BUPA insurance - help needed to make a complaint please

[Follycastle]

I’m trying to make a complaint against BUPA and would love some help please.

I have a policy with my employer, for which I get two allowances, one for mental health and one for outpatients.

Earlier this year I had some mental health treatment authorised. I was told that if I exceeded my MH allowance, I could use the outpatient one. I’m sure I asked at this point whether I would be told if one had been exceeded but I don’t honestly remember (my MH was in the toilet, so not a great time to remember that sort of thing).

I didn’t really give any of it another thought until a claim advice landed this morning (three weeks after date of letter due to strikes) which says I owe the provider of my treatment over £200 as my allowances have been exceeded. I have had further treatment since because I didn’t know I’d exceeded, which will mean I will end up owing them over £400

I’ve queried and they won’t budge, but my point of complaint is that this is a huge lack of transparency/communication from them. In none of my communications from them over the course of the last few months (and I’ve had regular claim advices) have they included a “remaining balance” or similar, they didn’t consider alternative communication during the postal strike (eg text or email) which could have at least prevented me getting further treatment that I’d have to pay full price for. When I raised this over the phone they said they expect their customers to know whether they are close to their allowance and couldn’t remind customers.

I am scouring the FCA Insurance: Conduct of Business Sourcebook in the hope I can throw the rule book at them, but can any knowledgeable mumsnetters help me out? I work in a similar industry and this just feels wrong to me.

Sorry but I don’t think you’ll have much luck. They’ve advised you of your benefit when you authorised the treatment and it’s your responsibility to manage your treatment and stay within that limit. You can still make a formal complaint to them and they’ll have 8 weeks to investigate and issue a final decision before you can go to FOS.

“When I raised this over the phone they said they expect their customers to know whether they are close to their allowance and couldn’t remind customers.”

I agree with Bupa. Grown adults don’t need constant balance reminders.

I also think it’s your responsibility to know the limits.

I used to work for a different health insurer and dealt with complaints. You can raise an official complaint with them and ask that the original preauthorisation calls be listened to. All will become clear what you were told at the time then and you can make a decision wether to approach financial ombudsman with the complaint. You can't go to FO first without having exhausted BUPAs complaints procedure.

If that is indeed true that you were told you could use the O/P limit if the MH one exceeded then surely they can just transfer the invoice across and pay out of that benefit. You would need to ascertain if that was what was definitely said to you at time of preauth as that seems to be the sticking point. They definitely wouldn't seek you out specifically to let you know you were nearing the limit but you should get sent something like a benefit statement after each claim is paid out showing how much of your allowance had been used.

I used to work for them. The policies are quite clear and it is up to you to check how much your treatment has cost to date.
You also have the option of ringing them at any time during the treatment to ask how much has been spent to date and how much is left.
They have too many customers to police how much people have spent so far and how much is left, it just isn't possible.
You won't get anywhere with this.

Okay, you do know this isn’t AIBU don’t you? Whilst everyone has made the same point, there really isn’t any need to take that tone with me. Did you see the bit about my MH? I know this is mumsnet and everything but really, I’m facing a bill of hundreds for a genuine mistake and, despite what you think, am a “grown adult”. Can you please show some kindness?

The FCA disagree with this and expect insurers to provide reminders during calls and written responses.

OP, write in with your complaint rather than call.

Failed... the first part was in response to drpet

They have too many customers to police how much people have spent so far and how much is left, it just isn't possible.

of course it’s possible - they’re not sitting there with pen and paper working it all out. Their system is undoubtedly perfectly capable of totting up the amount paid vs the amount of benefit and printing it on each letter. If it can’t do something that simple then their system isn’t for for purpose.

besides if it couldn’t keep a tally of the claim, how would they know when each customer had exceeded their limit?

Thanks everyone else for the help. I have had several months of treatment every week. In hindsight I should have… kept a spreadsheet or something? Do people really do that?

I am usually a pretty switched on person (particularly when my MH is good). I can’t have been the only one caught out by this and I guess I thought the FCA would have some protections in place for consumers which mean insurers have to be more transparent.

I don’t think it would actually be difficult for them to include a balance on each claim advice? I mean, that is information they must be tracking themselves so I do think it’s something they should do to protect consumers.

I think I’ve worked with consumer regulation for too long!

When I phoned they said I would have been told my balance when further treatment was authorised in August but I pointed out that I didn’t speak to them for that authorisation, it was my treatment provider who contacted BUPA.

I have had numerous letters though. None of which mentioned it.

Of course it’s not you op I work for an insurance company and I would expect them to tell where your balance is for that claim.

can you request they listen to the call where they said your outpatient balance would be carried over?

Sorry just realised I was really unclear on this. Apparently I’ve used both allowances. What I meant was I thought I checked they’d tell me whether the first had been exceeded. Seemingly I wasn’t told about the first or the second!

My plan for the complaint is to:

put it in writing
ask for the calls to be listened to
ask for their policy on transparency/communication
cite which FCA regs apply (if any)
ask if alternative communications for claims advices have been considered for the strike (which would at least have led to me knowing sooner that my allowances were gone, therefore my liability would be a lot smaller)

I know many people think I’ve got no chance but I’m still going to give it a go, if nothing else to give them some feedback to protect others in the future. It’s not a small amount of money I now owe, and this close to Christmas and with the cost of living being what it is, this one really hurts.

fingers crossed you get a positive response from them - I don’t know if they’ll be affected by the consumer duty changes coming up but they could be worth mentioning.

Oh in that case probably not much of a chance but really you should raise with them that their claim advice/benefit statement letters should really have notifications on how much o/p you have left. I believe ours do and I work for a different health insurer.

I am with Bupa (Global - the international branch). I don't personally think you will have any luck because the limits were set out clearly when you took out the policy. I have similar - I presume - limits and my doctors have written asking if I could have extra physio/osteopathy sessions and they've always said no. I have four long-term issues that I need physio for and only 30 sessions a year! I think it's especially a shame that they didn't increase these a couple of years ago when they increased the MH appointments.

Iff you argue you should have been kept up to date, they may say they don't that any more (they used to) because claims are being processed all the time and they can't tell how many sessions have been used because they might be waiting for claims to be processed. (Also all claims are treated individually and they don't look at the rest of your file when assessing them.)

I think you might get an 'ex gratia' payment out of them if they said you could use your outpatient allowance and then changed their mind - because that's clearly something they did. (I have never been able to use outpatient appointments for anything else... I should try it. I have MH and physio appointments up to the limit but never use all my dr appointments or other outpatient treatments.

I'm not unsympathetic to your problem, I just find Bupa very inflexible when it comes to paying for 'extras'.

im with BUPA through my employer too and have been using it for MH therapy for DD.
i use their online portal and it clearly shows on there how much they have paid out so its easy to know how much is left

I’ve just remembered I’m also covered by my husband’s policy, also with them. Perhaps they can settle the balance out of that allowance. That’s what I’ll try.

Raise a complaint with them. You can do it over the phone or email. They'll do a full investigation which will include listening to all calls and checking the preauths and contact history, and it will be done impartially. This is my job. If a mistake has been made, it'll be put right. You're likely to get a full response within 4 weeks. Raise it ASAP as January is an insane month.

I don't know any insurers where you are allowed to be doubly covered. If you bring it to their attention I imagine they will ask you to choose a policy to remain on and cancel the other one.

Don't waste your time quoting FCA source books that you don't understand, it will add nothing to your complaint whatsoever

Stick to the facts and tell then what outcome you would like

If you've 2 policies, it may provide cover. Email [email protected] to log your complaint. Means you don't have to faff about speaking to front line advisers. Ask them to contact the treatment provider if you're being chased for payment, just to say that you're in dispute with Bupa. You may also be asked for a treatment plan/medical report.

There'll be staff there from Wednesday from 8am till 6pm.

The only relevant thing I think you’ve missed out is that as a financial services provider they have specific responsibilities to vulnerable customers, which covers people with mh conditions. This is a relatively recent change in fca rules so might be worth including. The idea being that the threshold for what might be reasonable in terms of keeping a spreadsheet etc will differ according to what level of vulnerability you experience because of your mh conditions.

You posted asking for legal help and you’ve got the answer - albeit not the one you wanted.
Maybe show kindness to those taking time out of their day to help, and not throwing your toys out the pram because it’s not what you want to hear.