Following recent adverse publicity about Comminsure’s claims process, Bupa Australia has announced that as a result of a recent internal review, Bupa identified that 7740 rejected pre-existing condition (PEC) customer claims from the period January 2011 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 its claims process.
Bupa Australia has apologised 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.
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.
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.