Health insurer fined $35 million by ACCC for unlawfully rejecting claims

ABC NEWS (Australia)

Health insurer Bupa is being accused of denying legitimate claims, as well as problematic billing practices as it faces ongoing scrutiny by the competition watchdog. The insurer copped a 35 million dollar fine from the ACCC earlier this week for denying claims when customers' policies covered part of the procedure. Since then, the ABC has been contacted by Bupa customers as well as clinics and hospitals from around the country with concerns about the corporate giant.

Transcript

00:00So earlier this week, the ACCC announced that between 2018 and 2023, Bupa had been incorrectly

00:09dealing with mixed billing claims. So when you have a surgery, sometimes there can be

00:13a number of items that make up that surgery. And what was happening for patients, particularly

00:18if they had lower cover, was that where the systems said that one item wasn't covered,

00:24it was rejecting the claim in full. The ACCC said that the claims should have been paid

00:28at least in part. And a lot of Bupa customers over recent months would have been getting

00:34refunds because they should have been refunded, refunded their claim at the time.

00:39What are patients telling us about their experiences?

00:43So this ACCC action goes up to the point of 2023. But a patient got in touch with us to

00:49say as recently as April this year, she had bronze level cover for gynaecology in her cover.

00:56She needed to get investigative laparoscopy for a possible ovarian cancer.

01:02It was again a multi-part procedure. There was one item that wasn't covered.

01:07Bupa rejected the claim in full initially at the eligibility check stage.

01:12So with this surgery looming, she made lots of phone calls and contacts with Bupa trying

01:18to get the issue resolved. But it wasn't until hours after she went to the ombudsman that the

01:22claim was approved and would be paid. Now we're also hearing that day hospitals and clinics are

01:28also raising some concerns. Yeah, so a particular problem has emerged around bronze cover patients

01:35who need skin cancers done. Often skin cancer patients might need a skin graft or a flap of

01:41some sort. And what's been happening is Bupa's claims processes have said that these claims would

01:46be denied because only silver patients have plastic surgery cover. But in fact, when you get into the

01:51detail of the law, they are covered because it's a skin cancer treatment. Now Bupa says that this is

01:58an automated billing issue. It just needs a manual override. But clinics told us when they get in touch

02:03with Bupa, they get stonewalled. They can't escalate the issue. The staff don't know what's going on.

02:08Secondly, the other issue is that day hospitals said to us that Bupa will only cover the first most

02:17expensive item. And this means that patients and hospitals have to pick up the bill for the rest.

02:22Now this is compared to other insurers that might cover two or more procedures.

02:27What does Bupa have to say about all of this? Does it have any more complaints than other insurers?

02:32Well, Bupa has apologised regarding the ACCC action. It says it deals with six million

02:39complaints a year, most of them dealt with without issue. When you look at their complaints to the

02:44private health ombudsman, it's roughly on par with their market share, which is about 25%.

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