most paramedics do not raise the question of cost because their focus is, rightly, on provision of clinical care. The scenario mentioned in the blog, however, is quite common: an ambulance crew attends a scene and assesses a person with minor or no injuries, and then asks for personal details for the case record. This is all acting in accordance with the employer’s instructions, however at no stage is the person informed that by accepting even a cursory assessment and by giving their details they will be charged what many might regard as a hefty fee.
The general public is still largely unaware that ambulance services in most states are not free, and many don’t even know what organization runs the ambulance service. While it may be reasonable to presume they would know there would be some charge for a service, I doubt many would have any idea what the amount might be.
Informed consent now forms an important part of ambulance practice (or it should) and I believe patients should have information regarding costs in the same way they are informed about risks of medical procedures.
I recently had a police officer call an ambulance for me after I asked them not to. I specifically said no, because I can’t afford that. The officer said I would not be charged because they had called them.
I have just received a bill for over $1700.
Hi Meg! I have had the same thing happen to me recently as well. I was fully conscious and specifically asked them not to call the ambulance, as did my guardian. They called anyway and neither the officers or the paramedics explained any of the associated costs. I was unaware that I’d even be charged as it did not transport me anywhere. They took my vitals for about 10mins (the police had driven by as I’d had a mild asthma attack) and sent me home. Now I have a bill I cannot afford!
Have you made any progress? Could anyone offer advice?
Hi
did you have any luck with getting around this? I am in the same situation now I want to cry
I agree with Malcolm, particularly the aspect of Paramedics not raising the issue of costs at the time of treatment unless specifically asked. In the ACT the cost of medical checks or transport undertaken at car accidents are covered by the Road rescue fee for ACT residents and this helps eliminate patient costs for roadside observations and examination without transport.
I believe that ambulance services should provide their staff with a small printed card listing a breakdown of fees. The card can be handed to anyone enquiring about costs thus preventing any miscommunication or confusion. A suitable bold disclaimer and contact phone number on the card should also state that paramedics cannot alter or strike off compulsory fees for service. This would fully inform the patient and also help to alleviate bill-shock after the event.
As a NSW RFS volunteer firefighter we were in the field when one of our members twisted his ankle. A relatively minor issue with Rest, Ice, Compression, and Elevation being the only treatment required. An ambulance had been deployed to the location and was on standby.
After a look the ambulance officers agreed with the treatment but offered him a ride back in the ambulance as it was less bumpy than the fire tanker and better air conditioned. He was most surprised to receive a bill for treatment and transport. It took many letters and calls to sort it out.
Ambulance services should be covered by Medicare. If I am unable to provide consent, then I should not be billed for the service. What happens when a family member dies en route to hospital. Do the ambulance service then bill the family. That would be the equiv. Of funeral costs in some circumstances. In QLD the costs are incl. In electricity bill. This should be rolled out across the country so innocent victims of unauthorised treatment are not unfairly billed.
That is interesting. I had not noted, before, s 53B of the Ambulance Service Act 1991 (Qld) which provides that a person ‘whose principal place of residence is in Queensland’ is exempt from paying ambulance fees for services provided by Queensland Ambulance. Further Queensland Ambulance will meet the costs of ambulance services provided to Queensland residents when they are interstate – see https://www.qld.gov.au/emergency/emergencies-services/interstate-ambulance-treatment.html. I’m not sure if there is a levy with the electricity bill (see Community Ambulance Cover Levy Repeal Act 2011 (Qld)) but whether there is or is not, that’s a generous position of the Qld Government.
Surely an exemption for fees based on state of residence is unconstitutional?
Hi,
Queensland recently dropped the levy on their electricity bills, and the state covers the free service, but it is for Queensland residents only. If you are an interstate visitor, you will be billed 100% of the applicable services fees. In this instance you would forward your account to your state ambulance scheme (where they still might exist) or your health fund. Where you are not covered by a health fund, you will then personally owe the cost.
Thabks Jason, as the other comments here show, the levy was dropped in 2011. If the levy was in place the potential constitutional issue (also discussed in the comments) wouldn’t arise as the ‘disability or discrimination’ (ie the exemption from ambulance fees) would not be based on the state of residence but on whether or not the person was liable to leave pay a levy.
John, an exemption from fees based on state of residence may be unconstitutional if the Commonwealth did it (Australian Constitution, s 117) but states can make their own arrangements. Ambulance service are state based services so one state can chose to offer the service for free or collect a levy whilst others can make direct charges. We’ve seen differences in how fire services are funded (an insurance levy v property tax), registration and licence charges vary from state to state etc. It’s not the case that the Commonwealth sets ambulance fees and then exempts Queenslanders or that Queensland is paying the Commonwealth on behalf of its residents. Ambulance fees have nothing to do with the Commonwealth so I can’t see that the Constitution has anything to say on the matter.
While the position is far from clear i invite you to reconsider street v Queensland Bar. Then contrast that with sweedman v. Tac and see what you think.
Fair point- certainly s 117 does limit the power of the states to discriminate on the basis of residence and I have looked at the cases you have mentioned (Street v Queensland Bar [1989] HCA 53 and Sweedman v TAC [2006] HCA 8) and I can see the point that making the exemption based on residence may be contrary to s 117. It would appear that this would be avoided if Queenslanders did pay a contribution or levy for ambulance services but that has been scrapped. On 29 August 2012 Bridie Jabour of the Brisbane Times, in her article ‘Newman scrambles after ambulance levy stumble‘, reported:
In Street v Queensland Bar, Mason CJ said (at [35]) “In Davies and Jones, O’Connor J. stated (at p 53) that s.117 “does not prohibit a State from conferring special privileges upon those of its own people who, in addition to residence within the State, fulfil some other substantial condition or requirement”. It is implicit in that statement that a privilege granted upon the basis of residence alone may offend s.117.’ The exemption from ambulance fees appears to be based upon residence alone, not residence and payment of a levy or some other qualifying condition. So it would indeed appear to be arguable that this clause is unconstitutional.
I’m not a constitutional lawyer (clearly) but I have to say those cases do cause me to reconsider my earlier answer. Clearly I’m wrong that s 117 only limits the Commonwealth. I’m not sure whether s 53B of the Ambulance Service Act 1991 (Qld) is the sort of ‘… disability or discrimination … contemplated as falling within the proscription in s.117’ (Street v Queensland Bar, Mason CJ, [35])). Fortunately I work at the ANU with some leading constitutional lawyers, so I’ll ask for a second opinion and get back to you.
I said I would get a ‘second opinion’ on this one, so I approached my colleague Associate Professor Amelia Simpson, an expert on constitutional law and constitutional rights. She said:
So the best answer I can give, thanks to Amelia, is that s 53B is probably constitutional, but if someone who resides outside Queensland receives a bill from Queensland ambulance and wants to challenge it, there’s an opportunity to try to get to the High Court!
Thanks for the answer Michael.
My first response was really aimed at triggering some thought on state-of-residence discrimination and s 117.
My second just on pointing out that your initial response was clearly not well thought through.
It is an interesting and tricky area and one that has not yet had strong judicial treatment. I remember as a young man going to Victoria and being denied a concession train fare because I lived in WA. At the time I felt aggrieved, but it was not until some time later I found it may have been illegal.
However, as your friend points out – notwithstanding the clear prohibition in the Constitution the High Court may well find it to be reasonable given the State’s subsidy of transport services. I find this unsatisfactory. Any state legislation conferring a state of residence based exemption flies in the clear face of s. 117 and is therefore ineffective.
s. 117 is quite clear in its language and does not easily accommodate a ‘reading down’.
Anyway – just one of my little bugbears.
A friend recently had a bad blood nose that would not stop.
My friend’s Mother called for an ambulance as the caller was too weak to drive due the chemo therapy treatment.
The jurisdiction is St John Ambulance W.A. As St John is a private company, with the 000 contract for the state ambulance service.
My friend received a bill for about $900 dollars.
On contact with St John, it would seem if you don’t pay on time, the bill is handed to a debt collector.
The call receiver can decide on any priority classification they wish.
It would see there is no redress on ambulance fees.
My original post was in response to a question from Victoria. In Victoria the right to charge fees is set out in statute – Ambulance Services Act 1986 (Vic) s 10. There’s no similar statute in WA and given St John is a private contractor rather than a state instrumentality it would be easier to argue that they are engaged in trade and commerce and that the Australian Consumer law applies to them. I wonder if anyone has challenged the right of St John Ambulance (WA) to render a bill particularly where the person in need of care is unable to consent to treatment.
The posts on Constitution s 117 are very interesting. I recently speculated on s 117 and its application to prescriptions, both PBS and private. This wasn’t about emergencies, but health more generally. I’d be interested to know what others thought.
https://ajp.com.au/columns/opinion/opinion-need-national-poisons-law/
Thanks Andrew, that’s an interesting article and it is also of relevance to paramedics who may have to cross state borders see https://emergencylaw.wordpress.com/2016/06/27/carrying-scheduled-drugs-interstate-v-2/. In that post I said that I assumed there was also authority in Victoria to allow NSW paramedics to cross the border, but it does appear that there is not – see https://emergencylaw.wordpress.com/2017/09/14/paramedic-practice-in-nsw-and-victoria/. So whilst your post wasn’t about ’emergencies’ the issues are very relevant to the emergency, in particular paramedic, services.
my 17 y o daughter fainted on her way to school. She didn’t eat before she left in the a.m. She was on the bus so it caused quite a stir…bus pulled over and got everyone off. Someone called an ambulance and she was taken to hospital without our consent….she was clearly conscious when they arrived. Are we liable for the bill if we didn’t authorise this transport. She was 500 m from the hospital when it occurred and seems over the top treatment and transport for a faint.
It depends on what state you are in and whether you have private health insurance or membership of an ambulance fund, but in essence at least your daughter will be liable. Your authority or consent is not required, the right to charge fees is set out in statute and your daughter must have consented to the care provided. Consider the alternative, would you prefer that if your daughter was seriously ill, or someone thought she was, that they do nothing for fear you get the bill? And what was the alternative here? The bus driver could hardly proceed with a sick person on board, but neither could the driver put her off the bus or divert to the hospital. If you faint on the way to school or work you can pretty much expect someone’s going to call 000.
I took out a membership [ family] with Ambulance Victoria, 3 days before requiring a call out. They billed me $1786. I wrote them asking them to wave the fee given I was already a member. They stated that I had not qualified as it was required that because I had a pre-existing illness, I would have a period of 14 days to wait before the membership was valid. I challenged them on their business rules being discriminatory. They replied saying they could apply the private health insurance act 2007 to make policy that required people to wait before membership was fully active.
Add this to consumer consent issue [none] ,the bill shock , the discriminatory nature of AV business rules, the variability across states and you can easily see why multiple complaints go to the Ombudsman and health complaints commissioner.
This said I am alive and the clinicians were fantastic. I only wish some of their quality would filter into the business arm of AV.
I recently had surgery in South Australia, I had a friend stay until about 9.30pm, around 10.30 I developed severe pain to the point I could barely breath or move, I rang 000 and an ambulance came, The paramedics were lovely and said I should go to hospital I am on a disability pension & do not have ambulance cover my budget is air tight & set for the year I never have money to consider any extra & was clueless about the actual cost. When I was in the still parked ambulance and less pain I asked the paramedic how much this would cost me? The reply was “A bit” then I was asked if I had cover or insurance, I said “no”. I do not have enough to cover all of my needs as it is & go without a lot. The conversation then changed to which hospital we were going to.
I later received a bill for just over $1000, It nearly made me call another ambulance. I rang spoke to them & as I have a concession card it was reduced to $500 which I was thankful for but still have no way of paying. I applied for financial hardship. The letter in response was we can not waive your fee, you are required to pay $25 per fortnight; unfortunately I can not, I have proven my expenses are greater than my income, I am extremely good at budgeting and the stress caused by all of this goes against their key objectives “Ambulance Service (SAAS) is committed to save lives, reduce suffering and enhance quality of life, through the provision of accessible and responsive quality patient care and transport.” The stress and suffering caused by these fee are devastating, poor people have nothing left so how does forcing this huge bill help reduce suffering?
Under the Charter for Consumers of the South Australian Public Health System 5. Information – right to be informed Fees and financial assistance “You have the right to open, clear and timely communication about services, treatment options and costs in a way that you can understand” in every area other than Ambulance fees. I specifically asked what it would cost & was not given accurate information, if I had been told I would have gotten out of the vehicle & called a taxi as my pain had lessened, yet I am sure I would still have been charged.
Why is there no public advertising that lets people know as most are un aware. The weekend paper had a huge lift out on SA Ambulance covering what they do, how they need donations etc, gave no indication that it anything but a free benevolent service, this would of been the perfect time to advertise to get cover & what it costs if you do not. Then I see the second highest area of income is for them is fees, so if they told people & more got cover they would have less income.
I do not blame the Paramedics, this is controlled by SA Health. I am so tired of being punished for being poor when I do the right thing and now I am punished for being poor and sick. I believe the total lack of information on this is deliberate revenue raising & extremely cruel.
SA Ambulance didn’t have a big lift out in the weekend paper, it was St John Ambulance SA celebrating 135 years of service. St John have not provided an emergency ambulance service in metropolitan SA for more than 30 years.
Whilst I am sorry that your financial situation has been further impacted by your recent ambulance experience, however ambulance service delivery in SA has always been a ‘fee for service’ in SA. St John in previous times and more recently SA Ambulance Service have printed literature, extensive social media presence and web pages that talk about their fees and their subscription service for pensioners/concession card holders.
Ambulance cover has to be a shared responsibility both by the service provider and the end users. End users/broader public need to better inform themselves.
In addition to my comment, I now have a very clear card next to my Drivers License that states “Not to be taken or treated by Ambulance under any circumstance” and I am looking into an advance care directive to legalize it. I do not know what else to do.
A card saying “Not to be taken or treated by Ambulance under any circumstance” is unlikely to be effective. First imagine that you collapse in a shopping centre. The Centre can’t just let you die on their floor. The appropriate response is to ring an ambulance and the ambulance crew aren’t going to let you die on the floor either. As a community we won’t tolerate letting the bodies of the poor rest on the road side so you are going to be transported by ambulance if you’re not already dead. If you are able to express your wishes you may avoid ambulance transport but some alternative is going to have to be arranged. If you’re bleeding, incontinent, unable to sit etc no taxi or uber is going to take you so again it is going to be an ambulance unless a family member can be found.
That does raise the ethical issue of fees and why people are charged fees when they are vulnerable and there is no practical alternative. That is a matter for government. How governments chose to respond to this issue has a broad range. South Australia does not provide free ambulance for those on social security benefits, NSW does and Queensland provides free ambulance for everyone.
The other reason a ‘card next to [your] Drivers License’ is unlikely to be effective is that it is unlikely to be found. If you are critically ill, a sudden collapse, hit by a car etc, no-one is going to be looking for or in your wallet. Police may do that once you’re at hospital and all your personal effects have been collected but by then it will be a bit late.
If you are looking for advice on ‘what else to do’ and in particular for help with the current ambulance bill I’d suggest contacting one of South Australia’s community legal centres – see http://www.saccls.org.au/centres.php. The
Consumer Credit Law Centre SA provides a state wide service so they may be a good start with advice on the debt and making further representations to SA Ambulance.
Ambulance cover should be free to everyone unless the call was made frivolously. The latter can be easily substantiated by the outcome of the call.
I’m in SA. Late last year I had a stranger come to my door and rang my doorbell. They said they were having chest pains and asked me to call them an ambulance as they did not have a mobile phone. I agreed to call on their behalf and person waited out the front on the verge then I called 000 and explained to the operator that a person had come to my door requesting help. The operator put me through to an ambulance operator and he asked questions about the patient. They told me not to let the person drink water and to keep them awake and had me ask them a series of questions including their name. I made it quite clear to the Ambulance operator that I was calling on this person’s behalf and would not be paying for the ambulance service.
The Ambulance arrived and checked the patient then took to the hospital (I assume) and that was the last I heard of it until today.
Nearly three months later a letter addressed in the patient’s name arrived in my letter box with my address on it (from AusHealth Hospitals) as this is the address the Ambulance had attended. I have not opened it but I’m pretty sure it’s some sort of debt collection notice. I would not be surprised if it is as I believe the person was an Ice user so probably had no money based on responses I passed back to the Ambulance operator on the phone.
Why AusHealth would send this to my address I have no idea. I will be sending it back to them stating not at this address. If it is to chase up money then I will not be paying for any of it. Further more I placed myself in potential danger acting on the Ambulance drivers questions which I reluctantly agreed to asker the person concerned.
As stated I clearly informed the Ambulance opertor on the phone I would not be paying. Whether that is recorded by the Ambulance people I don’t know (I used my mobile phone).
So are they going to try and chase the money from me if they can’t recover it from the patient concerned?
David, if the letter’s addressed to the patient then they’re not chasing you, they’re chasing him and they’ve sent it to that address as that is the only address they have. Telling the ambulance/triple zero operator you’re not going to pay the bill isn’t going to help as they will have no ‘box’ in their system to record that information. If it’s taken 3 months to get to you ambulance may have been chasing the person up at the address they gave but they can’t now be found.
Whilst it’s annoying it’s a matter or recognising large institutions have systems, and don’t cope with things outside their system. So telling the ambulance operator you won’t pay the bill is not information for their system. If AusHealth Hospitals are chasing a bill their system will try the address the patient was picked up from. They can only get money from the patient, not you so of course you don’t pay it. Do indeed send it back with ‘Not known at this address’. If you get another one you open it and get back in touch with them explain that the person is not at that address and you don’t know him or where he is and if they try again complain to the Consumer Credit Law Centre South Australia (CCLCSA).
It’s annoying but it will go away if you’re firm with them
I live in south australia, in February/ March this year my sixteen year old son who suffers from depression rang life line as he was feeling suicidal. The call centre called a ambulance unknown to us! It turned up at our home and the paramedics told both my son and us he had to come with them to hospital. I followed the ambulance to the hospital after the situation with my son was discussed I asked weather we would receive a ambulance bill. I was told by a mental health worker that ( detained) persons where covered under the mental health act.my son was not kept in overnight!We later received a ambulance bill for$1170 dollars addressed the (guardian) I would like to know first does this sound fair and legal and second can they legally charge a parent if the person is sixteen. Does as ambulance charge suicidel patients, this sounds very low if so! We have had now help or clear answers from them. This has caused us a lot of pain!
I’m afraid the answer is in the post and the other comments. No, on many counts it’s not fair but it is legal – Health Care Act 2008 (SA) s 59. Note s 59(4) says “The fee for an ambulance service is payable by the patient transported to, or from, a hospital or other place whether or not he or she consented to the provision of the service”. I suppose you could argue that as the parent you are not the ‘patient transported’ but I don’t suppose you want your son chased by debt collectors. For specific advice on what to do, contact your local community legal centre.
Hi M. Eburn, your thoughts would be much obliged,
I called 000 in suburban Vic as I was home alone, it was 4am and I needed medical advice about scary nausea and vomiting, I repeatedly said do not call an ambulance and asked if there was any other way of seeking medical advice regarding if I should go to a hospital. Call taker signed me up and put me on a waitlist to speak with a GP via teleconference (they must refer to this 24hour GP service) but it would be a 60 min wait time. I fell asleep before the teleconference with this 24 hour GP and awoke to 2 paramedics knocking on my door at 8am saying it was unresolved on their system so they were sent to check on me. They took my vitals and details and now I have been invoiced despite not authorizing any ambulance service? Can I make a VCAT claim?
I’m unable to respond at the moment (see https://australianemergencylaw.com/2024/01/22/australian-emergency-law-offline-until-february/) but I’ll get back to you on this as soon as I can.