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Health insurer Bupa has been fined for unconcionable conduct including the rejection of hospital treatment claims that were in fact covered in members' policies, with an investigation from the consumer watchdog unveiling thousands of cases of misrepresentations of member benefit entitlements over five years.
Bupa HI Pty Ltd has been ordered by the Federal Court to pay $35 million in penalties over such practices, concluding that between May 2018 and August 2023 the company engaged in misleading or deceptive conduct and representations.
The company did so by telling members they weren't entitled to benefits for any part of a claim when, to the contrary, these members were entitled to benefits for any treatment covered under their policy.
The court also declared that Bupa engaged in unconscionable conduct between June 2020 and February 2021 in connection with its incorrect assessment of some mixed coverage claims.
Most of the claims impacted by Bupa’s conduct were for hospital treatment in which two or more procedures were performed at the same time. In cases where part of the treatment was covered by a member’s policy and part of the treatment was not covered, Bupa incorrectly rejected the entire claim.
Bupa cooperated with the Australian Competition and Consumer Commission (ACCC) during its investigation and agreed to make joint submissions with the ACCC to the court about proposed orders, including in relation to liability and penalties.
"Bupa’s conduct impacted thousands of consumers. During our investigation we heard from Bupa members who suffered significant harm, including financial harm as well as pain, suffering and emotional distress as a result of Bupa’s conduct," says ACCC Deputy Chair Catriona Lowe.
"Some of Bupa’s members decided to cancel, delay or forego necessary treatment, resulting in potential medical risks or complications, because they were incorrectly told they were not entitled to health insurance benefits.
"Private health insurance can be a significant expense for consumers and people rightly expect to receive the level of coverage they pay for."
Medical providers and hospitals were also impacted by Bupa’s conduct, including by not receiving the payments they were entitled to in respect of certain members’ claims.
In addition to the $35 million in penalties, the court also ordered an injunction restraining Bupa from engaging in the contravening conduct for a period of five years.
"We consider this to be extremely serious conduct, and this is reflected in Bupa’s admission that it engaged in unconscionable conduct, which is one of the most serious types of misconduct under the consumer laws that we enforce," Lowe says.
"Today’s outcome should serve as a reminder to all health insurers of their obligations under the Australian Consumer Law, including that they must ensure that claims are assessed correctly so that their members receive the benefits they are entitled to under their policies."
In June this year, Bupa provided the ACCC with a court enforceable undertaking to complete its remediation program to compensate affected members, hospitals and medical providers by Bupa’s misconduct. This includes compensation for the amount the member was entitled to but did not receive, plus interest.
Bupa commenced the remediation program prior to this court action. To date, more than $14.3 million has been paid to parties for more than 4,100 affected claims - almost all the impacted customers, according to the insurer.
"We remain deeply sorry for these errors and have apologised to our affected customers for the impact this has had on them and their families and have taken actions to ensure this doesn’t occur again," Bupa wrote in a statement today.
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