Bupa Customers Frustrated by Denied Health Claims

Health insurer Bupa has been accused of ongoing unscrupulous behaviour towards its customers amid legal action by the competition watchdog.

ABC News has been contacted by patients and medical practices from around the country concerned legitimate claims were denied.

Concerns were also raised about poor communication with patients, problematic billing practices, and lack of education among Bupa staff.

Earlier this week, the health insurer was fined $35 million by the Australian Competition and Consumer Commission for unlawfully rejecting thousands of claims between May 2018 and August 2023.

Bupa rejected claims in full when only part of a procedure was not covered.

The insurer admitted to engaging in misleading or deceptive conduct.

But Brisbane woman Tara Manning says she believes poor conduct has not stopped after she experienced difficulty with a claim in April 2025 — about 18 months after the period dealt with by the ACCC.

She said Bupa tried to reject a claim for laparoscopic surgery to investigate possible ovarian cancer when she went through the pre-surgery eligibility check.

The mother-of-two had bronze-level cover that included cover for gynaecological surgery. But because one part of the procedure was deemed "digestive" by the insurer and the government, the claim was initially rejected in full.

Facing a $14,000 bill, Ms Manning spent weeks calling and messaging BUPA ahead of her surgery and only had her claim approved hours after she submitted a complaint to the Commonwealth Ombudsman.

"It was an incredibly stressful time trying to get a hold of Bupa with wait times on the phone over an hour," she said.

"I was told very mixed opinions throughout the whole process.

"I think that behaviour has been really appalling."

Bupa said it could not comment on individual cases.

It said the ACCC case related to errors that occurred because of inaccurate or unclear instructions, training or guidance which meant Bupa did not always make correct assessments of these claims and eligibility checks or act quickly enough to fix these issues.

"We are deeply sorry for our failure to get this right in these instances. We know this isn’t good enough and we’re committed to doing better."

Skin cancer patients facing out-of-pocket expenses despite cover

Plastic surgery clinics also said their bronze cover patients were repeatedly having problems with Bupa when it came to skin cancer removals.

When patients needed a cancer surgically removed, they sometimes required a small skin graft or flap to cover the wound which Bupa deemed to be plastic surgery.

Plastic surgery was only covered under silver policies, leaving patients with out-of-pocket expenses of up to $4,500.

Jane Griffiths, chief executive officer of peak group Day Hospitals Australia, said private health legislation stated that plastic surgery related to skin surgery was, in fact, covered at bronze level.

She said their members regularly experienced this from Bupa.

"You can’t leave a patient without a closed skin lesion," she said.

Bupa said this was an industry-wide problem to do with automated billing and patients needed manual overrides.

It was raised with the federal government in 2021 but recommendations for reform were yet to be implemented.

In response, medical practices told ABC News other insurers had better processes to override the problem, whereas poorly trained Bupa staff would meet requests for overrides with "a blanket no" and the inability to escalate the issue.

Many patients were also unaware of the issue and simply paid the gap, the medical practices said.

"We are working with hospitals and medical practices to make this process smoother," a Bupa spokesperson said.

Bupa also refused to cover more than one surgical billing item a day, while other insurers would cover two or three, Ms Griffiths said.

This could be a problem for several types of procedures, including ophthalmology and chemotherapy which involved more than one element, and especially for skin cancers.

"If the patient needs to be covered for [multiple cancers], you would have to keep bringing the patient in multiple times which of course is not desirable for the patient or for the surgeon," Ms Griffiths said.

"It is a real problem and it’s very confusing."

Bupa said different health insurers took different approaches to funding same-day procedures.

Bupa is Australia’s second largest private health insurer.

Figures from the Commonwealth Ombudsman show 2024 complaint numbers were largely in proportion to its market share.

Patient should have declared ‘sign’ of heart disease

Queensland man David Anderson said he was left with a $48,000 bill for triple bypass heart surgery in 2022 after Bupa denied his claim.

He said the insurer delved into his medical records and discovered what it deemed a "sign" of heart disease and claimed it was a pre-existing condition.

That was despite three of his treating doctors signing statutory declarations that he was symptom-free prior to taking out the policy.

"I had climbed a mountain in Canada two months prior to diagnosis," he said.

Bupa declined to comment on individual cases but said under law those with pre-existing conditions were not covered even if it was discovered after a policy was taken out and the patient was symptom-free.

"What private health insurers can cover is limited by private health insurance legislation."

Bupa’s market power makes it hard for small operators

Ms Griffiths said day hospital operators had a lot of difficulties with Bupa compared to other insurers and "to some extent" they were abusing their market power.

She said Bupa was difficult to deal with in negotiations for their contracts with private hospitals.

"From the feedback I’ve had from members, a lot of them have difficulty — particularly very small, specialised units," she said.

"They have difficulty negotiating a reasonable indexation at the end of each contract."

Bupa said its main aim was a sustainable network across Australia.

"Bupa has an extensive private hospital network, and our relationships and commercial arrangements with hospital operators are both fair and equitable.

"Bupa is working closely with our hospital provider partners reach agreements that balance the needs of hospitals, while keeping health insurance affordable for our customers."

The company said it processed about six million hospital and medical claims each year and the overwhelming majority are assessed and paid without issue.

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