Circumstances in which the conduct occurred
63 The parties jointly submit that the culpability of the Respondents in respect of the representations changed over time. SDC commenced selling SDC Aligners and operating the SDC Platform in Australia on or around 29 May 2019. It was one of the first companies in Australia to support Aligner Treatment via a teledentistry platform, and without any in person, face-to-face consultation between the consumer and the Affiliated Dentist. SDC considers this is a mitigating fact but the ACCC does not agree. Prior to commencing operations in Australia, SDC had, over the course of a number of months, conducted research into the Australian private health insurance market and made inquiries of Australian private health insurers. However, none of that research included inquiries with Australian private health insurers to confirm, nor did that research otherwise confirm, that Australian private health insurers would cover clear aligner treatment provided exclusively via a teledentistry platform without face-to-face consultations. From May 2019, the representations were made without SDC LLC or SDC AU undertaking the appropriate investigations into whether any of the costs of the SDC Aligners and Aligner Treatment would be reimbursed by private health insurers.
64 The parties jointly submit that SDC LLC and SDC AU were made aware, as time continued, that the number and proportion of claims for coverage of SDC Aligners and Aligner Treatment under private health insurance policies with "extras" coverage for orthodontia that were being rejected was increasing and that some insurers specifically stated that they would not cover SDC Aligners and Aligner Treatment, but nevertheless continued to make the representations. By at least 15 January 2020, SDC understood that Australian private health insurers generally refused claims for SDC Aligners and Aligner Treatment because this Aligner Treatment was conducted via teledentistry and not face-to-face. It can be inferred that claims previously allowed were paid inadvertently, given that the fund rules and insurance policies of the vast majority of private health insurers excluded SDC Aligners and Aligner Treatment from coverage, making SDC's misleading conduct deliberate at least from 15 January 2020. The following chronology makes this clear:
(a) By 30 August 2019, SDC was aware that the private health insurer, HCF, would not recognise SDC, or one of its four Affiliated Dentists, Dr "Affiliated Dentist A", because HCF deemed it to be an online service. SDC AU's District Manager wrote: "This is their fund rules, all PHI providers have their own rules and decide what they want to pay etc. This means at the moment any HCF customers will not be able to get quotes or claim for their treatment. It is something that the legal team could try to overcome, in my experience, health funds are not easy to deal with about things like this."
(b) By at least 8 October 2019, SDC was aware that private health insurer Medibank had identified that it was an issue that SDC's, Dr "Affiliated Dentist A" had made claims from different locations for the same day.
(c) By 4 November 2019, SDC was aware that AHM, a Medibank brand, was not accepting claims for the Product from Dr "Affiliated Dentist A", because he was not a registered orthodontist. By 15 November 2019, SDC AU's Senior Director of Retail Operations - ANZ identified "Each provider makes an individual decision on whether they will accept the coverage, and not accepting could be because they won't cover if it's not a face to face dentist visit or the customers cover doesn't cover special orthodontic, & the more SDC is known in Australia the less we can expect insurers to cover us (it is likely many of them don't realise we are not face to face)."
(d) By 15 November 2020, SDC AU's Director of Operations, ANZ replied: "We are largely seeing things knocked back […] we have no dentist on sight that they have consult with. […] PHI are very hard to move on things and to get them to change their thinking takes a long time. Could be 12-18 Months before we see any providers start to accept claims from us. The interesting thing is though. A customer could visit a Branch to claim and it might get approved as the invoice looks fine and if they don't know we are "on line" service they wouldn't question it. It's all very hit and miss."
(e) In around November 2019, SDC engaged GRA Cosway to assist SDC to encourage some of the major private health insurers in Australia to provide coverage for SDC Aligners and Aligner Treatment.
(f) On 11 December 2019, GRA Cosway wrote to, inter alia, SDC LLC's President International, saying of Medibank: "My concern is that they are treating their engagement with us at present with a compliance mindset and approach. We need to move this away from compliance into the policy space, as Medibank policy changes may be required for SDC services to be covered."
(g) By 6 January 2020, after GRA Cosway had tried to secure a meeting between SDC and Medibank, SDC LLC's President International wrote: "If we can't make Medibank work, it'd be great to get one of the other three to meet with instead." GRA Cosway responded: "I will reach out to Bupa, HCF and Australian Unity today. These will be cold calls to a degree as we don't have the same level of relationship with them as we do with Medibank."
(h) On 7 January 2020, Medibank wrote to GRA Cosway. The email said: "Currently Medibank Fund Rules require that a dental consultation and treatment needs to be in the physical presence of the patient (excerpt below). […] We continuously review our fund rules and if this position changes, we will be sure to make contact with you."
(i) On 15 January 2020, Medibank sent an email to SDC LLC's President International (the 15 January 2020 email). The 15 January 2020 email stated: "I refer you to [name withheld]'s email, dated 7 January 2020. In her response, she explained that our Fund Rules defines a dental consultation and treatment to be one which requires the provider to be in the physical presence of the patient. Further to that, part 1.4 of Australia's Health Insurance Regulations (2018) state that a practitioner's provider number is one which "identifies the person and a place where the person practises the person's profession". The purposes of the audit request is primarily to seek to understand if the treatments Dr ["Affiliated Dentist A"] has billed to Medibank meets our Recognition Criteria, Fund Rules and industry standards. This includes, treating and consulting the patient in their physical presence.
(j) By at the latest 15 January 2020, SDC knew that the position of the private health insurers representing the overwhelming majority of the market in Australia was that the Product was not claimable under private health insurance.
(k) On 22 January 2020, Mr Coglan sent an email to, inter alia, Mr Oswald, Dr Sulitzer, and Ms Peetz (the 22 January 2020 email). The 22 January 2020 email attached:
(i) a letter from Bupa to Dr "Affiliated Dentist A" dated 25 September 2019 (but only received by SDC on 14 January 2020), stating that he was in breach of Bupa's Our Ancillary Provider Terms and HICAPS Provider Agreement Terms and Conditions and that Bupa were suspending his HICAPS account; and
(ii) a letter from myOwn Health Insurance to Dr "Affiliated Dentist A" dated 14 January 2020 (the 14 January 2020 letter), stating that his provider registration did not meet myOwn's recognition criteria, because the services were not provided face-to-face and were provided "either through Tele-dentistry, provided by a Smile Direct Club staff member other than a dentist, or are performed by the members themselves with a DIY impression kit",
and stated "Find attached the letter received from Bupa and an additional letter received from a different fund this week. It is similar in nature to the Medibank approach."
(l) On 18 June 2020, the Chief Clinical Officer of SDC LLC wrote: "To the best of my knowledge, Dr ["Affiliated Dentist A"] is not contracted with any insurance company or government entity. To this point in time, we were under the impression that the dental insurance companies/trusts would not offer a benefit for teledentistry and there was no option of ortho coverage from the government."
65 The parties jointly submit that SDC made attempts to address the contravening conduct during the Relevant Period, as follows:
(a) On 13 September 2019, SDC AU recommended that SmileShop staff make the following statement to consumers when distributing a Private Health Insurance Card: "Please check with your provider on how much you can claim and if you are covered".
(b) On 24 February 2020, SDC LLC amended statements on the "FAQ" page about private health insurance, and in March 2020 SDC LLC amended statements on the "Pricing" page about private health insurance, to refer to the provision of Aligner Treatment by teledentistry. However, SDC provided item codes which encouraged consumers to make the wrong enquiry of private health insurers.
(c) At the commencement of the ACCC's investigation in May 2020, SDC AU had already ceased distributing the Private Health Insurance Cards. It had also ceased sending the Good News Emails and Good News Texts described in paragraph 47(b) above.
(d) By July 2020, SDC had decided to make changes to the language used on the SDC Website relating to private health insurance. The statements on the "Pricing" page on the SDC Website were removed on 28 July 2020.
(e) Due to an administrative oversight, SDC staff omitted to remove the statements made on the "FAQ" page on the SDC Website at that time. The statements on the "FAQ" page were not removed until 8 October 2020. At the same time, SDC ceased sending the Future Grinner Email.
66 The parties jointly submit that SDC's operations were affected by the COVID-19 pandemic as follows:
(a) Of SDC's 115 Australian staff employed in March 2020, 106 were stood down on an indefinite basis on 5 April 2020.
(b) The 9 staff still working in the business were in the following roles:
(i) Head office operations (4 people, each working reduced hours equivalent to 50% full time equivalent (FTE));
(ii) Administration and accounts (1 person, working at 100% FTE); and
(iii) Logistics and supply chain operations (4 people, 1 at 100% FTE, 3 working reduced hours equivalent to 50% FTE).
(c) The remaining staff were required to take on additional duties and were focused on supporting the business as it pivoted to addressing the effects of the COVID-19 pandemic.
(d) Not all SDC AU staff returned from being stood down in April 2020, with some staff resigning and others being made redundant.
(e) The staff who did return to SDC AU were brought back progressively over the course of the second half of 2020. For example, SDC AU's Senior Manager, Marketing and Senior Director of Retail Operations returned on 8 June 2020.
(f) SDC LLC experienced equivalent effects on its business due to the COVID-19 pandemic, with 4,215 staff furloughed from 6 April 2020, including 94 in Marketing and 9 in Leadership. The team members who remained with the business were required to take on additional duties and were focused on supporting the United States and broader global business as it pivoted to addressing the effects of the COVID-19 pandemic.
67 I accept the parties' joint submissions in respect to the circumstances in which the contravening conduct occurred.