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.

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: