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.
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.
- Referral to Fund Guidelines (November 2010)
Pre-Existing Conditions - Best Practice Guidelines
The Best Practice Guidelines were released by the Department of Health in September 2001.
- Best Practice Guidelines for Health Funds (September 2001)
- Best Practice Guidelines for Hospitals (September 2001)
A Quick Guide to the Private Health Insurance Ombudsman’s New Inspection Powers
This document summarises the Office's powers to conduct inspections of private health insurance insurers and health insurance brokers. These powers came into effect in September 2018 following amendments to the Ombudsman Act 1976.
This document was developed in consultation with private health insurance industry stakeholders in 2019. It includes answers to frequently asked questions regarding how and when the new powers are likely to be used, and how this may affect insurers and brokers.
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.
- PHIO Mediation Guidelines (September 2012)
- PHIO Mediation Role - Frequently Asked Questions (September 2012)
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.
- Agreement Termination – Transition and Communication Protocols (version 1.2, December 2009)
Detrimental Changes to Health Fund Policies
PHIO's recommendations for insurers in relation to advising members of detrimental policy changes:
- Quarterly Bulletin 45 (December 2007)
- Quarterly Bulletin 69 (December 2013)
Consultations
The following are consultation drafts of our Mediation Guidelines and Transition and Termination Guidelines for Hospitals and Insurers. The current guidelines were developed in consultation with industry stakeholders several years ago. Although the processes have not significantly changed, the guidelines have been updated to reflect the current private health insurance environment and to reflect that the Private Health Insurance Ombudsman is now a function of the Commonwealth Ombudsman.
- Mediation Guidelines and FAQs—this document assists stakeholders in assessing whether mediation of a complaint is required and the process for facilitating the process.
- Termination and Transition Guidelines for Hospitals and Insurers—this document provides guidance on appropriate transitional arrangements and communication with health insurer members and patients in the event of a hospital contract cessation or dispute.
Feedback on the updated guidelines can be sent to phi@ombudsman.gov.au. The consultation period will close on 20 December 2019.