Bupa apologises to customers for incorrect process

Bupa Australia has today apologised to some of its private health insurance customers for using an incorrect assessment process when reviewing cases involving pre-existing medical conditions.

A pre-existing condition (PEC) is any ailment, illness or condition that a customer had signs or symptoms of during the six months before they joined Bupa as a member or upgraded their level of cover, as determined by a company-appointed medical practitioner.

During a recent internal review, Bupa identified that some customer claims from January 2011 through to May 2016 had been rejected by company claims assessors without review by a Bupa-appointed doctor. Medical review of pre-existing conditions is required as part of this process.

Bupa now has a new team of doctors looking at all 7740 rejected PEC customer claims from the relevant period and is writing to all potentially affected customers to advise that their cases are being reviewed. Where cases have been incorrectly assessed, the customer will be appropriately reimbursed.

Managing Director of Bupa Health Insurance Dr Dwayne Crombie said the company had investigated how the process breakdown occurred and was now introducing new measures to address it.

"We apologise unreservedly to any of our customers whose claims turn out to have been rejected in error. There has been a breakdown in process which we are now remedying. We will reimburse promptly anyone whose claim was rejected wrongly," Dr Crombie said.

"We strive to provide high quality and responsive services to support the health and care needs of our customers.

"Unfortunately, a recent internal review showed that we fell short of the high standards that we set, and this may have had an impact on certain customer claims applications.

"We are treating this matter with the utmost seriousness. It has resulted in considerable reflection and review within Bupa and we have worked to put better practices in place for our customers. Our new panel of medical practitioners will complete their assessments as quickly as possible.

Process improvements Bupa is undertaking include:

  • Improved policy and documentation management of claims involving pre-existing conditions;
  • Tailored compliance training for relevant staff; and
  • New leadership and organisational structure for the pre-existing condition assessment team, as well as new and increased resourcing of the medical review function. There will also be new quality assurance roles added to this area and the supporting functions.

"In the best interests of our customers, Bupa will ensure there is a new medical review of each case. Where claims have been incorrectly assessed, we will fully reimburse our customers for their wrongly rejected claims. We will be informing customers individually as we review their cases over the next few months," Dr Crombie added.

"Based on the new medical reviews conducted so far, it appears that in the vast majority of cases, the original determination has been correct – the error was that some cases were not reviewed by a medical practitioner.

"We recognise that people may have queries about how this matter relates to their own individual circumstance and as such, we’ve established a dedicated number for them to call."

Customers with queries about this matter are advised to phone 1300 510 736 or email Hospital.Review.AUS@bupa.com.au.