Typical Reasons OSHC/OVHC Claims Are Rejected and How to Appeal

Common Reasons for Claim Rejection

Claims under Overseas Student Health Cover (OSHC) or Overseas Visitors Health Cover (OVHC) are often denied due to pre-existing conditions, because these conditions are not covered until a specified waiting period has been served. Another frequent reason is that the treatment falls within the standard waiting period, during which no benefits are payable. Claims are also commonly rejected when the service is not listed on the Medicare Benefits Schedule (MBS), as the policy only covers MBS items.

How to Appeal a Rejected Claim

When a claim is denied, the first step is to request a formal review from the insurer. The request should be in writing and clearly state why the decision is disputed, referencing the policy terms and any supporting medical evidence. If the internal review upholds the rejection, the matter can be escalated to the relevant external complaints body, such as the Australian Financial Complaints Authority, provided the claim falls within its jurisdiction.

Evidence to Prepare for an Appeal

To support an appeal, gather all relevant documents including the original claim form, the insurer’s rejection letter, medical reports, test results, and treatment invoices. A letter from the treating doctor explaining the medical necessity of the service can be particularly important. Keep copies of all correspondence and note any phone conversations with dates and names of the representatives spoken with.

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FAQ

Q1: Why is my claim rejected because of a pre-existing condition?

Claims can be rejected because the policy does not cover pre-existing conditions until after a waiting period, and if treatment occurs during that time, no benefit is payable.

Q2: What should I include in a written appeal?

The written appeal should state the reasons for disputing the decision, reference the relevant policy terms, and attach supporting medical evidence such as reports and doctors’ letters.

Q3: Is there an external body to appeal to if the insurer refuses?

Yes, if the internal review is unsuccessful, you may lodge a complaint with the Australian Financial Complaints Authority, subject to its jurisdiction requirements.