Private Health Insurance Ombudsman State of the Health Funds Report 2018

Relating to the financial year 2017–18

Report required by 20D (c) of the Commonwealth Ombudsman Act 1976.

This work is copyright. Apart from any use permitted under the Copyright Act 1968, no part may be reproduced without written permission. Requests concerning reproduction and rights should be addressed to the Commonwealth Ombudsman © Commonwealth of Australia 2019.

FOREWORD

Photo of Commonwealth Ombudsman Michael Manthorpe PSM.

I am pleased to present the 14th annual State of the Health Funds Report, relating to the financial year 2017–18. The report provides comparative information on the performance and service delivery of all health funds1 during the financial year.

The information in the report supplements information available on our consumer website privatehealth.gov.au. The consumer website provides a range of information to assist consumers to understand private health insurance, and to select or update their private health insurance policies. The information on the consumer website, together with the State of the Health Funds Report, assists consumers to choose health insurance policies that better meet their individual needs.

The purpose of this report is to provide consumers with additional information to assist them to make decisions about private health insurance. For existing policyholders, the report details information that allows them to compare the performance of their fund with all other health funds. For those considering taking out private health insurance for the first time, the report provides an indication of the services available from each fund and a comparison of some service and performance indicators at the fund level.

The range of issues and performance information contained in the report has been chosen after taking into account the availability of reliable data and whether the information is reasonably comparable across funds. The information included in the report is based on data collected by the Australian Prudential Regulation Authority (APRA), as part of its role in undertaking statistical reporting and monitoring of the financial management of health funds. I would like to thank APRA for their assistance and advice in relation to the report.

Photo of Michael Manthorpe PSM’s signature.

Mr Michael Manthorpe PSM
Commonwealth Ombudsman
March 2019

CONTENTS

List of Figures

List of Tables

USING THIS REPORT TO COMPARE FUNDS

Disclaimer:

  • Nothing contained in this report should be taken as a recommendation by the Ombudsman in favour of any particular health fund or health insurance policy.
  • No single indicator should be used as an indicator of overall fund performance. In most cases, seemingly poor performance on one indicator will be offset by good performance on other factors.
  • The information used in this report to compare health funds is based on data collected for regulatory purposes. This information is the most appropriate, independent and reliable data available.
  • This report is intended to help consumers decide which health funds to consider, though it will not necessarily indicate which of the fund's policies to purchase. Virtually all funds offer more expensive policies that can be expected to provide better than average benefits as well as cheaper policies that provide less.

The State of the Health Funds Report

The State of the Health Funds Report (SOHFR) compares how health funds perform across the following criteria:

  • service performance
  • hospital benefits
  • medical gap schemes
  • general treatment (extras) benefits
  • financial management
  • health fund operations.

You can use the information contained in this report to identify possible funds to join, or to assess your existing fund's performance if you're reviewing your current needs.

You can use the range of indicators included in this report as a menu to choose the factors of most importance to you—not all factors will be of equal importance to every individual or family.

For instance, if you prefer to do business with a health fund in person, then you should consider the availability of retail offices to be an important consideration. More information about particular indicators is provided in the explanations preceding each of the tables in this report.

If you are considering taking out private health insurance for the first time, we suggest you use the report to identify a number of funds—preferably at least three—for further investigation.

Where to find more information about selecting a policy

Our brochure 'Health Insurance Choice: Selecting a Health Insurance Policy' includes important advice on what factors to consider and what questions to ask when selecting a policy. It also includes information on government incentives relating to hospital cover such as the 'Medicare Levy Surcharge Exemption' and 'Lifetime Health Cover'.

This brochure, as well as other publications, can be found at ombudsman.gov.au. Some brochures can be obtained in hard copy on request from our Office.

This report does not include detailed information on price and benefits for health insurance policies. Information on specific policies is available from the Ombudsman's consumer website privatehealth.gov.au, where you can search for and compare information about every health fund and policy in Australia.

Fund names

Throughout this report, health funds are referred to by an abbreviation of their registered name, rather than any brand name that they might use. This abbreviated name appears on the left side of the heading for each fund in the Health Fund Listing section. Some funds use several different brand names:

Brand nameFund
AAMI NIB
APIA NIB
Australian Country Health Medibank
Australian Health Management Medibank
Budget Direct GMHBA
Country Health Medibank
CY Health HBF
Druids GMHBA
Federation Health Latrobe
FIT GMHBA
Frank GMHBA
GMF Health HBF
Goldfields HBF
Government Employees Medibank
Grand United Australian Unity
HBA BUPA
Healthguard HBF
Hunter Health Insurance CDH
Illawarra Health Fund Medibank
IOOF NIB
IOR HCF
Kogan Medibank
Manchester Unity HCF
MBF BUPA
Mutual Community BUPA
Mutual Health Medibank
NRMA Health BUPA
Qantas Assure NIB
RACT GMHBA
Suncorp NIB
SGIC (SA) BUPA
SGIO (WA) BUPA
Unihealth Teachers Health
Union Health TUH

ABOUT THE DATA USED IN THIS REPORT

Open and restricted membership health funds

Membership of 'open' health funds is available to everyone.

'Restricted membership' health funds have certain membership criteria which mean they are not available to all consumers. For example, membership may be restricted to employees of certain companies or occupations, or members of particular organisations.

Where applicable, open and restricted membership funds are listed separately in each of the tables in this report.

Information about policies

The information included in the report on fund contributions and benefits indicates the average outcomes across all of a fund's policies, so cannot be taken as an indicator of the price or benefit levels that can be expected for any particular policy.

Virtually all funds offer more expensive policies that can be expected to provide better than average benefits and most also offer cheaper policies that provide less.

This report can help you to decide which health funds to consider, but won't necessarily help you to decide which of the funds' policies to purchase.

For information about specific policies, the website privatehealth.gov.au enables you to view standard information outlining the main features of any health insurance policy. You can compare Private Health Information Statements for any policy available for purchase from any fund, including the level of cover, excess and price. The website is Australia's leading source for independent and reliable information about private health insurance.

Data collection

The need to obtain independent and reliable data has been a key consideration in preparing this report. The data selected by the Ombudsman as the most appropriate available is collected by the industry regulator, the Australian Prudential Regulation Authority (APRA). APRA has supplied most of the data published in this report.

Funds report to APRA for regulatory purposes and not all of the data is publicly available. Some of this information is useful to consumers and is therefore reproduced in this report. You should note that the data is collected primarily for regulatory purposes and not for the purposes of the SOHFR. It is important to read the accompanying text explaining the data in conjunction with the tables.

As funds differ in size, most of the statistical information is presented as percentages or dollar amounts per membership, for easier comparison. No attempt has been made to weight the importance of various indicators, as these are subjective judgements which are dependent on individual circumstances, preferences and priorities.

The report provides additional information about the benefits that were paid by each fund over the last year. The report also provides information about the extent of cover provided for hospital, medical and general treatment, and any state-based differences in coverage. The selection of indicators used in this report are not intended to represent the full range of factors that should be considered when comparing the performance of health funds. The range of indicators has been limited to those where there is reliable comparative information available.

KEY CONSUMER ISSUES

Complaint issues in 2017–18

In 2017–18 private health insurance complaints to our Office declined 21 per cent to 4,553, which was a significant reduction compared to 5,750 in 2016–17. Our Office's private health insurance complaint workload over the past 10 years is shown in Figure 1.

The number of private health insurance complaints received has increased significantly over the last decade. In 2016–17, we received 5,750 complaints, compared to 4,416 in the previous year – an increase of over 1,300 complaints. This was the largest increase we have experienced over the past 10 years. Although complaints have moderated in 2017–18, there remains a steady increase in trend terms.

The number of consumer information enquiries received by the Office relating to private health insurance reduced by 21 per cent in 2017-18. We received 2,956 enquiries, of which 65 per cent were received through the consumer website privatehealth.gov.au.

Figure 1 — Total complaint and enquiries by year

Complaints have increased significantly over the last decade.

The top three complaint issues to our Office continued to be Benefits, Membership and Service.

For Benefit complaints, the main issue of concern was hospital policies with unexpected exclusions and restrictions. Some basic and budget levels of hospital cover exclude or restrict services that many consumers assume are routine treatments or standard items. The Office anticipates that the number of complaints about benefits will reduce significantly in future years with the implementation of private health insurance reforms in 2019, which will standardise clinical categories and give consumers more certainty about their benefits.

Delays in benefit payments and complaints about insurer rules that limited benefits also represented a significant proportion of complaints received.

Membership complaints typically related to policy administration issues, such as processing cancellations or payment of premium arrears. Delays in the provision of transfer (also known as clearance) certificates when transferring between health insurers was also a significant cause of complaint.

Service issues are usually not the sole reason for complaints and a service failure is often part of any complaint made to an external body like an Ombudsman. The combination of unsatisfactory customer service, untimely responses to simple issues and poor internal escalation processes can cause policy-holders to become more aggrieved and dissatisfied in their dealings with the insurer. The service itself then becomes a cause of complaint as well as the original issue. Notably, Service complaints dropped in volume from 2016–17, when ICT problems at one insurer caused a spike in complaints to our Office.

Figure 2 — Complaint issues over previous three years

The top three complaint issues to our Office continued to be Benefits, Membership and Service.

Consumer website privatehealth.gov.au

In 2017–18 we received 1,924 individual enquiries via the consumer website privatehealth.gov.au. We responded to these enquiries with written consumer information and advice. The website is Australia's leading source of independent information about health insurance for consumers.

Website usage has continued to grow annually since the website's launch in 2007, with 1,319,130 visits in 2017–18.

Figure 3 — privatehealth.gov.au visitors per year

Website usage has continued to grow annually since the website’s launch in 2007.

Private health insurance reforms

In 2017, the Government announced significant reforms to health insurance. A key aim of the reforms is to make health insurance simpler for consumers to understand by introducing common health insurance terms and classifying policies into simpler categories. The consumer website privatehealth.gov.au is being redeveloped as part of the reforms.

The major changes in these health insurance reforms are summarised below. For further information, please see health.gov.au/private-health-reforms.

Gold, Silver, Bronze and Basic hospital cover

Health insurers will begin rolling out four new tiers of hospital cover from early 2019. The four tiers of Gold, Silver, Bronze and Basic each have minimum inclusions and will become mandatory from 1 April 2020.

Private health insurers have one year, from 1 April 2019, to introduce these new tiers. Insurers have commenced informing consumers with existing health insurance policies about how their policies will change or have changed to fit into one of the new tiers.

Clinical categories

What is, and is not, covered in the Gold, Silver, Bronze and Basic tiers will be based on new standard clinical categories of treatment. These standard clinical categories are groups of hospital treatments that are covered under each policy. Each standard clinical category—for example, 'bone, joint and muscle' category, or 'heart and vascular system' category—sets out the hospital treatments that must be covered by the private health insurer. If a policy covers a certain category, then it must cover everything included in the category.

Private Health Information Statement (PHIS)

Insurers are required to send consumers a statement summarising what their policy covers at least once a year, and again each time their policy changes.

From 2019 onwards, policy information for new Gold, Silver, Bronze or Basic hospitals and new general treatment policies will be provided in the form of a Private Health Information Statement (PHIS) including information about what is covered based on the new tiers and clinical categories of treatment. From 1 April 2020, all policies will be summarised in PHIS documents.

Consumers can search for and compare a standard PHIS from every insurer in Australia on privatehealth.gov.au. Insurers can also offer a customised PHIS for their members and in their emails, letters and websites, which may include further information.

Mental health treatment waiting periods

Since 1 April 2018, health insurers have been providing greater access to mental health services by allowing people to upgrade their hospital cover without serving the usual two month waiting period for in-hospital psychiatric treatment. Policyholders are able to use this exemption from the usual waiting period on a once-off basis.

Natural therapies

From 1 April 2019, private health insurers will no longer be able to offer benefits for some natural therapies as part of a health insurance policy.

The affected natural therapies are Alexander technique, aromatherapy, Bowen therapy, Buteyko, Feldenkrais, western herbalism, homeopathy, iridology, kinesiology, naturopathy, Pilates, reflexology, Rolfing, shiatsu, tai chi, and yoga.

Discounts for 18–29 year olds

From 1 April 2019, insurers will have the option to offer people aged 18–29 years discounts of up to 10 per cent of their private health insurance hospital premiums. People will retain that discount until they turn 41, when it will be gradually phased out.

Travel and accommodation benefits for rural consumers

Insurers will have the option to offer travel and accommodation benefits as part of hospital cover for consumers that need to travel away from home for treatment. Some insurers already offer these benefits to their members under general treatment or extras cover.

Additional Ombudsman's powers

In addition to its current complaint-handling and information provision roles, our Office has new powers to inspect private health insurers to address complaints when they cannot be resolved through the usual channels.

HEALTH FUND LISTING AND CONTACT DETAILS

The following tables list all Australian registered health funds. The 'open' membership funds provide policies to the general public. The 'restricted' funds provide policies only through specific employment groups, professional associations or unions.

Table 1 — Health funds listing and contact details
Open Membership Health Funds  
Abbreviation Full name or other names Phone NumberWebsite
Australian Unity Australian Unity Health Ltd 132 939 australianunity.com.au
BUPA Bupa HI Pty Ltd 134 135 bupa.com.au
CBHS Corporate CBHS Corporate Health Pty Ltd 1300 586 462 cbhscorporatehealth.com.au
CDH CDH – Hunter Health Insurance 02 4990 1385 hunterhi.com.au
CUA Health CUA Health Ltd 1300 499 260 cua.com.au/health
GMHBA GMHBA Ltd, Frank 1300 446 422 gmhba.com.au
GU Health Corporate Grand United Corporate Health 1800 249 966 guhealth.com.au
HBF HBF Health Ltd 133 423 hbf.com.au
HCF Hospitals Contribution Fund of Australia 131 334 hcf.com.au
HCI Health Care Insurance Ltd 1800 804 950 hciltd.com.au
Health.com.au Health.com.au 1300 199 802 health.com.au
Health Partners Health Partners Ltd 1300 113 113 healthpartners.com.au
HIF Health Insurance Fund of Australia Ltd 1300 134 060 hif.com.au
Latrobe Latrobe Health Services 1300 362 144 latrobehealth.com.au
MDHF Mildura Health Fund Ltd 03 5023 0269 mildurahealthfund.com.au
Medibank Medibank Private Ltd, Australian Health Management 132 331;
134 246
medibank.com.au;
ahm.com.au
MO Health MyOwn Health Insurance 1300 300 338 myown.com.au
NIB NIB Health Funds Ltd, Qantas Assure, APIA 131 463 nib.com.au
Onemedifund National Health Benefits Australia Pty Ltd 1800 148 626 onemedifund.com.au
Peoplecare Peoplecare Health Insurance Limited 1800 808 690 peoplecare.com.au
Phoenix Phoenix Health Fund Ltd 1800 028 817 phoenixhealthfund.com.au
QCH Queensland Country Health Fund Ltd 1800 813 415 qldcountryhealth.com.au
St Lukes St. Lukes Health 1300 651 988 stlukes.com.au
Transport Health Transport Health Pty Ltd 1300 806 808 transporthealth.com.au
Westfund Westfund Limited 1300 937 838 westfund.com.au
Restricted Membership Health Funds  
Abbreviation Full name or other names Phone NumberWebsite
ACA ACA Health Benefits Fund 1300 368 390 acahealth.com.au
CBHS CBHS Health Fund Ltd 1300 654 123 cbhs.com.au
Defence Health Defence Health Ltd 1800 335 425 defencehealth.com.au
Doctors' Health The Doctors' Health Fund 1800 226 126 doctorshealthfund.com.au
Emergency Services Emergency Services Health Pty Ltd 1300 703 703 eshealth.com.au
Navy Navy Health Ltd 1300 306 289 navyhealth.com.au
Nurses and Midwives Nurses and Midwives Health Pty Ltd 1300 344 000 nmhealth.com.au
Police Health Police Health 1800 603 603 policehealth.com.au
Reserve Bank Reserve Bank Health Society Ltd 1800 027 299 myrbhs.com.au
RT Health Fund Railway and Transport Health Fund Ltd 1300 886 123 rthealthfund.com.au
Teachers Health Teachers Health Fund 1300 728 188 teachershealth.com.au
TUH Teachers' Union Health Fund 1300 360 701 tuh.com.au

SERVICE PERFORMANCE

The level of complaints that the Ombudsman receives about a fund, relative to its market share, is a reasonable indicator of the service performance of most funds.

Whether a fund can attract new members and, more importantly, retain members is also an indicator of member satisfaction.

Member retention

The member retention indicator is used as one measure of the comparative effectiveness of health funds and their level of member satisfaction. This indicator measures what percentage of fund members (hospital memberships only) have remained with the fund for two years or more.

This figure is calculated on the total gain or loss of members over the last two years, which takes into account consumers who take up membership and leave within that two year period. Figures are not adjusted for policies that lapse when a member dies, as these are not reported to APRA.

Most restricted membership funds rate well on this measure compared to open membership funds. This may be due to the particular features of restricted membership funds, especially their links with employment.

Membership change

The membership change indicator shows the change in the number of policy holders over the year from 30 June 2017 to 30 June 2018. Both the percentage change and number are included. Negative figures indicate that the fund has experienced a net reduction in membership over the period. Member deaths would contribute to this figure, as these are not reported separately to APRA.

Ombudsman complaints in context

The number of complaints received by the Ombudsman is very small compared to fund membership.

There are a number of factors (other than service performance) that can influence the level of complaints the Ombudsman receives about a fund. These include the information provided to fund members about the Ombudsman through general publicity or by the fund, and the effectiveness of the fund's own complaint-handling process.

Complaints percentage compared to market share percentage

Table 2A (on page 16) includes all funds with a national market share of 0.5 per cent or more.

In that table each fund's market share (as at 30 June 2018) is shown in the market share column. Subsequent columns show the percentage of Ombudsman complaints in various categories, received about each fund. These percentages should be compared with the market share percentage. If a fund has a higher complaints percentage than its market share, it indicates that members of that fund are more likely to complain than the average of all fund members.

The table also indicates what percentage of Benefit and Service complaints are received about each fund.

Benefit complaints include problems of non-payment, delayed payment, the level of benefit paid or the gap paid by the member.

Service complaints are about the general quality of service provided by fund staff, the quality of customer service advice and premium payment problems.

All complaints takes account of all complaints received by the Ombudsman about the fund. They include complaints investigated as well as complaints that were finalised without the need for investigation.

Complaints investigated is a measure of how many complaints required a higher level of intervention from the Ombudsman. Most complaints to the Ombudsman can be finalised by referring the matter to fund staff to resolve, or by the Ombudsman staff providing information to the complainant. Complaints which fund staff have not been able to resolve to a member's satisfaction are investigated by the Ombudsman's Office—so the rating on complaints investigated is an indicator of the effectiveness of each fund's own internal complaints-handling.

Smaller funds (less than 0.5 per cent national market share)

For these smaller funds, it is not practical to show the percentage of complaints in each of the above categories because of the very small numbers of complaints.

Table 2B (on page 17) therefore shows the actual number of all complaints received and the number of complaints investigated, as well as whether the number is below the number expected based on the fund's market share.

While these funds have a very low national market share, many are nevertheless very significant in a particular state or region.

Code of Conduct

The self-regulatory code for health funds deals with the quality of advice provided to consumers and sets standards for training of health fund staff and others responsible for advising consumers about private health insurance. It also requires funds to have effective complaint-handling procedures. Funds that have completed the compliance processes for becoming a signatory to the code are indicated in the table (as at January 2019).

For more information about the Code of Conduct, please see: privatehealthcareaustralia.org.au/codeofconduct/

Table 2A — Membership retention and complaints (greater than 0.5 per cent market share)
Fund Name (Abbreviated) Member retention (hospital cover) [1] Membership change % (number) [2] Market share Complaints % compared to market share % Code of conduct member
BenefitsService All complaints Complaints investigated
Open membership funds
Australian Unity 77% -4.2% (8,337) 2.9% 4.7% 3.9% 5.4% 5.9% Yes
BUPA 83% -1.9% (34,306) 26.3% 18.5% 17.2% 23.5% 30.8% Yes
CUA Health 72% -3.7% (1,472) 0.6% 0.9% 0.4% 0.7% 1.1% Yes
GMHBA 72% 5.3% (7,915) 2.4% 2.8% 3.0% 3.0% 2.5% Yes
HBF 85% -1.8% (9,538) 7.8% 4.8% 3.7% 7.0% 4.9% Yes
HCF 85% 3.1% (21,383) 10.7% 11.0% 11.1% 14.8% 15.9% Yes
Health.com.au 70% 0.3% (131) 0.6% 1.1% 0.9% 1.0% 3.0% No
Health Partners 88% 3.2% (1,327) 0.6% 0.5% 0.3% 0.3% 0.6% Yes
HIF 72% -3.6% (2,051) 0.8% 0.9% 0.7% 0.8% 0.8% Yes
Latrobe 73% -2.0% (879) 0.7% 0.3% 0.6% 0.5% 0.0% Yes
Medibank 81% 0.3% (4,813) 26.9% 18.5% 29.5% 24.4% 12.5% Yes
NIB 78% 3.0% (16,375) 8.5% 9.8% 6.1% 9.2% 10.8% Yes
Peoplecare 77% 1.3% (446) 0.5% 0.3% 0.1% 0.5% 0.4% Yes
Westfund 81% 7.3% (3,203) 0.7% 0.3% 0.1% 0.2% 0.2% Yes
Restricted membership funds
CBHS 92% 3.0% (2,857) 1.5% 1.6% 0.9% 1.4% 1.5% Yes
Defence Health 89% 5.0% (6,648) 2.1% 1.3% 1.0% 1.3% 1.3% Yes
Teachers Health 92% 5.0% (7,485) 2.4% 2.7% 1.3% 2.0% 3.2% Yes
TUH 83% 1.8% (678) 0.6% 0.5% 0.1% 0.4% 0.4% Yes

[1] The total gain or loss of members over the last two years, which takes into account consumers who take up membership and leave within that two year period.

[2] The industry experienced a growth of 0.55 per cent or 36,168 memberships overall.

Table 2B — Smaller funds (less than 0.5 per cent national market share)
Fund Name (Abbreviated) Member retention (hospital cover) Membership change [1] % (number) Number complaints Received Below market share? Number complaints investigated Below market share? Code of conduct member
Open membership funds
CBHS Corporate n/a 282% (595) 0 Yes 0 Yes No
CDH 89% 0.2% (6) 1 Yes 1 No No
GU Health Corporate 66% 0.7% (194) 35 No 4 No Yes
HCI 84% 7.3% (452) 8 No 0 Yes Yes
MDHF 88% 2.4% (364) 2 Yes 1 Yes No
MO Health n/a n/a 0 Yes 0 Yes No
Onemedifund 92% 1.6% (91) 0 Yes 0 Yes Yes
Phoenix 84% 9.1% (763) 11 No 3 No Yes
QCH 85% 9.1% (2,199) 3 Yes 0 Yes Yes
St Lukes 88% 6.5% (1,948) 8 Yes 0 Yes Yes
Transport Health 69% -16.5% (1,349) 15 No 1 No Yes
Restricted membership funds
ACA 92% 0.2% (12) 0 Yes 0 Yes Yes
Doctors' Health 88% 16.1% (2,665) 8 Yes 3 No Yes
Emergency Services n/a 283.5% (499) 0 Yes 0 Yes No
Navy Health 88% 4.9% (1,001) 5 Yes 1 Yes Yes
Nurses and Midwives n/a 270.8% (2,283) 3 No 0 Yes No
Police Health 91% 4.1% (879) 5 Yes 0 Yes Yes
Reserve Bank 89% -1.1% (27) 2 No 0 Yes Yes
RT Health Fund 87% 6.0% (1,406) 27 No 5 No Yes

[1] The industry experienced a growth of 0.55 per cent or 36,168 memberships overall.

Note: 'n/a' indicates no data as insurer commenced operations during 2017–18.

HOSPITAL

Table 3 provides a general comparison of health insurance for private hospital treatment. A higher percentage indicates that, on average, the fund's members are covered for a higher proportion of hospital charges.

It's important to remember most funds offer a choice of different policies—the percentages indicated in this table are not indicative of any single policy, but are an average of all policies offered by the fund.

Hospital policies

Table 3 provides a general comparison of health insurance for private hospital treatment (hospital policies) provided by each fund.

Hospital policies provide benefits towards the following costs if you elect to be a private patient in a private or public hospital:

  • hospital fees for accommodation, operating theatre charges and other charges raised by the hospital
  • the costs of drugs or prostheses required for hospital treatment
  • fees charged by doctors (surgeons, anaesthetists, pathologists, etc.) for in-hospital treatment.

Most funds offer a range of different policies providing hospital cover. These policies may differ on the basis of the range of treatments that are covered, to what extent those treatments are covered, the level of excess or co-payments you may be required to pay if you go to hospital and the price and discounts available to you.

Hospital charges covered

This column indicates the proportion of total charges associated with treatment of private patients covered by each fund's benefits. This includes charges for hospital accommodation, theatre costs, prostheses and specialist fees (not including the Medicare benefit), excesses or co-payments and associated benefits.

The figures shown are average outcomes across all of each fund's hospital policies. Higher cost policies will generally cover a greater proportion of charges than indicated by this average. Cheaper policies, including those with higher excesses or co-payments, may cover less.

The use of an average figure applying across all of each fund's policies will mean that funds with a high proportion of their membership in lower cost/restricted and excluded benefit policies will have a lower average figure.

Information is not provided for some funds in some states, where there were insufficient numbers reported to APRA—generally this occurs in states where the fund does not have a large membership.

The information provided in this table presents the position taking account of all of each fund's policies. It is not indicative of any individual policy offered by the fund but is an average for the total fund membership.

Additional information

The separate Health fund operations by state or territory tables in this report includes information on the number of 'agreement hospitals' under contract to each fund in each state.

For additional information on the medical gap benefits provided through hospital policies, please refer to the separate Medical gap schemes section.

The Ombudsman brochure 'Health Insurance Choice: Selecting a Health Insurance Policy' includes important advice on what factors to consider and what questions to ask when selecting a policy. It also includes information on government incentives relating to hospital policies such as the Medicare Levy Surcharge Exemption and Lifetime Health Cover. The brochure is available on ombudsman.gov.au and privatehealth.gov.au.

The privatehealth.gov.au website provides information about all private health insurance policies available in Australia, including benefits, prices and agreement hospitals for each health fund.

Table 3 — Hospital
Fund name (Abbreviated) % Hospital related charges covered [1]
ACTNSWVICQLDSAWATASNT
Open membership funds
Australian Unity 83.6% 87.3% 90.9% 88.6% 91.0% 88.8% 89.1% 82.6%
BUPA 81.2% 88.9% 92.8% 90.8% 95.2% 88.4% 93.8% 90.8%
CBHS Corporate 70.9% 87.1% 85.0% 95.2% 80.5% 96.6% n/a n/a
CDH 25.5% 96.4% 93.3% 78.2% 95.9% 71.7% 99.2% n/a
CUA Health 80.6% 88.6% 90.1% 92.0% 88.2% 89.0% 88.8% 81.0%
GMHBA 73.8% 80.7% 89.9% 84.4% 88.3% 87.6% 88.0% 83.6%
GU Health Corporate 85.6% 86.2% 88.9% 89.4% 89.9% 88.6% 89.5% 88.1%
HBF 84.7% 90.3% 93.5% 88.7% 94.0% 96.1% 95.9% 91.7%
HCF 87.7% 93.2% 93.4% 92.4% 95.1% 90.4% 93.4% 91.5%
HCI 96.7% 89.1% 94.2% 90.8% 94.2% 95.2% 95.7% 100.0%
Health.com.au 73.7% 81.0% 83.9% 83.8% 83.8% 84.5% 88.3% 85.1%
Health Partners 82.0% 89.0% 91.4% 91.5% 95.6% 89.9% 94.9% 90.9%
HIF 79.2% 86.9% 91.6% 90.3% 93.2% 92.2% 90.0% 86.5%
Latrobe 84.3% 88.0% 92.0% 91.6% 89.3% 89.9% 91.4% 87.8%
MDHF 84.2% 94.7% 94.4% 91.1% 89.1% 88.9% 97.4% 98.4%
Medibank 83.1% 89.4% 92.4% 89.9% 93.6% 90.4% 93.6% 90.0%
NIB 76.1% 87.4% 85.6% 84.2% 90.6% 84.9% 88.8% 78.0%
Onemedifund 93.7% 92.7% 95.0% 93.7% 96.4% 94.5% 94.7% n/a
Peoplecare 80.1% 91.7% 92.8% 90.6% 92.9% 90.7% 93.2% 91.7%
Phoenix 88.5% 94.1% 93.9% 93.1% 97.8% 94.0% 97.6% 89.6%
QCH 60.7% 90.8% 91.2% 89.5% 95.1% 90.8% 91.5% 80.9%
St Lukes 81.8% 93.2% 93.4% 91.4% 95.7% 86.3% 95.2% 48.5%
Transport Health 90.4% 89.9% 94.3% 91.2% 94.7% 95.0% 92.6% n/a
Westfund 86.8% 92.1% 96.3% 92.1% 97.0% 95.5% 92.2% 82.7%
Restricted membership funds
ACA 88.2% 94.3% 96.9% 92.4% 94.9% 97.9% 89.3% n/a
CBHS 84.8% 90.2% 94.3% 93.0% 95.8% 92.8% 95.6% 96.0%
Defence Health 84.3% 91.0% 93.7% 92.5% 94.8% 93.1% 94.7% 93.3%
Doctors' Health 90.8% 91.7% 92.3% 92.0% 89.5% 90.9% 91.7% 89.6%
Emergency Services 100.0% 93.1% 95.0% 96.5% 98.1% 94.4% 98.1% 78.7%
MO Health 56.6% 84.1% 84.8% 85.4% 81.9% 83.7% 67.3% n/a
Navy Health 86.6% 91.8% 93.4% 92.8% 94.0% 94.7% 95.1% 94.0%
Nurses and Midwives 50.4% 87.3% 89.9% 87.9% 89.9% 90.8% 94.0% n/a
Police Health 91.2% 90.9% 93.6% 92.6% 97.7% 93.7% 95.7% 92.7%
Reserve Bank 93.3% 92.5% 97.8% 97.2% 99.4% 97.1% 99.0% n/a
RT Health Fund 72.2% 94.3% 93.0% 93.3% 95.6% 93.8% 89.5% 92.9%
Teachers Health 86.7% 91.6% 93.0% 92.7% 94.3% 91.6% 94.2% 92.8%
TUH 89.8% 92.7% 90.6% 92.3% 94.6% 92.9% 96.6% 95.9%

[1] Includes charges for hospital accommodation, theatre costs, prostheses and specialist fees (not including the Medicare benefit) and associated benefits (after any excesses and co-payments are deducted).

Note: 'n/a' signifies no activity in that state. 100 per cent is likely to indicate small numbers (e.g. only 1 episode).

MEDICAL GAP SCHEMES

Health insurer 'medical gap schemes' are designed to eliminate or reduce the out-of-pocket costs incurred by a patient for in-hospital medical services. If a service is 'no gap,' it means no cost was incurred by the patient as the full cost was covered by Medicare and the health fund. A reduced cost is incurred by the patient for what is called a 'known gap' service.

If a health fund has a higher percentage of services covered at no gap than other funds, it indicates the fund has a more effective gap scheme in that state. The figures provided are averages—it is no guarantee that a particular doctor will choose to use the fund's gap scheme.

Fund gap schemes and agreements

Doctors are free to decide whether or not to use a particular fund's gap cover arrangements for each individual patient. Factors that can affect the acceptance of the scheme by doctors include:

  • whether the fund has a substantial share of the health insurance market in a particular state or region
  • the level of fund benefits paid under the gap arrangements (compared with the doctor's desired fee)
  • the design of the fund's gap cover arrangements, including any administrative burden for the doctor.

State-based differences

Information is provided on a state basis because the effectiveness of some funds' gap schemes can differ between states and these differences are not apparent in the national figures.

Most differences are due to the level of doctors' fees, which vary significantly between different states, and between regional areas and capital cities. In some states, funds are able to provide more effective coverage of gaps because doctors charge less than the national average. In addition, where a doctor's fee for an in-hospital service is at or below the Medicare Benefits Schedule fee, there will be no gap to the fund member.

If a health fund's percentage of services with no gap is higher than that of a fund in another state, it does not necessarily mean the fund's scheme is more effective, because state-based differences could be the cause.

Information is not provided for some funds in some states, as the numbers are not reported to APRA for states in which the fund does not have a sufficiently large membership (in which case, these figures are included with figures for the state in which a fund has the largest number of members).

Comparing different gap schemes

If a health fund has a higher percentage of services covered at no gap (in the same state/territory) compared with another fund, it is an indicator of a more effective gap scheme in that state. Over the whole fund, it is more likely that a medical service can be provided at no cost to the consumer, but it is no guarantee that a particular doctor will choose to use the fund's gap scheme.

Percentage of services with no gaps—the proportion of services for which a gap is not payable by the patient after the impact of fund benefits, schemes and agreements.

Percentage of services with no gap or where known gap payment made—this table includes both the percentage of no gap services and what is called 'known gap' services. Known gap schemes are an arrangement where the fund pays an additional benefit on the understanding that the provider advises the patient of costs upfront.

Tables 4A and 4B take into account all of the fund's policies. The information in the tables is not indicative of any individual policy offered by the fund but is an average for the total fund membership.

Table 4A — Medical services with no gap
Fund Name (Abbreviated) % of Services with no gap
ACTNSWVICQLDSAWATASNT
Open membership funds
Australian Unity 84.2% 91.3% 92.0% 92.3% 92.6% 88.5% 90.7% 82.1%
BUPA 81.9% 88.6% 89.0% 88.9% 88.8% 85.0% 89.5% 86.6%
CBHS Corporate 85.7% 67.8% 34.6% 96.0% 59.3% 89.7% n/a n/a
CDH n/a 88.1% 59.3% 66.0% 70.8% 59.1% 65.2% n/a
CUA Health 82.3% 91.0% 90.9% 94.2% 86.9% 88.7% 90.5% 86.7%
GMHBA 50.9% 74.6% 80.1% 81.3% 80.0% 70.8% 78.3% 61.0%
GU Health Corporate 83.1% 86.6% 88.8% 89.7% 90.6% 83.4% 85.3% 96.0%
HBF 45.3% 43.1% 34.8% 36.4% 36.0% 87.9% 38.9% 26.2%
HCF 80.2% 91.1% 89.5% 92.0% 90.3% 86.7% 88.8% 88.9%
HCI 91.4% 85.9% 90.4% 90.7% 90.7% 90.3% 92.3% 100.0%
Health.com.au 74.1% 84.7% 86.7% 87.6% 83.1% 85.3% 90.8% 89.3%
Health Partners 85.0% 91.2% 89.5% 94.0% 93.1% 83.7% 98.1% 86.5%
HIF 69.5% 84.8% 87.7% 88.3% 87.0% 86.3% 86.8% 78.8%
Latrobe 45.1% 78.4% 77.7% 81.8% 84.9% 67.5% 74.2% 34.4%
MDHF 28.6% 84.1% 82.6% 80.1% 79.7% 76.7% 88.3% 75.7%
Medibank 80.0% 88.4% 85.1% 88.6% 89.9% 72.1% 92.1% 82.9%
NIB 66.2% 92.6% 91.4% 85.9% 93.6% 81.8% 85.3% 77.2%
Onemedifund 56.5% 89.6% 92.7% 94.5% 90.7% 82.7% 92.3% n/a
Peoplecare 78.6% 92.5% 90.8% 91.5% 90.7% 87.4% 93.6% 85.1%
Phoenix 81.3% 92.3% 90.4% 90.8% 93.7% 86.7% 92.6% 83.9%
QCH 60.8% 93.2% 91.8% 91.7% 90.8% 85.5% 85.7% 72.5%
St Lukes 74.2% 87.2% 83.1% 76.9% 85.9% 79.7% 91.2% 60.0%
Transport Health 70.8% 88.5% 92.5% 91.2% 94.5% 90.6% 73.0% n/a
Westfund 59.4% 92.4% 93.0% 89.4% 92.3% 88.0% 76.8% 86.3%
Restricted membership funds
ACA 89.2% 91.1% 93.5% 94.0% 93.9% 92.9% 95.4% n/a
CBHS 85.0% 89.0% 90.9% 92.4% 90.7% 85.6% 93.1% 87.2%
Defence Health 79.5% 89.3% 91.1% 92.4% 90.3% 88.0% 91.4% 88.7%
Doctors' Health 87.2% 92.4% 93.4% 94.1% 91.0% 90.8% 88.5% 76.9%
Emergency Services 100.0% 88.8% 93.0% 91.5% 89.4% 81.5% 66.7% 54.2%
MO Health 75.0% 84.8% 85.4% 91.7% 93.8% 75.8% 14.3% n/a
Navy Health 82.6% 90.4% 91.9% 91.8% 93.3% 88.3% 92.6% 86.9%
Nurses and Midwives 76.5% 85.1% 84.3% 90.7% 86.9% 86.9% 80.3% n/a
Police Health 80.5% 87.7% 86.7% 88.8% 90.9% 81.7% 89.2% 83.3%
Reserve Bank 79.2% 91.4% 93.3% 95.7% 97.8% 90.2% 92.7% n/a
RT Health Fund 86.9% 93.4% 91.4% 93.5% 90.8% 87.3% 91.1% 84.8%
Teachers Health 82.0% 90.5% 90.7% 92.7% 89.9% 86.1% 92.8% 89.8%
TUH 86.9% 91.2% 85.1% 93.1% 86.7% 89.2% 96.2% 98.2%

Note: 'n/a' signifies no activity or very low activity in that state. 100 per cent is likely to indicate small numbers (e.g. only 1 episode).

Table 4B — Medical services with no gap or where known gap payment made
Fund Name (Abbreviated)% of Services with no gap or where known gap payment made
ACTNSWVICQLDSAWATASNT
Open membership funds
Australian Unity 93.3% 96.6% 97.7% 96.7% 98.5% 95.7% 97.6% 91.8%
BUPA 90.0% 93.4% 93.8% 92.5% 94.7% 91.8% 94.3% 92.8%
CBHS Corporate 85.7% 78.2% 65.4% 96.9% 92.6% 92.6% n/a n/a
CDH 50.0% 97.6% 84.8% 90.1% 95.8% 100.0% 100.0% n/a
CUA Health 96.6% 97.2% 98.2% 98.1% 98.9% 96.1% 99.5% 93.9%
GMHBA 77.3% 90.9% 92.8% 93.7% 94.9% 85.2% 89.5% 89.5%
GU Health Corporate 92.8% 94.8% 97.5% 96.3% 98.9% 94.2% 92.5% 96.0%
HBF 98.0% 98.9% 99.6% 99.4% 99.6% 99.7% 99.6% 99.1%
HCF 95.6% 98.5% 99.4% 99.1% 99.8% 98.1% 99.4% 98.7%
HCI 98.1% 94.7% 97.7% 96.5% 97.7% 99.4% 99.0% 100.0%
Health.com.au 92.8% 95.3% 97.4% 96.3% 97.6% 96.1% 98.7% 96.6%
Health Partners 93.8% 96.8% 97.7% 97.8% 99.7% 92.2% 98.3% 100.0%
HIF 88.4% 95.5% 98.0% 96.7% 98.9% 97.1% 96.8% 92.4%
Latrobe 99.7% 99.4% 99.9% 99.7% 99.9% 99.1% 99.5% 98.4%
MDHF 53.1% 97.7% 98.8% 93.8% 95.8% 93.0% 107.5% 100.0%
Medibank 92.4% 96.3% 93.8% 94.8% 99.0% 87.7% 98.3% 94.2%
NIB 66.2% 92.6% 91.4% 85.9% 93.6% 81.8% 85.3% 77.2%
Onemedifund 100.0% 96.3% 99.0% 98.4% 99.5% 94.2% 99.0% n/a
Peoplecare 92.7% 97.8% 98.6% 97.5% 99.1% 96.6% 99.3% 96.8%
Phoenix 95.4% 98.8% 98.9% 97.8% 99.7% 97.2% 100.0% 94.6%
QCH 81.0% 97.4% 97.2% 97.7% 99.1% 94.1% 95.0% 93.8%
St Lukes 82.0% 92.1% 90.4% 82.1% 93.0% 88.1% 98.7% 100.0%
Transport Health 93.1% 96.2% 98.6% 98.0% 100.0% 98.4% 86.5% n/a
Westfund 68.2% 96.8% 98.1% 96.1% 98.3% 96.6% 84.6% 98.0%
Restricted membership funds
ACA 95.4% 97.1% 99.1% 98.2% 99.7% 97.8% 101.3% n/a
CBHS 95.9% 96.4% 98.2% 97.3% 98.6% 95.5% 98.8% 95.5%
Defence Health 93.6% 96.6% 98.8% 97.7% 99.4% 96.3% 98.2% 96.4%
Doctors' Health 97.4% 98.2% 99.1% 98.7% 98.8% 97.7% 97.9% 97.5%
Emergency Services 100.0% 96.0% 98.1% 96.2% 100.0% 100.0% 100.0% 79.2%
MO Health 95.0% 94.9% 97.0% 100.0% 93.8% 93.7% 100.0% n/a
Navy Health 94.5% 97.0% 98.6% 97.6% 99.3% 97.2% 98.1% 94.0%
Nurses and Midwives 96.1% 95.9% 96.5% 96.0% 97.0% 95.4% 91.5% n/a
Police Health 96.5% 95.3% 97.2% 96.5% 99.4% 94.4% 98.5% 94.7%
Reserve Bank 83.3% 96.9% 99.3% 98.3% 99.1% 98.5% 100.0% n/a
RT Health Fund 96.7% 98.1% 98.5% 98.1% 99.3% 96.0% 99.4% 100.0%
Teachers Health 95.1% 97.2% 98.7% 97.9% 99.2% 95.9% 98.9% 98.1%
TUH 92.8% 97.2% 97.5% 97.9% 100.0% 96.9% 99.2% 99.1%

Note: 'n/a' signifies no activity or very low activity in that state. 100 per cent is likely to indicate small numbers (e.g. only 1 episode).

GENERAL TREATMENT (EXTRAS)

General treatment or extras policies provide benefits towards a range of out-of-hospital health services. The most commonly included services are dental, optical, physiotherapy and non-Pharmaceutical Benefits Scheme prescription medicines.

Table 5A (on page 26) shows the average proportion of service charges covered by each fund per state for all their policies and services. Table 5B (on page 27) shows the information according to the service being covered. Generally, higher-cost policies cover a higher proportion of charges.

General treatment

General treatment policies, also known as 'ancillary' or 'extras', provide benefits towards a range of health-related services not provided by a doctor, including, but not limited to:

  • dental fees and charges
  • optometry—cost of glasses and lenses
  • physiotherapy, chiropractic services and other therapies including natural and complementary therapies
  • prescribed medicines not covered by the Pharmaceutical Benefits Scheme.

Percentage of charges covered, all services, by state

Table 5A indicates what proportion of total charges, associated with general treatment services, is covered by each fund's benefits. This is an average of outcomes across all of each fund's general treatment policies and services. Higher cost policies will generally cover a greater proportion of charges than indicated by this average, while cheaper policies may cover less.

Average costs covered for each service type

Table 5B provides information on the proportion of the total charge for each service type covered by each fund on average, across all of the fund's general treatment policies.

This is intended to provide a broad comparative indicator of fund general treatment benefits to allow comparisons between funds and should not be regarded as an indicator of how much of a bill for any particular service will be covered.

Ambulance

Some funds do not provide ambulance cover through any of their general treatment policies but offer this as a component of hospital cover. These funds show as 'n/a' under the ambulance column. Most ambulance services in Queensland and Tasmania are provided free to residents of those states.

Preferred providers

Many funds establish 'preferred provider' or 'participating provider' arrangements with some suppliers of general treatment services. Those providers offer an agreed charge for fund members, resulting in lower out-of-pocket costs for members after fund benefits are taken into account. It is usually worth checking with your fund to see if a suitable preferred provider is available in your area.

Fund dental and eyecare centres

In some states, some funds operate their own dental and optical centres. These are usually only located in capital cities or major population centres.

Consumers who choose to use a fund's own dental or optical centre will normally get services at a lower out of pocket cost.

Additional information

The Ombudsman brochure 'Health Insurance Choice: Selecting a Health Insurance Policy' includes important advice on what to consider and what questions to ask when selecting a general treatment policy. The brochure is available at ombudsman.gov.au.

The Ombudsman's consumer website privatehealth.gov.au provides information about all private health insurance policies available in Australia, including benefits, prices and which hospitals a health fund has agreements with.

Table 5A — General treatment (extras)
Fund Name (Abbreviated) % General treatment (extras) charges covered
ACTNSWVICQLDSAWATASNT
Open membership funds
Australian Unity 44.7% 47.1% 50.6% 50.5% 53.8% 49.5% 47.6% 49.7%
BUPA 45.9% 50.0% 49.0% 53.2% 55.1% 58.1% 51.4% 58.7%
CBHS Corporate 36.7% 50.5% 51.9% 55.2% 58.2% 43.2% 44.4% 56.4%
CDH 36.5% 39.1% 41.9% 36.7% 37.0% 37.8% 43.6% n/a
CUA Health 43.2% 53.3% 49.6% 46.3% 49.3% 48.1% 44.9% 42.3%
GMHBA 51.9% 54.7% 50.9% 54.7% 55.3% 51.7% 50.2% 51.8%
GU Health Corporate 72.9% 74.3% 75.5% 73.0% 74.1% 76.1% 74.8% 76.2%
HBF 47.4% 50.8% 51.3% 51.6% 55.0% 58.4% 57.0% 56.5%
HCF 48.6% 51.0% 56.0% 57.9% 61.6% 59.0% 50.8% 51.7%
HCI 44.8% 55.9% 55.4% 50.5% 52.5% 51.5% 48.5% 54.8%
Health.com.au 2.9% 51.6% 53.2% 52.3% 54.4% 54.3% 54.1% 52.9%
Health Partners 49.7% 46.8% 43.7% 39.4% 57.1% 39.2% 45.6% 49.2%
HIF 42.0% 46.6% 46.6% 47.4% 50.2% 47.6% 46.5% 47.0%
Latrobe 25.1% 41.1% 35.5% 33.8% 37.3% 41.7% 34.0% 33.1%
MDHF 42.3% 54.3% 56.4% 49.2% 54.2% 46.4% 57.1% 51.4%
Medibank 47.9% 51.3% 53.1% 55.0% 59.0% 57.5% 54.0% 59.8%
NIB 53.6% 53.9% 58.4% 55.7% 59.8% 58.5% 55.5% 58.2%
Onemedifund 47.2% 52.3% 54.8% 53.0% 57.6% 55.6% 55.6% n/a
Peoplecare 48.2% 50.2% 49.0% 48.5% 52.1% 47.8% 46.7% 48.6%
Phoenix 48.5% 53.6% 54.1% 53.5% 57.2% 52.8% 51.8% 56.4%
QCH 44.9% 48.8% 48.4% 52.6% 53.5% 47.0% 50.3% 44.9%
St Lukes 58.2% 64.2% 61.5% 61.0% 65.8% 59.4% 60.7% 61.0%
Transport Health 42.1% 48.8% 54.5% 49.1% 50.1% 48.0% 54.2% 48.2%
Westfund 44.7% 50.2% 48.0% 53.4% 49.5% 48.9% 44.2% 42.1%
Restricted membership funds
ACA 57.7% 60.4% 61.5% 61.2% 66.0% 63.3% 57.6% 62.1%
CBHS 44.9% 49.1% 50.8% 51.6% 54.1% 51.0% 50.1% 45.3%
Defence Health 45.1% 48.8% 51.2% 51.5% 55.7% 51.7% 49.3% 53.4%
Doctors' Health 55.2% 53.8% 55.4% 56.5% 58.4% 55.6% 59.5% 52.2%
Emergency Services 58.8% 61.7% 64.9% 67.1% 67.3% 69.7% 61.5% 73.9%
MO Health 57.1% 58.0% 60.2% 59.8% 57.1% 62.3% 49.2% 56.9%
Navy Health 45.3% 49.4% 54.0% 51.4% 55.4% 52.5% 51.6% 51.7%
Nurses and Midwives 52.3% 53.4% 52.8% 52.7% 59.4% 56.3% 49.9% 47.8%
Police Health 65.2% 65.9% 68.9% 68.5% 71.1% 69.4% 67.8% 69.5%
Reserve Bank 71.1% 72.9% 73.7% 73.1% 81.0% 75.7% 77.8% 77.2%
RT Health Fund 45.7% 51.3% 47.9% 49.3% 52.2% 48.1% 46.5% 45.8%
Teachers Health 44.9% 50.2% 50.7% 50.3% 53.7% 52.0% 49.6% 46.9%
TUH 46.8% 50.0% 48.5% 55.5% 55.8% 49.6% 51.2% 50.0%

Note: 'n/a' signifies no activity in that state. 100 per cent is likely to indicate small numbers (e.g. only 1 episode).

Table 5B — General treatment (extras)
  Average amount of costs covered by service
Fund Name (Abbreviated) Dental [1] Optical [1]PhysiotherapyChiropracticPharmacyPodiatry Natural therapiesAmbulanceAcupuncture Psychology/Group Therapy Preventative health Hearing aids and Audiology Occupational Therapy
Open membership funds
Australian Unity 46.2% 64.8% 62.3% 47.3% 36.7% 47.3% 46.5% 99.1% 39.9% 34.2% 72.1% 15.2% 44.4%
BUPA 54.3% 56.7% 48.9% 50.3% 36.0% 48.8% 37.7% 99.9% 40.9% 42.2% 27.6% 18.4% 34.9%
CBHS Corporate 48.5% 54.8% 55.8% 60.2% 41.2% 52.1% 52.6% 0.0% 54.7% 46.6% 22.5% 42.7% 33.9%
CDH 39.8% 51.4% 49.7% 43.4% 41.9% 35.4% 27.6% 100.0% 43.1% 21.7% 58.3% n/a 28.2%
CUA Health 50.5% 60.7% 39.3% 42.2% 13.0% 56.0% 40.0% 100.0% 46.1% 35.3% 56.7% 33.5% 39.0%
GMHBA 52.0% 58.3% 48.8% 51.1% 38.7% 49.7% 46.6% 88.6% 47.9% 46.8% 61.1% 26.2% 43.6%
GU Health Corporate 79.2% 67.2% 82.8% 79.2% 53.5% 78.4% 80.6% 99.9% 78.8% 78.2% 53.6% 17.0% 87.6%
HBF 60.8% 59.1% 44.1% 46.2% 51.1% 49.4% 49.9% 99.9% n/a 42.4% 80.4% 31.3% 46.8%
HCF 58.3% 57.3% 43.8% 42.6% 36.2% 40.6% 32.5% 100.0% 31.2% 46.7% 47.2% 28.6% 45.1%
HCI 53.4% 53.6% 44.6% 53.4% 46.4% 45.8% 54.3% 100.0% 59.1% 33.7% 59.4% 49.4% 40.6%
Health.com.au 50.3% 45.9% 60.0% 59.4% 32.8% 60.0% 59.6% 100.0% 58.0% 0.7% n/a 10.5% 56.5%
Health Partners 60.3% 53.9% 59.2% 43.9% 48.3% 32.4% 25.7% 99.6% 29.8% 32.6% 68.1% 31.8% 38.1%
HIF 49.0% 59.9% 36.8% 36.9% 41.8% 36.6% 23.2% 99.1% 22.0% 34.2% 36.3% 30.3% 34.3%
Latrobe 32.6% 54.1% 33.2% 35.6% 23.5% 36.5% 25.4% 76.5% 41.8% 33.1% 28.8% 13.6% 40.3%
MDHF 61.8% 65.4% 43.0% 46.7% 24.4% 46.1% 39.2% 82.2% 33.6% 27.3% 49.1% 22.3% 34.3%
Medibank 52.5% 68.1% 47.8% 53.0% 25.7% 51.7% 51.8% 100.0% 43.4% 30.8% 56.3% 26.5% 36.7%
NIB 56.0% 53.4% 58.4% 57.4% 41.4% 56.4% 54.2% 100.0% 55.4% 55.2% 47.1% 19.2% 56.6%
Onemedifund 58.9% 51.8% 53.2% 46.7% 39.6% 45.2% 38.7% 99.1% 38.3% 33.8% 72.1% 52.4% 42.5%
Peoplecare 49.1% 61.6% 40.3% 43.8% 35.8% 40.2% 38.7% 99.6% 42.2% 38.5% 65.6% 34.4% 37.9%
Phoenix 57.2% 61.3% 50.2% 47.7% 40.3% 51.4% 35.4% 99.2% 44.9% 41.2% 49.7% 41.0% 43.7%
QCH 52.3% 58.7% 46.6% 60.2% 38.6% 60.7% 40.3% n/a 43.6% 44.3% 41.4% 35.7% 38.5%
St Lukes 64.6% 75.9% 52.4% 52.9% 41.2% 48.5% 42.3% 85.9% 46.6% 48.5% 53.2% 47.0% 49.1%
Transport Health 55.5% 58.3% 45.6% 54.3% 33.1% 52.3% 41.7% 100.0% 35.0% 29.9% 54.5% 33.3% 30.2%
Westfund 54.7% 53.6% 50.0% 55.7% 39.1% 46.9% 40.2% 99.7% 37.8% 39.3% 68.1% 38.8% 48.9%
Restricted membership funds
ACA 64.6% 71.6% 43.9% 49.4% 46.2% 72.7% 38.5% 99.6% 38.1% 49.9% n/a 41.8% 58.6%
CBHS 50.0% 52.8% 52.1% 60.6% 41.5% 44.3% 44.5% 96.6% 45.7% 40.9% 43.2% 36.0% 35.3%
Defence Health 49.6% 52.3% 53.2% 55.3% 45.7% 51.8% 39.2% 100.0% 35.6% 49.1% 93.4% 29.7% 49.6%
Doctors' Health 58.6% 61.0% 46.5% n/a 46.5% 50.7% n/a n/a n/a 51.0% 30.8% 21.4% 38.7%
Emergency Services 67.5% 55.9% 73.3% 75.7% 46.9% 66.5% 35.2% 100.0% 75.5% 77.8% n/a 25.2% 65.2%
MO Health n/a 66.8% n/a 56.8% 62.2% 100.0% 29.8% 62.0% 100.0% n/a 61.5% 61.9% 61.2%
Navy Health 48.0% 58.8% 54.6% 61.5% 45.7% 53.7% 46.7% 99.4% n/a 42.2% 100.0% 29.2% 36.5%
Nurses and Midwives 54.8% 60.9% 45.9% 61.7% 43.2% 58.0% 45.7% 100.0% 42.8% 41.5% 52.2% 21.3% 59.2%
Police Health 70.1% 67.3% 75.7% 77.1% 44.6% 68.6% 39.5% 98.9% 75.6% 75.7% 100.0% 36.4% 71.0%
Reserve Bank 72.6% 71.7% 71.9% 73.6% 62.3% 79.8% 77.7% 98.9% 77.1% 76.3% 40.0% 77.1% 70.8%
RT Health Fund 48.7% 62.7% 51.7% 51.6% 39.0% 47.3% 40.5% 100.0% 52.5% 21.5% 50.0% 29.2% 31.4%
Teachers Health 53.0% 53.9% 45.2% 57.6% 39.9% 56.4% 46.1% 100.0% 42.2% 41.3% 40.0% 35.5% 59.8%
TUH 60.1% 54.1% 49.3% 55.0% 36.5% 60.0% 51.1% 90.7% 44.7% 44.3% 49.8% 44.3% 37.6%

[1] For some funds, the data does not take account of discounts at some providers or fund dental/optical centres.

Note: All percentages based on health fund reporting to APRA. 'n/a' signifies no activity and 100 per cent is likely to indicate small numbers (e.g. only 1 episode).

FINANCES AND COSTS

All health funds are required to meet financial management standards to ensure their members' contributions are protected. Generally, funds aim to set premium levels so their income from contributions covers the expected cost of benefits plus the fund's administration costs.

The percentage of contribution income which goes towards administration and management expenses is a key measure of fund efficiency.

The regulation of health fund finances

The Private Health Insurance Act 2007 (the Act) specifies solvency and capital adequacy standards for funds to meet and outlines financial management and reporting requirements for all funds.

The Private Health Insurance (Prudential Regulation) Act 2015 (the Prudential Regulation Act) ensures that private health insurers must comply with prudential standards made by APRA and with directions given by APRA. APRA has monitoring and investigative powers in relation to private health insurers in order to monitor the financial performance of the funds and ensure that they meet prudential requirements.

Premium increases

Under the Act, health funds require the approval of the Minister for Health before they can raise their premiums.

The Minister assesses premium applications to ensure proposed increases are kept to the minimum necessary. This takes into consideration fund solvency requirements, forecast benefit payments and prudential requirements, while also ensuring the affordability and value of private health insurance as a product.

Finances and Costs

The following Finances and Costs table (table 6) is drawn from data collected by APRA for the purposes of an annual publication providing financial and operational statistics for the funds for each financial year.2

Benefits as a percentage of contributions

This column in Table 6 shows the percentage of total contributions, received by the fund, returned to contributors in benefits. Funds will generally aim to set premium levels so that contribution income covers the expected costs of benefits plus the fund's administration costs.

A very high percentage of contributions returned as benefits may not necessarily be a positive factor for consumers, particularly if it means that the fund is making a loss on its health insurance business. This indicator should therefore be considered in conjunction with other factors, such as the Surplus (-loss) and Management Expenses ratings.

Management expenses

Management expenses are the costs of administering the fund. They include items such as rent, staff salaries, and marketing costs.

As a percentage of contribution income

This figure is regarded as a key measure of fund efficiency. In this table, management expenses are shown as a proportion of total fund contributions.

Per average policy

A comparison of the relative amount each fund spends on administration costs is also demonstrated through provision of information on the level of management expenses per membership by each fund.

On average, restricted membership funds have lower management expenses as a proportion of benefits paid then open membership funds. This is partially due to lower expenditure on marketing. However, unusually low management expenses by some restricted membership funds can also be the result of those funds receiving free or subsidised administrative services from the organisations with which they are associated.

Surplus (-loss) from health insurance

The surplus or loss (indicated as a negative figure) made by the fund in 2017–18 from their health insurance business is expressed as a percentage of the fund's contribution income. This does not take account of additional income that the fund may derive from investment or other non-health insurance activities.

All health funds maintain a sufficient level of reserves to cover losses from year to year. However funds with high or continuing losses might be expected to have to increase premiums by a higher relative amount than other funds.

Overall profit (-loss) as a percentage of total revenue

The overall profit or loss (indicated as a negative figure) takes account of additional income made by the fund, mainly through investment. This is shown as a percentage of all revenue received by the fund to allow a comparison of performance between funds of differing sizes. Overall profit takes into account tax that is paid for a small amount of funds.

Not-for-profit fund

If a health fund is listed as 'not-for-profit' this means it is a mutual organisation, with the premiums paid into the fund used to operate the business and cover benefits for members.

'For-profit' funds aim to return a profit to their owners (which may be another health fund or corporation) or shareholders.

Table 6 — Finances and costs
Fund name (Abbreviated) Benefits as % contributions Management expenses Surplus (-Loss) from health insurance Overall profit (- Loss) as % total revenue Not-for-profit fund
as % of contribution income Per average policy (see MREAust Tab)
Open membership funds
Australian Unity 81.5% 11.1% $387 7.5% 6.2% No
BUPA 85.0% 7.8% $288 7.2% 6.1% No
CBHS Corporate n/a n/a n/a n/a n/a No
CDH 83.4% 13.2% $568 3.4% 5.1% Yes
CUA Health 83.5% 9.8% $362 6.7% 6.1% No
GMHBA 87.0% 11.5% $398 1.4% 3.3% Yes
GU Health Corporate 78.1% 12.7% $771 9.2% 8.2% No
HBF 90.2% 9.7% $311 0.1% 3.5% Yes
HCF 89.0% 9.5% $355 1.5% 4.5% Yes
HCI 91.2% 11.2% $425 -2.4% 0.1% Yes
Health.com.au 86.7% 6.1% $194 7.2% 5.6% No
Health Partners 87.6% 9.6% $359 2.7% 9.0% Yes
HIF 91.3% 11.7% $351 -3.0% 1.1% Yes
Latrobe 88.5% 9.0% $339 2.5% 4.8% Yes
MDHF 87.3% 8.1% $258 4.6% 5.3% Yes
Medibank 83.4% 8.4% $291 8.2% 7.3% No
NIB 82.7% 10.5% $333 6.8% 6.4% No
Onemedifund 78.2% 8.4% $448 13.4% 10.3% No
Peoplecare 91.8% 9.6% $387 -1.4% 1.5% Yes
Phoenix 88.5% 8.7% $396 2.8% 5.2% Yes
QCH 88.9% 10.1% $462 1.0% 2.6% No
St Lukes 89.7% 11.4% $469 -1.1% 2.5% Yes
Transport Health 87.2% 13.8% $455 -1.0% 1.2% No
Westfund 80.3% 15.4% $605 4.3% 6.3% Yes
Restricted membership funds
ACA 82.2% 11.5% $605 6.3% 8.9% Yes
CBHS 91.6% 7.8% $331 0.6% 4.0% Yes
Defence Health 94.1% 6.5% $253 -0.6% 3.2% Yes
Doctors' Health 82.9% 10.4% $547 6.7% 5.7% No
Emergency Services n/a n/a n/a n/a n/a Yes
MO Health n/a n/a n/a n/a n/a No
Navy Health 91.0% 9.7% $383 -0.7% 5.7% Yes
Nurses and Midwives 104.2% 33.7% $1,171 -37.9% -34.3% Yes
Police Health 91.1% 6.8% $381 2.1% -3.3% Yes
Reserve Bank 85.4% 11.9% $763 2.6% 4.7% Yes
RT Health Fund 83.8% 13.7% $621 2.5% -12.4% Yes
Teachers Health 88.3% 7.0% $292 1.5% 3.3% Yes
TUH 84.9% 9.4% $455 5.8% 7.3% Yes

Note: 'n/a' indicates no data as insurer commenced operations during 2016–17 or 2017–18.

HEALTH FUND OPERATIONS BY STATE OR TERRITORY

Some funds have little presence in most states but may have a large market share in one state or territory. Every fund will still have agreements with hospitals throughout Australia even if they don't have a local branch network or a significant proportion of policy holders in each state. Australian health insurance policies are usually priced according to the policy holder's state of residence, but the benefits extend nation-wide.

Some funds use different brand names or offer different policies in different states and territories. The following separate tables for each state/territory are therefore provided to give an indication of the extent and importance of each fund's business in each area.

Most fund websites allow members to view fund information, join or change their policy and submit claims. Links to all health fund websites are available at Table 1 — Health fund listing and contact details.

Percentage market share

This column (in Tables 7A–7H) indicates how much of the total health insurance business within each state or territory each fund accounts for. It is an indicator of the size and significance of each fund within each state.

Funds with a significant market share in the relevant state or territory can normally be expected to have more extensive networks of branch offices, agencies, agreement hospitals and preferred ancillary providers in those states/territories. They are also more likely to obtain the participation of doctors in their gap cover arrangements. However, funds participating in schemes such as the Australian Health Services Alliance (AHSA) will generally have access to a wide range of agreement hospitals in all states.

Percentage of fund's membership in state

This column (in Tables 7A–7H) indicates how much of each fund's health insurance membership is within each state. It is an indicator of how significant that state is to each fund's health insurance business.

In general, funds can be expected to design their policies (benefits, conditions, contracts, etc.) to suit the arrangements applying in the states in which they do a significant proportion of business. However, some nationally-based funds tailor their policies and prices to take account of different state arrangements.

Health fund costs differ from state to state, which accounts for the variation in premiums across states.

Agreement hospitals3

All health funds establish agreements with some or all private hospitals and day hospitals for the treatment of their members. These agreements generally provide for the fund to meet all of the private hospital's charges for treatment of the fund's members. The member is not required to pay any amount to the hospital, other than any agreed excess or co-payment and any incidental charges that may apply for certain extra services (e.g. television rental or internet).4

Where a fund has a comparatively low number of agreements with private hospitals or private day hospitals, this is an indicator that consumer choices about the location of their treatment may be more limited. Treatment at a non-agreement hospital will mean a significantly higher out of pocket cost for the patient.

While funds do not have agreements with public hospitals, all funds will fully cover hospital costs for treatment as a private patient in a public hospital unless the particular treatment is excluded under the individual's policy, or there is an extra charge for a private room or similar extra costs.

Fund outlets—retail offices and agencies

Retail offices are full-service offices operated by health funds with staff employed by the fund.

Agencies are generally limited service outlets operated by the fund or under arrangements with pharmacies, credit unions, etc.

Tables 7A–7H, indicate whether the fund operates retail offices and/or agencies in the state or territory.

Table 7A — New South Wales
Fund name (Abbreviated) % Fund market share this state % Fund's membership in this state Agreement hospitals [1] Fund outlets
Private hospitals Private day hospitals Retail officesAgencies
Open membership funds
Australian Unity 1.6% 18.1% 93 88   
BUPA 25.2% 31.6% 89 76 Yes  
CBHS Corporate 0.0% 53.6% 75 65   
CDH 0.1% 88.6% 68 29 Yes  
CUA Health 0.4% 25.6% 96 90 Yes  
GMHBA 1.2% 16.5% 97 90   
GU Health Corporate 0.7% 51.3% 97 94   
HBF 0.9% 3.8% 93 86   
HCF 19.6% 60.5% 80 87 Yes  
HCI 0.0% 12.3% 96 99   
Health.com.au 0.6% 35.5% 81 73   
Health Partners 0.0% 1.8% 97 90   
HIF 0.3% 12.2% 95 92   
Latrobe 0.2% 7.6% 76 53   
MDHF 0.1% 11.0% 77 51   Yes
Medibank 23.0% 28.3% 84 81 Yes Yes
NIB 13.8% 53.3% 97 94 Yes  
Onemedifund 0.1% 41.2% 97 90 Yes  
Peoplecare 0.7% 45.6% 97 90 Yes  
Phoenix 0.2% 45.4% 96 89 Yes  
QCH 0.0% 1.6% 93 88   
St Lukes 0.1% 3.7% 75 48   
Transport Health 0.0% 14.7% 97 90   
Westfund 1.3% 60.7% 96 91 Yes  
Restricted membership funds
ACA 0.1% 57.8% 96 90 Yes  
CBHS 2.1% 45.5% 76 65   
Defence Health 1.2% 18.2% 97 90   Yes
Doctors' Health 0.4% 39.9% 97 90   
Emergency Services 0.0% 23.7% 94 91   
MO Health 0.09% 35.8% 93 89   
Navy Health 0.3% 29.7% 94 89   
Nurses and Midwives 0.1% 49.1% 95 89   
Police 0.0% 2.3% 94 91   
Reserve Bank 0.1% 61.3% 97 90 Yes  
RT Health Fund 0.6% 49.5% 97 90 Yes  
Teachers Health 4.9% 68.6% 96 91 Yes  
TUH 0.1% 4.4% 96 92   

[1] Agreement hospitals data is sourced from Privatehealth.gov.au as of 10 January 2019.

Table 7B — Victoria
Fund name (Abbreviated) % Fund market share this state % Fund's membership in this state Agreement hospitals [1] Fund outlets
Private hospitals Private day hospitals Retail officesAgencies
Open membership funds
Australian Unity 7.4% 60.9% 76 72 Yes  
BUPA 23.7% 21.3% 74 59 Yes  
CBHS Corporate 0.0% 16.0% 70 46   
CDH 0.0% 4.6% 69 42   
CUA Health 0.4% 17.0% 76 72 Yes Yes
GMHBA 6.3% 63.3% 78 71 Yes Yes
GU Health Corporate 0.4% 22.3% 76 72   
HBF 1.2% 3.7% 76 70   
HCF 6.7% 14.8% 67 48 Yes  
HCI 0.1% 24.3% 76 76   
Health.com.au 0.8% 33.7% 68 59   
Health Partners 0.1% 4.8% 78 71   
HIF 0.6% 15.6% 74 73   
Latrobe 2.4% 88.2% 74 61 Yes Yes
MDHF 0.9% 84.4% 73 60 Yes Yes
Medibank 32.8% 28.9% 68 52 Yes  
NIB 7.7% 21.3% 75 70 Yes  
Onemedifund 0.1% 24.9% 78 71   
Peoplecare 0.7% 32.8% 78 71 Yes  
Phoenix 0.1% 23.5% 74 70   
QCH 0.0% 0.9% 77 71   
St Lukes 0.1% 5.5% 72 60   
Transport Health 0.3% 68.9% 78 71   
Westfund 0.0% 1.5% 76 72   
Restricted membership funds
ACA 0.0% 12.9% 76 72   
CBHS 1.5% 24.4% 70 46   
Defence Health 2.6% 29.9% 78 71 Yes Yes
Doctors' Health 0.4% 29.3% 78 71   
Emergency Services 0.0% 25.0% 77 72   
MO Health 0.13% 36.6% 75 71   
Navy Health 0.4% 27.5% 75 71 Yes  
Nurses and Midwives 0.1% 25.3% 76 73   
Police 0.1% 3.5% 77 72   
Reserve Bank 0.0% 23.0% 78 71   
RT Health Fund 0.2% 12.3% 78 71   
Teachers Health 1.5% 15.1% 77 72 Yes  
TUH 0.1% 3.5% 77 71   

[1] Agreement hospitals data is sourced from Privatehealth.gov.au as of 10 January 2019.

Table 7C — Queensland
Fund name (Abbreviated) % Fund market share this state % Fund's membership in this state Agreement hospitals [1] Fund outlets
Private hospitals Private day hospitals Retail officesAgencies
Open membership funds
Australian Unity 2.0% 12.7% 52 46   
BUPA 32.0% 21.5% 53 42 Yes  
CBHS Corporate 0.0% 14.3% 46 33   
CDH 0.0% 4.9% 39 23   
CUA Health 1.7% 52.5% 52 46 Yes Yes
GMHBA 1.5% 11.5% 52 49   
GU Health Corporate 0.3% 10.3% 54 48   
HBF 0.8% 1.8% 50 44   
HCF 7.0% 11.7% 47 38 Yes  
HCI 0.1% 10.9% 57 51   
Health.com.au 0.6% 18.9% 44 37   
Health Partners 0.1% 2.1% 52 49   
HIF 0.5% 9.6% 52 44   
Latrobe 0.1% 2.3% 53 32   
MDHF 0.0% 1.8% 47 31   
Medibank 32.2% 21.1% 52 41 Yes Yes
NIB 6.4% 13.2% 56 47 Yes  
Onemedifund 0.1% 12.6% 52 49   
Peoplecare 0.4% 12.1% 52 49   
Phoenix 0.1% 14.5% 52 46   
QCH 2.1% 95.4% 50 46 Yes Yes
St Lukes 0.1% 2.9% 48 31   
Transport Health 0.1% 11.9% 52 49   
Westfund 1.4% 35.0% 53 48 Yes  
Restricted membership funds
ACA 0.1% 19.4% 53 48   
CBHS 1.3% 15.4% 46 33   
Defence Health 3.5% 29.2% 52 49   Yes
Doctors' Health 0.4% 21.3% 52 49   
Emergency Services 0.0% 25.0% 50 44   
MO Health 0.08% 17.1% 53 45   
Navy Health 0.3% 18.8% 52 43   
Nurses and Midwives 0.0% 10.3% 52 48   
Police 0.7% 34.6% 50 44   
Reserve Bank 0.0% 6.4% 52 49   
RT Health Fund 0.7% 33.6% 52 49 Yes  
Teachers Health 0.4% 3.4% 53 47   
TUH 3.0% 90.9% 53 48 Yes  

[1] Agreement hospitals data is sourced from Privatehealth.gov.au as of 10 January 2019.

Table 7D — South Australia
Fund name (Abbreviated) % Fund market share this state % Fund's membership in this state Agreement hospitals [1] Fund outlets
Private hospitals Private day hospitals Retail officesAgencies
Open membership funds
Australian Unity 1.5% 4.1% 25 24   
BUPA 48.7% 14.3% 25 26 Yes  
CBHS Corporate 0.0% 3.3% 26 20   
CDH 0.0% 0.9% 21 7   
CUA Health 0.1% 1.1% 25 26   
GMHBA 0.5% 1.5% 24 29   
GU Health Corporate 0.1% 1.7% 25 27   
HBF 0.6% 0.6% 25 25   
HCF 6.9% 5.0% 23 19 Yes  
HCI 0.0% 2.6% 26 29   
Health.com.au 0.2% 2.8% 26 23   
Health Partners 7.4% 90.0% 24 29 Yes Yes
HIF 0.3% 2.6% 25 28   
Latrobe 0.0% 0.6% 22 18   
MDHF 0.1% 2.1% 22 14   
Medibank 22.0% 6.3% 27 19 Yes Yes
NIB 3.5% 3.2% 24 27   
Onemedifund 0.1% 5.0% 24 29   
Peoplecare 0.3% 4.8% 24 29   
Phoenix 0.2% 12.0% 25 24   
QCH 0.0% 0.2% 25 24   
St Lukes 0.1% 1.6% 22 14   
Transport Health 0.0% 1.8% 24 29   
Westfund 0.1% 0.9% 25 26   
Restricted membership funds
ACA 0.0% 3.4% 25 26   
CBHS 0.9% 4.6% 26 20   
Defence Health 2.3% 8.4% 24 29   Yes
Doctors' Health 0.1% 3.3% 24 29   
Emergency Services 0.0% 13.5% 25 25   
MO Health 0.0% 2.2% 25 25   
Navy Health 0.2% 5.6% 25 25   
Nurses and Midwives 0.0% 7.3% 24 24   
Police 1.5% 35.2% 25 25 Yes  
Reserve Bank 0.0% 3.5% 24 29   
RT Health Fund 0.1% 1.7% 24 29   
Teachers Health 1.9% 6.3% 25 25   
TUH 0.0% 0.2% 25 25   

[1] Agreement hospitals data is sourced from Privatehealth.gov.au as of 10 January 2019.

Table 7E — Western Australia
Fund name (Abbreviated) % Fund market share this state % Fund's membership in this state Agreement hospitals [1] Fund outlets
Private hospitals Private day hospitals Retail officesAgencies
Open membership funds
Australian Unity 0.5% 2.4% 19 21   
BUPA 11.5% 5.8% 20 18 Yes  
CBHS Corporate 0.0% 8.4% 16 11   
CDH 0.0% 0.3% 16 8   
CUA Health 0.1% 2.2% 21 23 Yes  
GMHBA 0.9% 5.0% 22 23   
GU Health Corporate 0.4% 12.2% 21 25   
HBF 53.1% 89.4% 24 23 Yes Yes
HCF 3.3% 4.1% 18 13 Yes  
HCI 0.0% 1.3% 21 23   
Health.com.au 0.2% 5.4% 18 17   
Health Partners 0.0% 0.5% 22 23   
HIF 3.7% 58.4% 21 23 Yes Yes
Latrobe 0.0% 0.4% 18 13   
MDHF 0.0% 0.3% 18 13   
Medibank 20.2% 9.9% 21 20 Yes Yes
NIB 2.9% 4.5% 23 23   
Onemedifund 0.1% 11.2% 22 23   
Peoplecare 0.1% 2.6% 22 23   
Phoenix 0.0% 2.8% 21 22   
QCH 0.0% 0.5% 19 23   
St Lukes 0.0% 0.5% 17 13   
Transport Health 0.0% 1.5% 22 23   
Westfund 0.0% 0.7% 21 23   
Restricted membership funds
ACA 0.0% 4.3% 21 23   
CBHS 0.8% 7.1% 16 11   
Defence Health 0.7% 4.4% 22 23   Yes
Doctors' Health 0.1% 2.4% 22 23   
Emergency Services 0.0% 5.2% 20 23   
MO Health 0.04% 5.8% 19 23   
Navy Health 0.2% 7.2% 20 23   
Nurses and Midwives 0.0% 3.3% 21 23   
Police 0.3% 13.5% 20 23   
Reserve Bank 0.0% 3.2% 22 23   
RT Health Fund 0.0% 1.5% 22 23   
Teachers Health 0.5% 3.1% 21 23   
TUH 0.0% 0.2% 21 23   

[1] Agreement hospitals data is sourced from Privatehealth.gov.au as of 10 January 2019.

Table 7F — Tasmania
Fund name (Abbreviated) % Fund market share this state % Fund's membership in this state Agreement hospitals [1] Fund outlets
Private hospitals Private day hospitals Retail officesAgencies
Open membership funds
Australian Unity 1.0% 0.7% 8 3   
BUPA 34.3% 2.7% 8 5 Yes  
CBHS Corporate 0.0% 1.7% 8 2   
CDH 0.0% 0.4% 8 2   
CUA Health 0.1% 0.4% 8 3   
GMHBA 1.1% 1.0% 5 7   
GU Health Corporate 0.1% 0.4% 8 5   
HBF 0.8% 0.2% 9 3   
HCF 3.6% 0.7% 8 4   
HCI 2.3% 47.5% 8 5 Yes  
Health.com.au 0.2% 0.7% 8 3   
Health Partners 0.1% 0.2% 5 4   
HIF 0.2% 0.6% 8 5   
Latrobe 0.2% 0.5% 6 8   
MDHF 0.0% 0.2% 8 6   
Medibank 28.0% 2.1% 5 4 Yes  
NIB 2.6% 0.6% 5 6   
Onemedifund 0.2% 4.9% 5 4   
Peoplecare 0.2% 0.7% 5 4   
Phoenix 0.0% 0.6% 6 3   
QCH 0.0% 0.2% 8 3   
St Lukes 20.0% 85.6% 8 6 Yes Yes
Transport Health 0.0% 0.5% 5 4   
Westfund 0.1% 0.3% 8 3   
Restricted membership funds
ACA 0.0% 1.3% 8 3   
CBHS 1.1% 1.5% 8 2   
Defence Health 1.2% 1.2% 5 4   Yes
Doctors' Health 0.1% 0.9% 5 4   
Emergency Services 0.0% 1.9% 8 4   
MO Health 0.02% 0.4% 8 3   
Navy Health 0.2% 1.3% 8 3   
Nurses and Midwives 0.1% 2.3% 5 3   
Police 0.5% 2.9% 8 4   
Reserve Bank 0.0% 1.1% 5 4   
RT Health Fund 0.1% 0.4% 5 4   
Teachers Health 1.2% 1.1% 8 3   
TUH 0.1% 0.3% 8 3   

[1] Agreement hospitals data is sourced from Privatehealth.gov.au as of 10 January 2019.

Table 7G — Australian Capital Territory
Fund name (Abbreviated) % Fund market share this state % Fund's membership in this state Agreement hospitals [1] Fund outlets
Private hospitals Private day hospitals Retail officesAgencies
Open membership funds
Australian Unity 1.4% 1.0% 5 7   
BUPA 21.9% 1.7% 4 5 Yes  
CBHS Corporate 0.0% 2.5% 5 4   
CDH 0.0% 0.4% 4 3   
CUA Health 0.3% 1.0% 6 7 Yes  
GMHBA 1.3% 1.2% 5 4   
GU Health Corporate 0.3% 1.5% 6 7   
HBF 1.0% 0.3% 4 7   
HCF 14.6% 2.8% 5 6 Yes  
HCI 0.0% 1.0% 6 8   
Health.com.au 0.7% 2.3% 6 6   
Health Partners 0.1% 0.3% 5 7   
HIF 0.3% 0.8% 6 7   
Latrobe 0.1% 0.4% 5 6   
MDHF 0.0% 0.1% 5 6   
Medibank 28.6% 2.2% 5 4 Yes  
NIB 15.2% 3.6% 6 7 Yes  
Onemedifund 0.0% 0.2% 5 7   
Peoplecare 0.4% 1.3% 5 7   
Phoenix 0.1% 1.0% 6 7   
QCH 0.0% 0.2% 5 6   
St Lukes 0.0% 0.2% 5 6   
Transport Health 0.0% 0.7% 5 7   
Westfund 0.3% 0.8% 6 7   
Restricted membership funds
ACA 0.0% 0.8% 6 7   
CBHS 1.0% 1.3% 5 4   
Defence Health 7.5% 7.3% 5 7   Yes
Doctors' Health 0.4% 2.5% 5 7   
Emergency Services 0.0% 1.5% 6 7   
MO Health 0.08% 1.9% 6 7   
Navy Health 1.4% 8.7% 6 7   
Nurses and Midwives 0.0% 1.9% 6 7   
Police 0.1% 0.5% 6 7   
Reserve Bank 0.0% 1.3% 5 7   
RT Health Fund 0.1% 0.7% 5 7   
Teachers Health 2.6% 2.2% 5 7   
TUH 0.1% 0.3% 5 7   

[1] Agreement hospitals data is sourced from Privatehealth.gov.au as of 10 January 2019.

Table 7H   — Northern Territory
Fund name (Abbreviated) % Fund market share this state % Fund's membership in this state Agreement hospitals [1] Fund outlets
Private hospitals Private day hospitals Retail officesAgencies
Open membership funds
Australian Unity 0.5% 0.1% 2 1   
BUPA 37.9% 1.1% 1 1 Yes  
CBHS Corporate 0.0% 0.1% 1 0   
CDH 0.0% 0.0% 1 0   
CUA Health 0.1% 0.2% 2 1   
GMHBA 0.3% 0.1% 2 1   
GU Health Corporate 0.1% 0.2% 2 1   
HBF 2.0% 0.2% 2 1   
HCF 5.2% 0.4% 1 1   
HCI 0.0% 0.1% 2 1   
Health.com.au 0.5% 0.6% 1 1   
Health Partners 0.1% 0.1% 2 1   
HIF 0.2% 0.2% 2 1   
Latrobe 0.0% 0.1% 1 1   
MDHF 0.0% 0.1% 1 1   
Medibank 40.2% 1.2% 1 1 Yes  
NIB 2.9% 0.3% 2 1   
Onemedifund 0.0% 0.0% 2 1   
Peoplecare 0.1% 0.1% 2 1   
Phoenix 0.0% 0.2% 2 1   
QCH 0.5% 0.9% 2 1   
St Lukes 0.0% 0.0% 1 1   
Transport Health 0.0% 0.1% 2 1   
Westfund 0.1% 0.1% 2 1   
Restricted membership funds
ACA 0.0% 0.1% 2 1   
CBHS 0.4% 0.2% 1 0   
Defence Health 3.9% 1.4% 2 1   Yes
Doctors' Health 0.1% 0.4% 2 1   
Emergency Services 0.1% 4.1% 2 1   
MO Health 0.02% 0.2% 2 1   
Navy Health 0.4% 1.1% 2 1   
Nurses and Midwives 0.0% 0.4% 2 1   
Police 3.1% 7.4% 2 1   
Reserve Bank 0.0% 0.1% 2 1   
RT Health Fund 0.1% 0.2% 2 1   
Teachers Health 0.9% 0.3% 2 1   
TUH 0.1% 0.1% 2 1   

[1] Agreement hospitals data is sourced from Privatehealth.gov.au as of 10 January 2019.

ABOUT THE PRIVATE HEALTH INSURANCE OMBUDSMAN

The Private Health Insurance Ombudsman (PHIO) protects the interests of people who are covered by private health insurance, through our complaint-handling, consumer information and advice services, as well as advice to government and industry about issues of concern to consumers in relation to private health insurance.

The Private Health Insurance Ombudsman

The PHIO is one of the roles of the Commonwealth Ombudsman. The Ombudsman deals with enquiries and complaints about any aspect of private health insurance. Our Office is independent of the private health funds, private and public hospitals and health service providers.

We deal with complaints about private health insurance, including private health funds, brokers, hospitals, medical practitioners, dentists or other practitioners. Generally, anyone can make a complaint as long as it relates to private health insurance.

How do I make a complaint?

You should first contact your health fund or the organisation or provider you're complaining about—they may be able to resolve your complaint for you.

If your fund doesn't provide a satisfactory response, you can contact us in one of the following ways:

Website: ombudsman.gov.au (including online complaints form)

Call: 1300 362 072

Write: Private Health Insurance Ombudsman, Commonwealth Ombudsman, GPO Box 442, CANBERRA ACT 2601

Email: privatehealthinsuranceombudsman@ombudsman.gov.au

Please include:

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

We'll let you know if any other information is needed.

WHAT HAPPENS AFTER I MAKE A COMPLAINT?

Many complaints result from misunderstandings. Your case officer may be able to resolve your complaint by explaining what has happened and why.

Otherwise, we'll contact your health fund or the body you are complaining about to get their explanation and any suggestions they have for fixing the problem. We deal with most complaints by phone or email, and most can be settled quickly.

Where complaints are more complex, we will write to the health fund or other body, seeking further information or recommending a certain course of action. Your case officer will keep you regularly informed, usually by telephone. They 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?

You can seek information about private health insurance information by:

We also have brochures and publications about private health insurance arrangements which you can find on our website or which we can post on request.

Who can I contact if my complaint is about a medical issue?

Complaints about the quality of service or clinical treatment provided by a health professional or a hospital should be directed to the health care complaints body for your state or territory. These are listed in the state government section of your telephone directory. You can also find a contact list on privatehealth.gov.au under Links.

TEN TIPS FOR AVOIDING HEALTH INSURANCE PROBLEMS

  1. Consider taking out the highest level of hospital cover you can afford and choosing a higher excess, rather than restrictions or exclusions, to save money on premiums.
  2. Review your Private Health Information Statement (PHIS) every year. Think about whether your policy will continue to meet your needs over the coming year. This is particularly important if you are thinking about starting a family, or your health needs are changing as you grow older.
  3. Read all of the information your fund sends you carefully. Important information about your cover will be sent in a personalised letter and should not be ignored.
  4. Ensure your premiums are up to date. If you pay by direct debit, check your bank or credit card statements every month to ensure payments are being correctly deducted.
  5. Tell your fund if you change address, add a partner, have a child, or any other circumstance which might affect your cover.
  6. Make sure you understand any waiting periods, restrictions or limits applying to your cover.
  7. Contact your fund before you go to hospital to check whether you will be covered and what costs you may need to pay yourself.
  8. Talk to your doctors about their fees and ask whether they will bill you under your health fund's gap scheme.
  9. If you decide to change funds, make sure you understand the difference in benefits before changing.
  10. Visit privatehealth.gov.au for information and advice about private health insurance.

More information can be found in the 'Health Insurance Choice' and 'Ten Golden Rules' brochures, available at privatehealth.gov.au and ombudsman.gov.au.

FOOTNOTES

1 For the purposes of this report, Australian registered private health insurers are referred to as 'health funds'.

2 The 'Operations of the Private Health Insurers' report is available on the APRA website: apra.gov.au.

3 According to privatehealth.gov.au, 10 January 2019, or as supplied by the fund.

4 These agreements do not apply to fees charged by private doctors for in-hospital treatment, these medical fees may be covered by a fund's medical gap scheme arrangements.