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.