Page last updated: 11 December 2025
As previously announced on the 30 June 2025, Bupa reached an agreement with the Australian Competition and Consumer Commission (ACCC) and had jointly agreed a proposed penalty of $35 million for contraventions of the Australian Consumer Law. The Court has now approved the orders including an agreed $35 million penalty.
Bupa incorrectly rejected some mixed coverage claims and advised some health insurance customers that they would not be covered for their mixed coverage treatment, when in fact their hospital policy did cover one or more parts of their treatment.
Bupa also wrongly rejected some uncategorised item claims – claims that include at least one treatment that had a Medicare Benefits Schedule (MBS) item number, or hospital clinical code, that did not map to a standard clinical category in our claims assessment systems.
We're deeply sorry for our failure to get this right in these instances and we are saddened by any impact this may have had on our affected customers and their families. We also regret any impact this has had on our health insurance provider community.
You can view Bupa's updated media statement.
We want to reassure customers and providers that we are committed to ensuring they get the right advice and the benefits to which they are entitled. We are continuing to take steps to understand and fix the issue including making changes to the way we work, and improving our processes to help ensure that we're correctly assessing mixed coverage and uncategorised item claims and eligibility checks. We are continuing to work hard to protect and strengthen our operations.
Bupa pays out about 20 million claims (including six million hospital and medical claims) every year. In the vast majority of cases, we get things right. In this instance, we did not and we know this is unacceptable. We're committed to doing better.
As part of our commitment to ensure all eligible, affected health insurance customers and providers are compensated, we are asking Bupa customers and providers who have not already been contacted by Bupa to contact us if they believe an eligibility check or claim for hospital or medical benefits was incorrectly assessed between 1 May 2018 and 31 August 2023, and we will review their case.
If you have any questions about this matter, or believe you, or someone you know, may have had a mixed coverage or uncategorised item claim or related eligibility check incorrectly rejected between 1 May 2018 and 31 August 2023, please visit our website at www.bupa.com.au/mixedcoverage to submit a review request, call 134 135, or visit us in store, and we'll check if it was assessed correctly.
A mixed coverage claim includes treatment covered under the customer’s policy (covered treatment) and treatment that is not covered under the customer’s policy (excluded treatment).
Example:
Mary’s ankle replacement
Mary has a painful ankle and lower leg that isn’t straight. Mary’s doctor has recommended that she has an ankle replacement as well as an operation on the bone in the lower leg to correct it, known as an osteotomy.
Mary has Silver tier health insurance cover, so she is covered for the osteotomy, however, she isn’t covered for joint replacement, as this falls under the Gold tier cover. This means her private hospital policy will cover the osteotomy to straighten the lower leg, but not the ankle replacement – advice shared with Mary as part of the informed financial consent process ahead of undertaking her surgery. This means, if Mary elects to proceed with the surgery, Mary will be responsible for the additional expenses related to surgical replacement of her ankle joint. This would result in Mary or her provider submitting a mixed coverage claim to Mary’s private health insurer.
This example is for illustrative purposes only. You can find out more on our website about which clinical categories are included in each tier of health insurance products.
An uncategorised item claim is a claim that included at least one treatment that had a Medicare Benefits Schedule (MBS) item number, or hospital clinical code, that did not map to a standard clinical category in our claims assessment systems. Pre-defined clinical categories form the basis of each tier of Australian private health insurance hospital cover.
Example:
During an admission to hospital Gemma had a CT scan on her right knee. CT scans are categorised as 'Support List' services and are not mapped to any specific clinical category in Bupa's automatic assessment system. As a result, when Gemma's doctor submitted the claim, Bupa's automatic claims system incorrectly deemed the CT scan to be excluded treatment under her policy, which caused the entire claim to be rejected.
This example is for illustrative purposes only. You can find out more on our website about which clinical categories are included in each tier of health insurance products.
An eligibility check is when a customer or someone acting on their behalf enquires about eligibility for benefits regarding a potential claim, before the customer receives treatment.
The ACCC action relates to the assessment of some mixed coverage and uncategorised item claims, and mixed coverage eligibility checks undertaken between 1 May 2018 and 31 August 2023.
Bupa received about 34 million hospital and medical claims between May 2018 and August 2023. Less than 0.02% were affected mixed coverage claims and less than 0.004% were affected uncategorised item claims. While in the vast majority of cases, we get things right, in these instances we did not. We know this is not good enough and we’re committed to doing better.
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.
If a customer has already been contacted by Bupa relating to an incorrectly rejected uncategorised item or mixed coverage claim or eligibility check, we would like to reassure them that they do not need to take any further action. However, should customers have any concerns or questions, our team is available to assist.
We encourage you to contact us if you have concerns about a claim or eligibility check related to this matter.
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Contracted private hospitals can raise a query via their contract manager.
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Non-contracted hospitals and medical providers can contact our Provider Operations team on 1800 060 239.
Please speak with your Bupa partnership manager to understand how you can support your employees and/or clients.
Bupa policy holders can contact our customer team directly should they wish to enquire about a past claim or eligibility check. Specifically, if the enquiry relates to:
- A mixed coverage treatment or uncategorised item claim; whereby
- The treatment took place or would have taken place between 1 May 2018 and 31 August 2023; and
- The customer held Bupa hospital cover at the time they had, or were going to have their treatment.
No, this only impacts a subset of hospital and medical claims related to a hospital admission, and related eligibility checks, between 1 May 2018 and 31 August 2023.
Bupa Australia has already compensated almost all our impacted customers, and as of November 5, 2025, we have paid back a total of $14.3 million.
As part of our commitment to ensure all eligible, affected health insurance customers and providers are compensated, we are asking Bupa customers and providers who have not already been contacted by Bupa to contact us if they believe an eligibility check or claim for hospital or medical benefits was incorrectly assessed between 1 May 2018 and 31 August 2023, and we will review their case.
If a customer has already been contacted by Bupa relating to an incorrectly rejected uncategorised item or mixed coverage claim or eligibility check, we would like to reassure them that they do not need to take any further action. However, should customers have any concerns or questions, our team is available to assist.
If you believe your enquiry was for a mixed coverage or uncategorised item treatment between 1 May 2018 to 31 August 2023, or if you are unsure and would like our team to check on your behalf, please submit an online enquiry or call 134 135 or visit a Bupa health insurance store to discuss your situation with a member of our team.
We are committed to ensuring all affected customers and providers are identified and compensated as appropriate.
You will be contacted within 10 business days from submitting your enquiry with an update or an outcome. While you wait, if you are a current Bupa health insurance customer, please check that your details are up to date in myBupa.
We have a dedicated team reviewing and investigating each enquiry to ensure that any affected customers and providers are identified and compensated.
Bupa is providing a free, confidential counselling service for affected customers, and anyone supporting them, including family, friends and carers. Provided by Procare, an independent third-party, customers can access up to six sessions of confidential psychological support, at no cost.
The penalty is paid to the Australian Government as a legal sanction. It is not paid to the Australian Competition and Consumer Commission (ACCC) or to customers. Once received, the Government uses the funds as part of the Consolidated Revenue Fund to support public services and programs, rather than being tied to the specific case. The fine is separate from compensation paid to affected customers and providers.