Bupa, Australia’s second-largest private health insurer Bupa, is in the hot seat. The Australian Competition and Consumer Commission (ACCC) has docked the company a record $35 million for illegally denying thousands of claims from May 2018 to August 2023. Public policy holders are enraged. They’ve had to pay huge out-of-pocket costs after their claims for necessary medical services—such as heart surgery or sarcoma removal surgeries—were declined.
Anderson, who in 2022 felt firsthand the painful effects of Bupa’s claim denial. He eventually received a stunning $48,000 charge for triple bypass heart surgery. Bupa at first denied his legitimate claim. This occurred even though three of his treating physicians had confirmed that he was symptom-free at the time he bought the policy. The situation highlights serious concerns regarding Bupa’s claim assessment processes and the impact on patients’ financial burdens.
For Tara Manning, who had a bronze-level policy with Bupa, she was in the same boat. She was hit with a surprise $14,000 surgery bill. Within hours of her escalating her complaint to the Commonwealth Ombudsman, the surgery was approved. Manning called her experience “absolutely harrowing,” citing hours-long wait times just to reach someone at Bupa to help her.
Regulatory Actions and Financial Penalties
The ACCC’s recent actions against Bupa stem from an investigation that revealed systemic issues within the company’s claims processing system. Their unlawful rejection of many claims placed a tremendous financial burden on those policyholders affected, as discovered by the commission.
Bupa processes over six million hospital and medical claims every year. While the majority of these claims are evaluated and reimbursed without issue, the cases of some publicized denials have raised alarms about the giant insurer’s practices.
A spokesperson for Bupa addressed the concerns, stating, “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.” Critics say these assurances come too little, too late. Others have lived through months of financial strain due to wrongful claim denials.
Policy Limitations and Coverage Confusion
Bupa’s policies are unclear on their level of coverage, leading to widespread confusion amongst its members. As an example, plastic surgery is only paid for under silver policies, leaving patients with bronze-level coverage with high out-of-pocket costs. For Manning, her bronze-level policy did not pay for the procedure she needed, leaving her with a significant and unexpected out-of-pocket expense.
Jane Griffiths, the CEO of Day Hospitals Australia, made one of the most salient points. She highlighted that private health legislation requires that plastic surgery, which is a form of skin surgery, be covered at bronze level with Bupa. She then addressed the issues with patient confusion, calling for more transparency, particularly from insurance companies, to reduce ambiguity in insurance policies. “It is a real problem and it’s very confusing,” Griffiths remarked, noting that many patients struggle to understand their coverage options.
Moreover, Griffiths highlighted the limitations of private health insurance legislation, stating, “What private health insurers can cover is limited by private health insurance legislation.” Patients who require multiple different treatments each pose a greater burden. Yet, they have to first swim through a dense thicket of policy barriers.
Ongoing Issues and Patient Experiences
Even with these regulatory measures brought against Bupa, questions remain about if and when Bupa’s bad behavior will stop. Tara Manning’s experience in April 2025 should remind all of us that not every policyholder is out of the woods just yet. Bupa and the federal government first rejected her claim because they had deemed part of the procedure as “digestive.” This idealized scenario shows just part of the broken nature of claim classifications.
David Anderson’s story puts an important human face on the emotional toll these experiences can have on patients. He recalled being in peak physical condition just two months before his heart diagnosis: “I had climbed a mountain in Canada two months prior to diagnosis.” His story is a powerful reminder that sudden acute health issues can impose catastrophic financial burdens both when claims are wrongfully denied by insurers.
Griffiths further highlighted the harm that these blanket denials cause to both providers and patients. “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,” she stated, emphasizing the inefficiencies created by current insurance practices.
