Private Health Insurance

The role of the Private Health Insurance Ombudsman (PHIO) is to protect the interests of people covered by private health insurance. PHIO carries out this role in a number of ways, including our independent complaints handling service, our education and advice services for consumers and our advice to industry and government about issues of concern to consumers.

The focus of PHIO’s complaints handling service is on ensuring we are independent, objective, accessible, effective and timely. In dealing with complaints, we assist people to resolve disputes and act as an umpire in dispute resolution at all levels within the private health insurance industry.

Complaints Overview

What can I complain about?

Complaints need to be about private health insurance or a related matter. They can be about a private health fund, a broker, a hospital, a medical practitioner, a dentist or other practitioners (as long as the complaint relates to private health insurance).

However, complaints about the quality of service or treatment provided by a health professional or a hospital should be directed to the health care complaints body for your state or territory.

Who can make a complaint?

Generally, anyone can make a complaint, as long the complaint is relevant to private health insurance. The objective of the Private Health Insurance Ombudsman is to "protect the interests of people who are covered by private health insurance". The Ombudsman will look into complaints that concern private health insurance consumers but the office may not investigate complaints of a purely commercial nature that do not have a significant impact on the rights of consumers.

What should I do if I want to make a complaint?

You should first contact your health fund or the body you are complaining about. They may be able to resolve your complaint for you.

Then if you are not satisfied, or if you have any questions, please contact us.

What information does the Ombudsman need?

When you contact the Ombudsman you should provide the following information:

  • a clear description of your complaint;
  • the name of your health fund and your membership number; and
  • what you think would resolve the matter for you.

The Ombudsman’s staff will let you know if any other information is needed.

What can happen after I make a complaint?

Many complaints result from misunderstandings. The Ombudsman’s staff may be able to explain what has happened and why, and this often solves the complaint.

Otherwise, the Ombudsman’s staff will contact your health fund or the body you are complaining about to get their explanation and any suggestions they have for fixing the problem.

The Ombudsman will deal with most complaints by phone, email and fax and most can be settled quickly.

Where complaints are more complex, the Ombudsman will write to the health fund or other body, seeking further information or recommending a certain course of action.

The Ombudsman’s staff will keep you regularly informed, usually by telephone and will give you their name and contact number, in case you need to contact them.

What if I just want some information about health insurance?

We can help with information about private health insurance arrangements if you want to phone, email or contact us by fax.

We also have a number of brochures and publications about private health insurance arrangements such as:

  • State of the Health Funds Report - which compares different health funds across a number of performance criteria;
  • Individual Health Fund Report Cards - summarising each health fund's details as provided in the State of the Health Funds Report;
  • Annual Reports - providing information about the office and our annual performance, including complaint statistics;
  • Quarterly Bulletins - listing health fund complaints and issues for each quarter and providing updates on industry related matters;
  • Facts and Advice - factsheets about a range of health insurance topics such as obstetrics (pregnancy) and the pre-existing conditions rule.

All our brochures and publications are available on our website or can be provided on request.

Industry Resources

The following publications are often referenced by our office in dealing with health insurers and industry when resolving complaints.

PHIO Referral to Fund Guidelines

Overview of PHIO's complaint handling processes where a consumer makes a complaint against a health fund.

Pre-Existing Conditions - Best Practice Guidelines

The Best Practice Guidelines were released by the Department of Health in September 2001.

PHIO Mediation Guidelines

The Private Health Insurance Ombudsman (PHIO) has had legislative power to require health insurers and healthcare providers to attend formal mediation, in order to resolve disputes that may affect consumers’ rights and entitlements under their private health insurance cover. These disputes usually occur when there is disagreement between parties about the renewal of a Hospital Agreement.

Hospital Agreements: Transition and Communication Protocols

The following protocols are arrangements agreed within the private health industry to ensure
adequate consumer protection and minimise undue disruption and risk to the industry when
contractual agreements between health funds and hospitals are terminated.

The protocols have been developed by the Private Health Insurance Ombudsman, in
consultation with the Australian Health Insurance Association, the Health Insurance Restricted
Membership Association of Australia, the Australian Health Services Alliance, the Australian
Private Hospitals Association and the Department of Health.

Detrimental Changes to Health Fund Policies

PHIO's recommendations for insurers in relation to advising members of detrimental policy changes:

National Private Patient-Public Hospital Acute Care Certificate

A new acute care certificate has been developed to certify acute care provided to private patients treated in public hospitals.

The work to develop this new certificate began in early 2010 after Health Ministers requested SA and NSW Health to work with PHIO to review acute care certificate arrangements for private patients in public hospitals.

Please note the following important points about the development of the new certificate:

  • The new certificate was developed by a small industry working group with representatives from Medibank Private, Bupa, SA Health, NSW Ministry of Health and PHIO. Although the small working group was not formed to represent all States and Territories and health insurers, SA and NSW health department representatives worked closely with their counterparts in other jurisdictions. Similarly, the Bupa and Medibank representatives worked closely with their peak body (Private Healthcare Australia) and all funds and insurer peak bodies have had the opportunity to provide submissions on an earlier draft of the new certificate.
  • PHIO strongly supports the new certificate. It is fit for purpose. It elicits a transparent summary of the acute care provided to a patient with more than 35 days of continuous hospital admission.
  • There is no legislative basis for imposing the new certificate, so the decision to adopt it will be a matter for each State and Territory health department and each insurer. PHIO strongly encourages health insurers and State health authorities to begin discussions about the use of the new certificate now that it has been finalised.
If you have questions about the new certificate, please contact Leonie Hull at phio.info@ombudsman.gov.au. Feedback about the new certificate can also be provided to Leonie at the same email address.
A copy of the new certificate and all the explanatory material that has been distributed to industry is below: