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

Common Reasons for Claim Rejection

Overseas Student Health Cover (OSHC) and Overseas Visitor Health Cover (OVHC) claims can be denied for several typical reasons. A common cause is treatment related to a pre-existing condition, where the ailment or condition existed before the policy started and falls within an exclusion or waiting period. Claims may also be rejected when the service is provided during a waiting period that has not yet been met for certain benefits. Another frequent reason is that the medical service is not listed on the Medicare Benefits Schedule (MBS), meaning it is not a recognised item under the Australian healthcare system and may not be covered.

How to Prepare Your Appeal

If your claim is rejected, you have the right to request a review. Start by carefully reading the insurer's reason for denial, which should be stated in the decision letter. Collect all relevant evidence, including receipts, medical reports, referral letters, and any supporting documents that show the treatment was necessary and, if applicable, that it was not for a pre-existing condition excluded by your policy. Ensure you have copies of your policy documents that outline the benefits and waiting periods, and check the dates of service against when your coverage began.

Submitting Your Appeal

Write a clear, factual appeal letter addressing each point of denial. Reference your policy terms and attach the evidence. Send the appeal to your insurer's complaints or review department according to their official process, which is typically outlined on their website or in the denial notice. Keep records of all correspondence and note any deadlines for submitting your appeal.

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FAQ

Q1: Why was my claim rejected due to a pre-existing condition?

A claim can be rejected if the insurer determines that the treatment was for a condition that existed before your policy began, and your cover does not include such conditions or the waiting period for pre-existing conditions has not been completed.

Q2: What can I do if my claim is denied because of a waiting period?

Check your policy start date and the service date to confirm whether the waiting period had indeed passed. If you believe the claim was wrongly assessed, gather proof of your policy commencement and the date of treatment, and follow the appeal steps with that evidence.

Q3: How can I prove that a medical service should be covered by my OSHC or OVHC?

Ask your doctor to provide a detailed report explaining why the service was medically necessary, and check if the item has an MBS item number. Submit this documentation with your appeal to demonstrate that the service meets the criteria for coverage under your policy.