Bupa responds to ACCC action: We’re deeply sorry
Bupa Health Insurance has today apologised to affected customers for incorrectly assessing some mixed coverage and uncategorised item claims and advising some customers they would not be covered for some treatments between May 2018 and August 2023.
Bupa has reached an agreement with the ACCC on a proposed penalty of $35 million for making false or misleading representations relating to incorrectly assessing mixed coverage and uncategorised item claims and related eligibility checks. Bupa has also admitted to engaging in unconscionable conduct relating to its assessment of 388 mixed coverage claims.
Bupa APAC CEO Nick Stone said: “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. This should never have happened.
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. This should never have happened.
“Our priority has been to communicate and compensate our affected health insurance customers and providers, along with putting in place measures to help ensure this does not happen again,” Mr Stone said.
Mr Stone said Bupa had already begun compensating affected customers and providers, including interest and customer goodwill payments. To date, Bupa has paid a total of $14.3 million for around 4,100 affected claims and eligibility checks.
The ACCC’s action relates to Bupa contravening Australian Consumer Law for incorrectly assessing, in some instances, two sub-categories of hospital and medical claims - ‘mixed coverage’ and ‘uncategorised items’ - and related eligibility checks.
A mixed coverage claim includes both treatment that is covered under a customer’s policy and treatment that is not covered under their policy. Uncategorised item claims include at least one item for which a member was eligible for benefits under their policy and at least one item which was not linked to a clinical category in Bupa’s system.
“We take great pride in being trusted by our 4.4 million health insurance customers and we know that in this instance we did not meet the standards that our customers, providers and people expect of us,” Mr Stone said.
Bupa pays out about 20 million customer claims every year, including six million hospital and medical claims. Mr Stone said while the mixed coverage claims relating to this matter represent less than 0.02% of all hospital and medical claims that were assessed between May 2018 and August 2023, and uncategorised item claims represent less than 0.004% of claims, we didn’t get this right.
“We know this isn’t good enough and we’re committed to doing better. This doesn’t reflect the hard work our people put in every day to support our customers and meet their healthcare needs.
Mr Stone said these errors occurred as a result of inaccurate or unclear instructions, training or guidance which meant Bupa didn’t always make correct assessments of these claims and eligibility checks or act quickly enough to fix these issues.
“That’s why our team has been focused on fixing these issues including making changes to the way we work and improving our systems and processes to help ensure this doesn’t happen again,” Mr Stone said.
Actions we are taking include:
- Resolving system issues and how we process claims.
- Establishing a dedicated team that has manually reviewed almost 20,000 historical mixed coverage and uncategorised item claims to ensure they were assessed and paid correctly.
- Introducing manual assessments in circumstances where automation is not suitable.
- Improving education and training for our customer-facing teams, and
- Strengthening our governance and internal processes.
As part of our commitment to ensure all eligible, affected customers have been identified and compensated, we are asking health insurance customers and providers to contact us if they believe they may have had a mixed coverage claim, eligibility check, or uncategorised item claim incorrectly assessed between 1 May 2018 and 31 August 2023.
To request a review of a historical claim or eligibility check, customers and providers can visit our website here, call us on 134 135, or visit us in one of our stores and a member of our team will help support their enquiry and if needed, pass their case to our specialist team.
Bupa has continued to cooperate with the ACCC throughout this process agreeing with the ACCC to jointly propose to the Federal Court a penalty of $35 million and an Enforceable Undertaking to continue our work to compensate affected customers and providers.
The settlement will be considered by the Federal Court for approval, and we will continue to communicate with affected customers and providers throughout this process.
