Private health insurer in hot water

The Australian Consumer and Competition Commission (ACCC) has instituted proceedings in the Federal Court against Medibank Private Limited trading as ‘ahm Health Insurance’ (Medibank), alleging that Medibank made false representations about benefits covered by its health insurance policies, in breach of the Australian Consumer Law.

The ACCC alleges that Medibank falsely represented to members holding ahm ‘lite’ or ‘boost’ policies, who were making claims or inquiries, that they were not entitled to cover for joint investigations or reconstruction procedures, when in fact their policies covered these procedures.

ahm is Medibank Private’s low-cost brand, which currently has over 900,000 members across health, life, travel and pet insurance. In the relevant period, the ‘lite’ and ‘boost’ policies had around 130,000 members.

“We will allege that Medibank incorrectly rejected claims or eligibility inquiries from over 800 members for benefits that they were entitled to and were paying for,” ACCC chair Rod Sims said.

“As part of our case, we estimate about 60 members needlessly upgraded their policies, so they could access the joint investigation and reconstruction procedures they were already entitled to under their existing, cheaper insurance policies.

“In some cases, it is alleged that members who upgraded their policies were also required to serve a further waiting period to access these procedures,” Mr Sims said.

“Medibank’s alleged misrepresentations had serious consequences for members requiring procedures including spinal surgery, pelvic surgery, hip surgery and knee reconstructions, which often cost thousands of dollars.

“Some members were forced to delay surgery due to high out-of-pocket costs for these procedures and to seek alternative remedies to manage pain, when they were in fact entitled to insurance cover,” he said.

The ACCC’s proceedings against Medibank involve alleged misrepresentations in relation to ahm ‘lite’ policies from February 2013 to July 2018, and ahm ‘boost’ polices from February 2017 to July 2018.

Medibank self-reported this conduct to the ACCC and has begun compensating affected members. ahm members who believe they have been denied a benefit should contact ahm directly or complete a compensation form on the ahm website.

The ACCC also alleges that Medibank breached the Australian Consumer Law by failing to supply insurance cover for joint investigations and reconstructions, despite accepting payment from members for that cover.

The ACCC is seeking penalties, consumer redress, declarations, injunctions, publication orders, the implementation of a compliance program and costs.

Do you have private health insurance? Are you insured through ahm or Medibank Private? Do you fully understand what things your health policy covers or do you trust your insurer?

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