How Bupa Health Insurance 'Duped' Thousands Over Medical Claims – Were You Affected?

Bupa, one of Australia's largest private health insurers with over 4 million members, has admitted to misleading thousands of customers over their private health coverage, incorrectly rejecting medical claims and leaving many policyholders thousands of dollars out of pocket.

According to reports, the Australian Competition and Consumer Commission (ACCC) found Bupa's conduct deeply affected thousands of members between 2018 and 2023, prompting the company to agree to pay a $35 million penalty.

Reports suggest that some members paid for treatments themselves after being wrongly told they weren't covered, while others upgraded to more expensive policies unnecessarily. In more serious cases, some patients delayed or even cancelled vital medical procedures, risking complications and prolonged health issues.

CEO Nick Stone Expresses Regret

Bupa acknowledged the failings on their side and has begun compensating customers, hospitals and medical providers. So far, it has returned over $14.3 million related to more than 4,100 affected claims.

'This should never have happened,' said Bupa APAC CEO Nick Stone. 'We are deeply sorry for failing to get things right for our customers and are saddened by the impact this has had on them and their families.'

Stone also added that the company had prioritised communication and compensation for those affected, and has introduced measures to prevent similar mistakes in future.

The Nature of the Error Explained

The ACCC revealed the issue centred on 'mixed-coverage' claims, situations where a patient's policy only partially covered the procedures they were receiving. However, rather than assessing these correctly, what Bupa did was that they often rejected the entire claim, even though members were entitled to partial reimbursement.

These mistakes occurred both before treatments, when customers were checking their eligibility, and afterwards, during the claims process. According to the watchdog, these errors were caused by poor training, unclear internal guidance, and a failure to review complex claims manually.

'Bupa's conduct is very serious and fell well short of what is expected of one of the largest health insurers in Australia,' said ACCC Chair Gina Cass-Gottlieb. 'It caused harm to consumers, some of whom delayed, cancelled or went without treatment for which they were, at least partially, covered.'

Medical Oversight History Dates Back to 2016

This isn't the first time Bupa has come under fire over its claims processes. According to a report by The Guardian, in 2016, the private insurer admitted to rejecting thousands of claims without proper medical oversight, in some cases falsely telling customers that a doctor had assessed the decision.

Although the company detected and reported those earlier failings itself, records revealed that concerns had been raised by the Commonwealth Ombudsman as early as 2014. An investigation into the full scope of those problems never took place.

Since then, Bupa claims it has overhauled its processes, increased staff training, and improved compliance systems. A spokesperson then said the company had taken the issue seriously and was committed to complete transparency with regulators.

Government and Industry Reaction

The case has drawn sharp criticism from across the board, including from Australian Health Minister Mark Butler, who called Bupa's actions 'deliberate' and 'unacceptable.'

'Australians pay their hard-earned money to private health insurance providers and they deserve better,' he said. 'The $35 million penalty reflects Bupa deliberately misled and ripped off their customers.'

Meanwhile, Private Healthcare Australia, the industry's peak body, urged Bupa to continue working to resolve the matter fully and rebuild trust with its members.

What You Can Do

In a step towards helping the affected policyholders, Bupa has launched a dedicated webpage 'www.bupa.com.au/mixedcoverage' for customers who believe their claims may have been incorrectly assessed. Affected members can also contact Bupa directly on 134 135.

According to reports, the ACCC has accepted an undertaking from Bupa to continue compensating impacted customers and providers, with more refunds expected as investigations continue.

While Bupa moves forward with its remediation efforts, for many customers, rebuilding trust may take much longer than receiving financial compensation.