Health insurer fined $35m 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.  The insurer copped a 35 million dollar fine from the ACC earlier this week.

Transcript

00:00This week the ACCC announced that Bupa would be getting a $35 million fine over its practices

00:09relating to mixed billing between 2018 and 2023.

00:14Essentially when patients had cover, often lower levels of cover, and they went to have

00:18surgery they would either do an eligibility check or find out after their surgery that

00:22they were having their claim denied in full.

00:25But in fact they had part of their operation covered because of their level of cover.

00:32And this was something that Bupa customers in recent months should be getting refunds

00:37for.

00:39What are patients telling the ABC about their experiences?

00:43So the period that the ACCC action is about runs up until 2023, but we had a patient get

00:49in touch with us who claims as recently as April this year they encountered something

00:54very similar.

00:56They had bronze level cover that included some cover for gynaecology.

01:01When they went to do their eligibility check were told their claim would be denied in full.

01:06It was many weeks of phoning and messaging the company and it wasn't until this particular

01:11customer took her complaint to the ombudsman that hours later her claim was approved and

01:17she could go ahead with the surgery.

01:19But in the meantime amid a cancer scare was facing a $14,000 bill.

01:25We also had a number of customers also raise concerns about claims being denied and their

01:29belief that they should have been covered.

01:32Some of these issues though aren't specific to Bupa necessarily, but certainly the response

01:37from Bupa has really angered patients when they haven't been able to get through or get

01:41correct information.

01:43Okay.

01:44What concerns do day hospitals and clinics have?

01:48So skin cancer clinics talk to us about a specific issue they've been having with skin

01:52cancer patients, especially once they've got bronze level cover which is a lower level

01:56of cover.

01:57So a lot of people think their skin cancer should be covered and under law it should.

02:02The problem happens when they need a skin graft.

02:05Now Bupa has been saying this is plastic surgery and only covered at a silver level.

02:10But in fact there is a clause in the law that says if it's to do with the skin cancer you

02:14are covered.

02:15Now Bupa said what's been happening is these claims have been automatically rejected under

02:19the computerized system and all it needs is a manual override.

02:23But the clinics told us when they then contact Bupa to get this manual override they can't get

02:28through, they're told blanket no's, they have no ability to kind of escalate this complaint.

02:34And day hospitals told us the other issue they encounter with Bupa is that when it comes

02:40to these kind of multi-layered operations where there's lots of item numbers that get billed,

02:45Bupa will only cover one, it's the most expensive one in the operation.

02:49And this is compared to other insurers who might cover two or three.

02:53And what that means for patients and hospitals is that they have to pick up the gap.

02:58So this is something that Bupa says it does, you know, on purpose it thinks that it benefits

03:05the customer and that simply all insurers do it differently.

03:10Alison, is it possible to gauge whether Bupa has more complaints than other insurers?

03:14Bupa does occupy significant market share.

03:18So across the board they have about a quarter of the health insurance market and it's much

03:23higher in some places like Queensland.

03:25When you look at their complaint numbers they sit roughly in proportion to their market share.

03:31And overall Private Health Australia says that complaints about the health insurance industry

03:35are trending down.

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