What’s New in 2025?

Starting 1 July 2025, a new OSHC Deed came into effect. This document outlines the rules that insurers must follow for OSHC policies - from what’s covered and excluded to waiting periods and refund conditions.

Here’s what’s important for you:

• The Deed clearly defines maximum waiting periods and exclusions for certain treatments (like pre-existing or pregnancy-related conditions).
• All insurers offering OSHC must comply with this Deed.

It’s also worth noting that sometimes, claim rejections happen due to technical or system errors - not necessarily because you did something wrong. For example, some insurers have had to reimburse customers after incorrectly rejecting hospital claims.

Common Reasons Why Claims Get Denied

Here are the most frequent causes of OSHC/OVHC claim rejections in Australia:

1. Treatments or Services Not Covered

• ‍‍Your policy might not include some services such as cosmetic surgery, dental, or optical treatments (unless you have extras cover).
• OSHC policies also don’t cover treatments outside Australia, except for medical repatriation.

2. Pre-Existing Conditions

• ‍‍If your health issue existed before your policy started, it might fall under a pre-existing condition rule.
• For example, insurers like Allianz check for symptoms that appeared in the six months before your policy began.
• Under the 2025 Deed, there can be a waiting period of up to 12 months for hospital treatment related to pre-existing conditions.

3. Waiting Periods Not Completed

• ‍‍Most policies have waiting periods for specific services - such as 2 months for general treatments or 12 months for maternity services. Claims made before these periods end are usually not approved.

4. Unrecognised or Out-of-Network Provider

• ‍‍If you were treated by a doctor or hospital not recognised by your insurer’s network, your claim might be reduced or rejected.

5. Treatment Not Considered “Medically Necessary”

• ‍‍If an insurer believes the treatment was elective or cosmetic, they may reject the claim.
• You can counter this by asking your doctor to provide a statement explaining why it was necessary.

6. Missing or Incorrect Documents

• ‍‍Claims can fail if any documents are incomplete or missing - for example, invoices without item codes, unsigned forms, or missing reports.

7. Policy Lapsed or Payment Overdue

• ‍‍If your premium wasn’t paid or your policy was inactive during treatment, your claim may not be valid.

8. Late or Incorrect Submission

• ‍‍Submitting your claim after the allowed time or using the wrong form can also lead to denial.

How to Appeal a Denied Claim?

Here’s a simplified step-by-step guide to help you challenge the decision effectively:

Step 1: Review the Denial Letter

• Your insurer must send you a written explanation of why your claim was rejected.
• Go through it carefully - note the policy clause, waiting period, or reason mentioned.
• Then, check your Product Disclosure Statement (PDS) or Certificate of Cover to verify their reasoning.

Step 2: Ask for More Details or a Review

• If the explanation is unclear, request a detailed review or clarification in writing.
• You can contact your insurer’s complaints or review team and ask them to recheck the decision.
• Always keep copies of emails, letters, or reference numbers for your records.

Step 3: Collect Supporting Documents

Build your case with all the relevant evidence:

• Doctor’s notes, referral letters, hospital summaries
• Test results and imaging reports
• Itemised invoices and payment receipts
• A statement from your doctor explaining why treatment was necessary
• Proof that your waiting period was completed
• Copies of emails or prior approvals
• Any correspondence showing your claim was submitted on time

Step 4: Write a Clear Appeal Letter

Keep it polite and factual. Your letter should include:

• Your details (name, policy number, claim number)
• Reason for writing – to appeal a denied claim
• Your explanation – why you believe the decision was incorrect
• Evidence summary – what documents support your case
• Your request – for reconsideration or full payment

Attach all documents and mention them in an Attachment List (A, B, C…).

You can also quote your doctor’s opinion or refer to the 2025 OSHC Deed if your insurer’s decision seems inconsistent with it.

Step 5: Submit Your Appeal

• Most insurers give you up to 90 days (sometimes 180 days) from the date of rejection to file an appeal.
• Send it through your insurer’s official channel (email, portal, or mail) and keep proof of submission.
• Ask for an acknowledgment and a reference number for tracking.

Step 6: Follow Up

Stay in touch with your insurer. Keep a simple log with:

• Date and time of your calls or emails
• Who you spoke to
• What was discussed

Internal reviews may take 30–90 days, so patience and polite persistence are key.

Step 7: Escalate if Needed

If your appeal is still denied, you have further options:

• Independent Review or Ombudsman: You can contact the Private Health Insurance Ombudsman or the Australian Financial Complaints Authority (AFCA). They offer free, independent dispute resolution.
• Medical Expert Review: Some cases may be reassessed by an independent doctor.
• Legal Help: For large or complex claims, a lawyer familiar with insurance law can help you understand your rights.
• Negotiation: Sometimes hospitals or providers may offer to settle or adjust charges if the insurer refuses full payment.

Appeal Timeline at a Glance (2025)