HBF Health Insurance Claim Denied in WA: How to Appeal

HBF Health Insurance Claim Denied in WA: How to Appeal

HBF Health is Western Australia's largest private health insurer and one of Australia's largest member-owned health funds, serving over 1 million members. As a not-for-profit fund owned by its members, HBF has traditionally been associated with strong service and competitive benefits — but claim denials still occur, and members have the same rights to challenge them as with any other Australian health insurer.

If HBF has denied your hospital or extras claim, this guide explains your rights and the steps to appeal.

About HBF

HBF's main products include:

• Hospital cover — Basic, Bronze, Silver, Gold tiers covering a range of inpatient treatments
• Extras cover — dental, optical, physio, chiro, psychology, podiatry, and more
• Combined hospital and extras policies
• Ambulance cover (included in most HBF policies for WA members)
• Business health insurance (through HBF Business)

HBF operates primarily in Western Australia but accepts members from all Australian states and territories.

Common HBF Denial Reasons

Hospital cover denials:

• Waiting periods: HBF applies standard waiting periods — pre-existing conditions (12 months), obstetrics (12 months), psychiatric care (2 months), rehabilitation (2 months). Claims made before waiting periods expire are denied.
• Pre-existing condition: HBF may classify a condition as pre-existing based on a medical assessment of your health before joining.
• Clinical category not covered: Your hospital cover tier determines which treatments are covered. Lower-tier (Basic, Bronze) policies have restricted and excluded categories.
• Excluded services: Some HBF policies explicitly exclude certain services (e.g., joint replacements, pregnancy/birth on lower tiers).
• Non-agreement hospital: HBF has agreements with most major WA hospitals. Treatment at a hospital without an HBF agreement may result in gaps or denial.

Extras cover denials:

• Annual or lifetime limits reached: Each extras service has annual and/or lifetime benefit limits. Beyond these, claims are denied.
• Service during waiting period: Extras services typically have 2–6 month waiting periods, with major dental and orthodontics having 12-month waits.
• Provider not recognised: Services must be by AHPRA-registered or otherwise recognised practitioners.
• Service not included: Not all extras services are included in every HBF policy. Some are only available as optional add-ons.

Your Australian Rights When HBF Denies a Claim

PHIO: The Private Health Insurance Ombudsman provides free, independent dispute resolution for all Australian private health insurance members. The PHIO can investigate HBF decisions and direct resolution.

AFCA: The Australian Financial Complaints Authority handles complaints about financial services firms including health insurers, with binding authority over HBF.

Private Health Insurance Act 2007: Federal minimum standards apply to all Australian private health insurers including HBF.

Step-by-Step: How to Appeal an HBF Denial

Step 1: Understand the Denial Reason

HBF must provide a written denial with the reason. Key questions:

• Is this a waiting period denial?
• Is this a pre-existing condition denial?
• Is this a clinical category exclusion?
• Is this an annual limit denial?

Step 2: Review Your HBF Policy

Log into myHBF (online member portal) or use the HBF app to review:

• Your specific cover tier and covered clinical categories
• Your extras benefits, annual limits, and remaining limits
• Your policy commencement date and waiting period expiry dates
• Any exclusions on your policy

Step 3: Gather Supporting Evidence

For pre-existing condition disputes:

• GP records showing when your condition first presented
• Specialist letters confirming the condition was not present or symptomatic before your HBF policy started
• Any evidence of a new, distinct episode of illness unrelated to prior conditions

For clinical category disputes:

• Letter from your surgeon/specialist confirming the procedure's clinical category
• Evidence that the procedure falls within a covered category under your policy tier

For waiting period disputes:

• Evidence of prior health fund membership (certificate of previous membership) if you transferred to HBF

Step 4: Contact HBF and Request a Review

HBF Contact:

• Phone: 133 423
• Online: hbf.com.au/contact
• In-person: HBF branches across Western Australia

Call HBF and ask to speak with a senior claims representative. Explain why you believe the denial is incorrect and provide supporting documentation.

For pre-existing condition determinations, HBF is required to have a medical practitioner assess the claim. Request that this review occur if it has not already.

Step 5: Submit a Formal Written Complaint to HBF

If the phone review doesn't resolve the issue, submit a formal written complaint:

HBF Complaints:

• Email: complaints@hbf.com.au
• Post: HBF Health, GPO Box 4174, Perth WA 6842

Include your policy number, claim number, detailed explanation of why the denial is incorrect, and all supporting documentation.

Step 6: Escalate to the PHIO

If HBF's formal response is unsatisfactory:

• Online: ombudsman.privatehealth.gov.au
• Phone: 1800 640 695 (free)
• The PHIO investigates at no cost to you and has authority to direct HBF to pay valid claims

Step 7: Escalate to AFCA

For broader financial conduct issues:

• Online: afca.org.au
• Phone: 1800 931 678 (free)
• AFCA decisions are binding on HBF

HBF-Specific Tips

Pre-existing condition medical assessment: If HBF is denying on pre-existing condition grounds, you have the right to request that a medical practitioner employed or contracted by HBF makes the determination (not just an administrative decision). Request this explicitly.

Member-owned fund: As a member-owned not-for-profit, HBF sometimes takes a more member-friendly approach to dispute resolution than for-profit insurers. Escalating to a senior member services representative and explaining your situation clearly sometimes resolves disputes that would not be resolved at other funds.

WA hospitals: HBF has strong agreements with major WA hospitals (Royal Perth, St John of God, Fiona Stanley, Hollywood Private, etc.). Using an HBF agreement hospital in WA minimises gap payments.

Transfer of waiting periods: If you transferred from another Australian health fund to HBF within 30 days (with a certificate of previous membership), most waiting periods already served transfer across. Ensure HBF has your previous fund's certificate.

Extras network: HBF has a dental and optical network. Using HBF's network providers typically means no or reduced gap payments.

Conclusion

HBF is a member-owned fund with a strong reputation in Western Australia, but claim denials — particularly pre-existing condition determinations and clinical category disputes — do occur. The PHIO and AFCA provide free, independent channels to challenge HBF's decisions. Don't accept a denial without pursuing a formal review. Use ClaimBack at claimback.app to generate a professional appeal letter for your HBF health insurance dispute.

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Related Reading:

• nib Health Insurance Claim Denied: How to Appeal
• HCF Health Insurance Claim Denied: How to Appeal
• Australian Unity Claim Denied: How to Appeal
• How to File an AFCA Complaint Against Your Insurer in Australia