Medibank Claim Denied: How to Appeal Your Health Insurance Decision in Australia

Medibank Claim Denied: How to Appeal Your Health Insurance Decision in Australia

Medibank is Australia's largest private health insurer by membership, serving over 3.9 million members with hospital cover, extras cover, and health management services. Medibank is for-profit, listed on the ASX (MFG), with a subsidiary called ahm health insurance targeting budget-conscious consumers.

If Medibank has denied your hospital or extras claim, or if it has refused to cover a service you believe is covered by your policy, you have strong rights under Australian law — including the right to escalate to the Private Health Insurance Ombudsman (PHIO) and the Australian Financial Complaints Authority (AFCA).

About Medibank

Medibank's core products include:

• Hospital cover — various tiers (Bronze, Bronze Plus, Silver, Silver Plus, Gold) covering inpatient treatment
• Extras cover — dental, optical, physiotherapy, and other ancillary services
• Combined hospital and extras policies
• Ambulance cover
• International student health cover
• Overseas visitors health cover

Since 2019, Australian private health insurance has been structured under a tiered category system (Bronze, Silver, Gold) defining minimum hospital cover requirements. Your hospital cover tier determines what procedures and services Medibank must cover.

Common Medibank Denial Reasons

Hospital cover denials:

• Waiting periods not served: All Medibank hospital policies have waiting periods for pre-existing conditions (12 months), psychiatric treatment (2 months), obstetric services (12 months), and rehabilitation (2 months). Services received before these periods are served are denied.
• Pre-existing condition: Medibank may deny a claim for a condition it determines existed before you joined the policy (within a 12-month waiting period).
• Clinical category not covered: Your hospital cover tier (Bronze, Silver, Gold) determines which clinical categories are covered. If you claim for a procedure in a category not included in your tier, it will be denied.
• Excess and co-payments: Medibank plans have annual excesses and (in some plans) daily co-payments for hospital stays. These are your responsibility and not claimable — disputes arise when members don't understand what they owe.
• Non-agreement hospital: Medibank has agreements with most major hospitals. Treatment at a hospital with which Medibank does not have an agreement may result in a gap payment or denial.
• Private patient in public hospital: Complex Medicare and private insurance interaction rules apply when you choose to be a private patient in a public hospital.

Extras cover denials:

• Annual limits reached: Extras policies have annual limits for each service (e.g., $500/year for dental). Once the limit is reached, further claims are denied.
• Service by non-registered provider: Medibank requires treatment by registered health practitioners. Treatment by practitioners not registered with the relevant national registration board is not covered.
• Service not included in your extras policy: Your extras policy determines which services are covered and at what benefit level.
• Waiting periods for extras: Some extras services have waiting periods (typically 2–6 months).

Overseas visitors and students:

• Treatment for conditions not covered under overseas visitor health cover
• Gap payments from private hospitals

Your Australian Rights When Medibank Denies a Claim

PHIO: The Private Health Insurance Ombudsman is a free, independent service for resolving disputes between private health insurance members and funds. The PHIO can investigate Medibank's decision and recommend or direct resolution. PHIO complaints about Medibank are relatively common and frequently resolved in members' favour.

AFCA: The Australian Financial Complaints Authority handles complaints about financial services firms including health insurers. AFCA is free for consumers, and its decisions are binding on Medibank.

Private Health Insurance Act 2007: This federal law sets minimum standards for private health insurance in Australia. If Medibank's denial violates these standards, you have grounds for a regulatory complaint.

Australian Competition and Consumer Commission (ACCC): If Medibank's conduct involves misleading or deceptive practices, the ACCC may be relevant.

Step-by-Step: How to Appeal a Medibank Denial

Step 1: Review Your Explanation of Benefits Statement

Medibank should provide an Explanation of Benefits (EOB) or denial letter explaining:

• The service denied and why
• The policy provision or waiting period cited
• Your right to complain

Step 2: Review Your Medibank Policy Cover Summary

Log into the Medibank member portal (medibank.com.au) or use the Medibank app to review:

• Your exact hospital cover tier and clinical categories covered
• Your extras cover limits and benefit rates
• Waiting periods and when they expire
• Any exclusions or restrictions noted on your policy

Step 3: Gather Supporting Evidence

For hospital cover disputes:

• Letter from your treating specialist explaining the medical necessity and urgency of the treatment
• Medical records supporting the diagnosis
• Evidence that the service falls within your clinical cover category

For pre-existing condition disputes:

• GP records and specialist letters showing when your condition first manifested
• Evidence that symptoms did not exist before your policy commenced
• Medical opinion that the current episode is a new condition unrelated to any prior one

For waiting period disputes:

• Evidence of continuous prior health fund membership and previous waiting period service (if you transferred from another fund, some waiting periods may be waived)

Step 4: Contact Medibank and Request a Review

Medibank Contact:

• Phone: 132 331 (general) or 1800 365 411 (complaints)
• Online: medibank.com.au/contact
• In-person: Medibank stores nationally

Request a formal review of the denial. Ask specifically:

• What is the exact policy provision relied on?
• Was the pre-existing condition determination made by a medical practitioner?
• Is there new evidence that could change the decision?

For pre-existing condition determinations, Medibank must have a medical officer review the decision if you dispute it.

Step 5: File a Formal Complaint with Medibank

If the review doesn't resolve the issue, file a formal written complaint with Medibank. Medibank must:

• Acknowledge your complaint
• Investigate and respond

Step 6: Escalate to the Private Health Insurance Ombudsman (PHIO)

If Medibank's response is unsatisfactory:

• Online: ombudsman.privatehealth.gov.au
• Phone: 1800 640 695 (free from landlines)
• Email: phio@phio.gov.au
• The PHIO investigates complaints at no cost to you and can direct Medibank to reverse incorrect decisions

Step 7: Escalate to AFCA

For broader financial conduct complaints:

• Online: afca.org.au
• Phone: 1800 931 678
• AFCA decisions are binding on Medibank

Medibank-Specific Tips

Waiting periods for transfers: If you transferred to Medibank from another health fund with equivalent or higher cover, you generally do not need to re-serve waiting periods you already served. Ensure Medibank has a record of your prior coverage.

Medibank network hospitals: Medibank negotiates agreements with hospitals that eliminate or reduce gaps. Using a Medibank network hospital minimises your out-of-pocket costs and reduces the risk of denial.

'Known gap' and 'no gap' medical services: Medibank has arrangements with many medical practitioners for no-gap or known-gap services. Ask your specialist whether they participate in Medibank's gap cover scheme before treatment.

ahm (Medibank subsidiary): If your insurer is ahm (Medibank's subsidiary), the same complaint and escalation process applies. ahm is regulated by the same laws and bodies as Medibank.

Ambulance: Ambulance cover rules vary by state. In Queensland and Tasmania, ambulance is covered by the state government. In other states, ambulance cover is a private insurance product. Verify your ambulance coverage before an emergency if possible.

Conclusion

Medibank is Australia's largest private health insurer, but size doesn't mean its denials are correct. Waiting period determinations, pre-existing condition classifications, and clinical category disputes are among the most commonly challenged — and frequently overturned — Medibank decisions. Use the PHIO and AFCA for free, independent review. Use ClaimBack at claimback.app to generate a professional appeal letter for your Medibank health insurance dispute in Australia.

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Related Reading:

• Bupa Australia Claim Rejected: How to Appeal
• nib Health Insurance Claim Denied: How to Appeal
• How to File an AFCA Complaint Against Your Insurer in Australia
• How to Find Your Insurance Ombudsman