Private Health Insurance Ombudsman State of the Health Funds Report 2019

Relating to the financial year 2018–19

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

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Foreword

I am pleased to present the 15th annual State of the Health Funds Report, relating to the financial year 2018–19. The Ombudsman Act 1976 requires that the Private Health Insurance Ombudsman (PHIO) publish the report after the end of each financial year to provide comparative information on the performance and service delivery of all health funds [1] during that 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 itself, makes it easier for 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 preparation of this report.

Photo of Michael Manthorpe PSM’s signature.

Michael Manthorpe PSM

Commonwealth Ombudsman

February 2020

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 this Office 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 indicators.
  • 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 won't necessarily indicate which of the fund's policies to purchase. Most funds offer more expensive policies that can be expected to provide better than average benefits as well as cheaper policies that provide less benefits.

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.

Consumers can use the information contained in this report to identify possible funds to join, or to assess their current fund's performance relative to other funds.

The range of indicators included in this report allow consumers to focus on factors of most importance to them—not all factors will be of equal importance to every individual or family.

For example, if a consumer prefers to do business with a health fund in person, then the availability of retail offices would be an important consideration. However, if they prefer to do as much of their business as possible online, the range of services available through the funds' websites will be more important.

More information about particular indicators is provided in the explanations preceding each of the tables in this report.

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

Where to find more information about selecting a policy

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

Further information, brochures and factsheets on private health insurance can be found at ombudsman.gov.au. Some brochures can also be obtained in hard copy on request from the Ombudsman's Office.

Fund names

In this report, health funds are referred to by an abbreviation of their registered name, rather than any brand name 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 this 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.

Data collection

The majority of data selected by the Ombudsman as the most appropriate available is collected by the industry regulator, APRA. While funds report to APRA for regulatory purposes, some of this information is useful to consumers and is therefore reproduced in this report. As this data is collected primarily for regulatory purposes, 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 very much dependent on the consumer’s individual circumstances, preferences and priorities. For this reason, it would not be valid to average all the scores indicated to obtain some form of consolidated performance or service delivery score.

The report provides consumers with 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 is 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 for which there is reliable comparative information available.

Key consumer issues

Complaints and enquiries in 2018–19

In 2018–19 we received 4,042 complaints, an 11 per cent decrease on the previous year’s total of 4,553. The number of consumer information enquiries received relating to private health insurance increased by 5 per cent to 3,064 enquiries compared to 2,956 enquiries over the previous financial year.

Figure 1—Total complaints and enquiries by year

Complaints have increased significantly over the last decade.

Complaints

The number of complaints about almost all issues reduced compared to the previous year, showing a general improvement across the industry.

Concerns about Benefits, Membership and Service continued to be the major cause of complaints to our Office.

The most significant Benefit complaint issues were general treatment (extras/ancillary) benefits, and complaints about unexpected hospital policy exclusions and restrictions.

General treatment complaints usually concern disputes over the amount payable under ‘extras’ policies such as dental, optical, physiotherapy and pharmaceuticals, or the insurer’s rules for benefit payments (such as certain minimum claim criteria).

Some basic and budget levels of hospital cover exclude or restrict services that many consumers assume are routine treatments or standard items. We anticipate that the number of complaints about benefits will reduce in future years with the implementation of private health insurance reforms in 2019–20 that standardise clinical categories and give consumers more certainty about their benefits.

Delays in benefit payments and complaints about hospital and medical ‘gaps’, resulting in an out of pocket expense to patients, also represented a significant proportion of complaints received.

Membership complaints typically involved policy administration issues, such as the processing of 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 complaints.

Service issues are usually not the sole reason for complaints and a service failure is often just part of a complaint made to our Office. The combination of unsatisfactory customer service, delays in responding to simple issues and poor internal escalation processes can cause policyholders to become more aggrieved and dissatisfied with the insurer.

Figure 2—Complaint issues over previous three years

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

Enquiries

The majority of enquiries received by our Office are general queries about how private health insurance works and what factors should be considered when selecting a policy. Twenty-eight per cent of enquiries in 2018–19 fell into this category of private health insurance queries.

Nineteen per cent of enquiries were about Lifetime Health Cover (LHC). LHC is a set of rules which determines what an individual pays for private hospital insurance. Generally, if a person purchases hospital cover earlier in life and maintains cover, they will avoid paying an extra amount called 'LHC loading'. Some exemptions can apply for new Australian residents and Australians who have been living overseas. We experience an increase in contacts about LHC in the May to June period each year, as the deadline to take up private hospital insurance without incurring an extra LHC loading for most individuals is 30 June.

Consumers also contacted our Office to seek information about government incentives such as the government rebate and Medicare levy surcharge, health insurance for visitors to Australia, the role of the Ombudsman and general advice about Australia’s healthcare system.

Some contacts received via our consumer website privatehealth.gov.au also provided feedback about website content and the tools available to consumers, such as the policy search feature and the LHC calculators.

Private health insurance reforms

From 1 April 2019, the Australian Government introduced reforms to help make private health insurance simpler, and make it easier for people to choose the cover that best suits them.

Four new tiers of hospital cover were introduced in early 2019 and will become mandatory from 1 April 2020. These tiers are Gold, Silver, Bronze and Basic.

A number of other reforms have also been implemented, including the new Private Health Information Statement (PHIS) to summarise every policy, better access to mental health treatment in hospital, removal of benefits for some natural therapies, discounts for 18 to 29 year olds, and travel and accommodation benefits for rural consumers.

The wide-ranging nature of these reforms means almost every insured person has been or will be affected. It is pleasing to note that our Office received a relatively small number of complaints about the reforms (61 complaints in2018–19), relative to the privately insured population, and that most of these complaints did not require escalation. Feedback from the industry also indicated that generally the reforms have been well received by consumers.

We will continue to monitor the impact of the reforms on consumers as the new product tiers become mandatory on 1 April 2020.

Consumer website privatehealth.gov.au

The website privatehealth.gov.au is Australia’s leading independent source of consumer information about private health insurance. It is also the only website that allows users to search the features and premium costs of every policy available in Australia.

In 2018–19 we received 1,740 enquiries via the consumer website, which we responded to with information and advice. Of those enquiries, 68 per cent were received by email or web form, and 32 per cent by telephone via the dedicated website hotline.

Website usage has continued to grow every year since the website's original launch in 2007, with 1,441,712 visits in 2018–19, an increase of over 9 per cent compared to the previous financial year.

Figure 3—privatehealth.gov.au visitors per year

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

On 1 April 2019, the Office launched an updated version of its privatehealth.gov.au website. The website’s new features include:

  • Information about the government’s private health insurance reforms, including new product tiers for hospital policies (Gold, Silver, Bronze and Basic).
  • An improved search feature for comparing policies that allows users to filter results based on the services they are most interested in, or the premium they would like to pay. Search results are displayed in a vertical ‘tile’ format, allowing users to compare policies side-by-side.
  • A simpler PHIS, which summarises the most important features of the policy. Users can download, print or email copies of the PHIS to consider the information at a time that suits them.
  • A new premium estimator so users can decide whether to compare policies according to the base premiums or an estimated premium, which takes into account their rebate and/or LHC loading.
  • An updated look and feel, including compatibility with mobile devices.
  • Improvements to existing features such as the agreement hospitals finder, which shows what hospitals are covered by each insurer.
  • Reviewed and enhanced security settings.

Pre-existing condition complaints

As part of our role, we investigate complaints from consumers about pre-existing condition (PEC) decisions and ensure the PEC rules have been correctly applied by the insurer. The Office acts as an independent third party when dealing with complaints about PEC waiting periods.

The number of PEC complaints received by the Office has risen over the past five years from 283 in 2014–15 to 349 in 2018–19.

The Office regularly publishes information about complaint issues for the industry and consumers. Insurer responsibilities in making PEC determinations have been regularly covered in our quarterly bulletins and other publications.

In making determinations about complaints about the PEC waiting period, the Office ensures the waiting period has been applied correctly and that the insurer and hospital have complied with the Pre-Existing Condition Best Practice Guidelines. In circumstances where individual complaints highlight systemic issues with the application of the private health insurance regulatory framework, the Office may provide feedback to the insurer in our complaint finalisation correspondence, or the Ombudsman may initiate an own motion investigation or refer the matter to the regulator—for PEC matters this is the Department of Health.

We encourage policyholders in the first instance to speak with their health insurer if they have any concerns about a PEC assessment, including whether the decision was made by a medical practitioner as required by the legislation. If they are not satisfied, they can contact our Office for advice or to lodge a complaint.

Medical specialists’ out of pocket costs

On 2 March 2019, the Australian Government announced activities to increase the transparency of medical specialists’ out of pocket costs. This includes the development of a new website to provide improved transparency of costs and an education initiative.

A Medical Costs Finder tool is now available on the Department of Health website at health.gov.au/medical-costs-finder. Initially the tool will help people understand the cost of common medical procedures provided by specialists in the private health system. Over time more treatments and functionality are being added so people will be able to find costs for specialists’ services outside of hospital and also see the fees for particular medical specialists. The website helps people understand the impact of Medicare and any private health insurance arrangements on the amount patients pay.

The Medical Costs Finder also includes information explaining costs in the private and public health systems for people being treated either in or out of hospital.

Our Office continues to monitor complaint trends about out of pocket costs and provides a number of resources for consumers on this topic, including a factsheet on Informed Financial Consent [2] and a brochure on Doctors Bills. [3] Consumers can also find information on out of pocket expenses and gap doctor arrangements for people with health insurance on our website privatehealth.gov.au.

Health fund listing and contact details

The following table lists 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
AbbreviationFull name or other namesPhone NumberWebsite
Australian UnityAustralian Unity Health Ltd132 939australianunity.com.au
BUPABupa HI Pty Ltd134 135bupa.com.au
CBHS CorporateCBHS Corporate Health Pty Ltd1300 586 462cbhscorporatehealth.com.au
CDHCDH – Hunter Health Insurance02 4990 1385hunterhi.com.au
CUA HealthCUA Health Ltd1300 499 260cua.com.au/health
GMHBAGMHBA Ltd, Frank1300 446 422gmhba.com.au
GU Health CorporateGrand United Corporate Health1800 249 966guhealth.com.au
HBFHBF Health Ltd133 423hbf.com.au
HCFHospitals Contribution Fund of Australia131 334hcf.com.au
HCIHealth Care Insurance Ltd1800 804 950hciltd.com.au
Health.com.auHealth.com.au1300 199 802health.com.au
Health PartnersHealth Partners Ltd1300 113 113healthpartners.com.au
HIFHealth Insurance Fund of Australia Ltd1300 134 060hif.com.au
LatrobeLatrobe Health Services1300 362 144latrobehealth.com.au
MDHFMildura Health Fund Ltd03 5023 0269mildurahealthfund.com.au
MedibankMedibank Private Ltd, Australian Health Management132 331;
134 246
medibank.com.au;
ahm.com.au
MO HealthMyOwn Health Insurance1300 300 338myown.com.au
NIBNIB Health Funds Ltd, Qantas Assure, APIA131 463nib.com.au
OnemedifundNational Health Benefits Australia Pty Ltd1800 148 626onemedifund.com.au
PeoplecarePeoplecare Health Insurance Limited1800 808 690peoplecare.com.au
PhoenixPhoenix Health Fund Ltd1800 028 817phoenixhealthfund.com.au
QCHQueensland Country Health Fund Ltd1800 813 415qldcountryhealth.com.au
St LukesSt. Lukes Health1300 651 988stlukes.com.au
Transport HealthTransport Health Pty Ltd1300 806 808transporthealth.com.au
WestfundWestfund Limited1300 937 838westfund.com.au
Restricted Membership Health Funds
AbbreviationFull name or other namesPhone NumberWebsite
ACAACA Health Benefits Fund1300 368 390acahealth.com.au
CBHSCBHS Health Fund Ltd1300 654 123cbhs.com.au
Defence HealthDefence Health Ltd1800 335 425defencehealth.com.au
Doctors' HealthThe Doctors' Health Fund1800 226 126doctorshealthfund.com.au
Emergency ServicesEmergency Services Health Pty Ltd1300 703 703eshealth.com.au
NavyNavy Health Ltd1300 306 289navyhealth.com.au
Nurses and MidwivesNurses and Midwives Health Pty Ltd1300 344 000nmhealth.com.au
Police HealthPolice Health1800 603 603policehealth.com.au
Reserve BankReserve Bank Health Society Ltd1800 027 299myrbhs.com.au
RT Health FundRailway and Transport Health Fund Ltd1300 886 123rthealthfund.com.au
Teachers HealthTeachers Health Fund1300 728 188teachershealth.com.au
TUHTeachers' Union Health Fund1300 360 701tuh.com.au

Service Performance

The level of complaints that we receive 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 policyholders over the year from 30 June 2018 to 30 June 2019. Both the percentage change and number are included. Negative figures indicate that the fund has experienced a net reduction in membership over the period. As indicated above, member deaths would contribute to this figure.

Ombudsman complaints in context

The number of complaints received by this Office is very small compared to fund membership.

There are a number of factors (other than service performance) that can influence the level of complaints we receive 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

The first table (2A) 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 2019) 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. Where a fund had a higher complaints percentage than its market share, it indicated that members of that fund were 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 this Office about the fund. All complaints includes complaints investigated as well as complaints that were finalised without the need for investigation.

Complaints investigated is a measure of the percentage of complaints that required a higher level of intervention from the Ombudsman, in relation to all complaints investigated. Most complaints to the Ombudsman can be finalised by referring the matter to fund staff to resolve, or by 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 complaint handling.

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

For funds with less than 0.5 per cent of the national market share, 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 shows the actual number of all complaints received and the number of complaints investigated, as well as whether the number is below 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 of conduct 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.

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 shareComplaints % compared to market share %Code of conduct member
BenefitsServiceAll complaintsComplaints investigated
Open membership funds
Australian Unity78%-4.5% (8441)2.7%5.0%5.8%5.0%1.6%Yes
BUPA83%-1.4% (23,832)25.8%19.2%16.5%24.0%33.1%Yes
CUA Health77%3.6% (1,383)0.6%0.8%1.1%0.7%1.4%Yes
GMHBA71%-0.7% (1,051)2.3%4.3%2.4%3.7%3.5%Yes
HBF83%-4.0% (20,570)7.5%5.3%5.0%6.1%4.3%Yes
HCF86%4.8% (33,640)11.1%16.3%14.9%15.4%14.6%Yes
Health.com.au70%2.2% (835)0.6%1.8%0.4%1.3%3.3%No
Health Partners88%4.8% (2,046)0.7%0.4%0.2%0.5%0.8%Yes
HIF72%-3.6% (1,967)0.8%1.0%1.3%1.1%0.5%Yes
Latrobe74%0.4% (159)0.7%0.5%0.6%0.5%0.8%Yes
Medibank79%0.8% (15,039)26.9%21.1%33.1%22.3%16.5%Yes
NIB79%1.9% (10,968)8.6%11.0%8.0%8.4%8.9%Yes
Peoplecare78%-3.8% (1,371)0.5%0.3%0.6%0.6%1.1%Yes
Westfund88%12.6% (5,972)0.8%0.6%0.7%0.6%0.0%Yes
Restricted membership funds
CBHS80%2.6% (2,632)1.5%2.1%2.2%1.7%2.7%Yes
Defence Health 88%2.4% (3,317)2.1%1.2%0.4%1.1%1.4%Yes
Teachers Health91%3.9% (6,068)2.4%4.3%1.3%2.5%0.3%Yes
TUH84%1.4% (533)0.6%0.8%0.0%0.5%0.5%Yes
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 ReceivedBelow market share?Number complaints investigatedBelow market share?Code of conduct member
Open membership funds
CBHS Corporate70%N/A1Yes0YesYes
CDH87%6.3% (164)1Yes0YesNo
GU Health Corporate65%5.8% (1,659)1No5NoYes
HCI81%-5.8% (384)5Yes1YesYes
MDHF89%3.4% (531)3Yes1NoNo
MO Health N/AN/A8No0YesNo
Onemedifund92%1.1% (65)0Yes0YesYes
Phoenix83%1.2% (110)14No1NoYes
QCH85%4.7% (1,226)5Yes1YesYes
St Lukes87%5.0% (1,580)11Yes2YesYes
Transport Health69%-10.0% (682)10No1NoYes
Restricted membership funds
ACA92%1.4% (70)2Yes0YesYes
Doctors' Health88%14.0% (2,688)11Yes1YesYes
Emergency ServicesN/A94.1% (635)3Yes1YesNo
Navy Health86%5.2% (1,113)12No1YesYes
Nurses and MidwivesN/A52.9% (1,654)2No0YesNo
Police Health91%5.2% (1,161)1Yes1YesYes
Reserve Bank88%-0.6% (14)0Yes0YesYes
RT Health Fund86%-0.3% (85)21No2NoYes

[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.

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

Private hospital treatment

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

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.

Table 3 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 is no activity in that state reported to APRA—generally this occurs in states where the fund does not have a large membership.

Hospital related charges covered (%) is calculated as: (Hospital benefits paid by insurer/fees excluding medicare benefit)*100.

‘Fees’ is equal to the total amount the patient would have to pay to the provider(s) in the absence of any private health insurance, inclusive of hospital, medical and prostheses fees. This amount excludes the Medicare benefit. The difference between fees charged and benefits paid is the amount that the patient has to pay (out of pocket costs).

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 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 Unity83.9%87.4%91.4%87.4%89.8%88.4%90.7%81.0%
BUPA83.6%89.6%93.3%91.4%95.3%89.1%94.3%90.7%
CBHS Corporate80.7%82.8%70.0%85.0%91.3%93.0%80.9%N/A
CDH71.6%95.8%85.5%94.9%96.7%90.9%89.9%N/A
CUA Health81.4%89.3%90.6%92.3%89.4%89.4%89.6%82.5%
GMHBA69.8%81.2%90.1%84.3%88.6%87.8%89.2%75.7%
GU Health Corporate85.9%85.6%89.1%87.5%89.4%88.0%92.5%85.6%
HBF83.5%89.5%93.1%92.3%93.7%95.2%95.0%90.6%
HCF87.7%93.2%93.4%92.3%94.6%89.3%93.6%90.8%
HCI88.5%90.7%93.9%92.4%94.4%95.8%96.1%N/A
Health.com.au74.8%81.5%83.2%83.5%84.9%82.9%87.2%79.3%
Health Partners75.1%89.7%89.7%90.3%95.4%86.1%92.0%93.6%
HIF78.7%87.7%91.6%90.7%92.2%92.3%92.4%81.9%
Latrobe79.1%90.0%92.0%91.0%92.2%88.4%89.2%93.5%
MDHF78.7%93.4%93.8%90.6%92.0%95.6%95.0%74.9%
Medibank84.2%90.0%92.9%90.5%93.7%90.3%93.9%89.8%
MO Health 78.1%80.6%86.8%85.4%85.8%87.8%83.1%87.1%
NIB76.3%87.6%85.9%84.3%89.8%85.6%90.9%85.4%
Onemedifund89.8%92.7%94.9%94.0%95.1%95.7%95.7%N/A
Peoplecare82.2%91.8%92.6%91.1%93.6%91.0%88.3%93.8%
Phoenix65.9%93.9%92.3%93.1%95.8%92.8%90.9%90.1%
QCH81.0%91.1%91.7%89.4%94.8%93.7%91.2%85.2%
St Lukes84.0%89.6%91.7%90.1%93.9%93.7%93.8%92.0%
Transport Health87.4%87.9%93.5%91.2%85.6%90.9%86.4%N/A
Westfund94.2%94.1%95.4%92.4%96.1%93.1%95.3%93.8%
Restricted membership funds
ACA93.8%94.4%96.8%95.1%94.2%97.1%97.4%N/A
CBHS86.1%90.4%93.9%92.8%95.9%93.2%94.6%82.9%
Defence Health 83.7%88.6%93.0%91.5%93.9%90.4%93.4%91.1%
Doctors' Health90.1%91.2%93.1%92.4%92.5%91.3%88.0%86.5%
Emergency Services82.7%95.9%95.8%91.2%96.5%95.3%100.0%88.7%
Navy Health86.2%91.5%94.0%91.6%94.3%92.0%93.3%90.9%
Nurses and Midwives81.4%90.7%90.7%89.1%92.9%87.9%87.7%84.1%
Police Health74.0%92.0%94.2%92.9%96.9%92.0%95.7%92.3%
Reserve Bank86.1%91.8%97.1%95.2%98.1%96.6%97.8%N/A
RT Health Fund86.3%93.8%92.9%93.2%95.3%92.7%93.9%88.4%
Teachers Health86.4%91.5%92.6%93.3%93.4%90.9%93.3%90.8%
TUH84.9%91.8%92.1%92.1%93.3%92.5%96.4%93.8%

[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.

These tables 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 Unity83.9%91.2%91.7%91.7%92.0%87.3%91.9%85.8%
BUPA81.3%87.0%86.1%87.9%86.1%83.1%86.7%84.0%
CBHS Corporate83.3%85.0%88.0%86.3%87.0%85.9%66.0%N/A
CDH57.1%87.9%75.6%74.4%66.7%50.0%42.3%N/A
CUA Health81.2%91.5%90.6%94.5%86.7%86.6%93.2%89.8%
GMHBA47.7%72.9%79.5%81.0%80.8%72.3%75.7%74.4%
GU Health Corporate85.3%78.8%82.4%84.0%87.6%78.8%93.5%88.6%
HBF73.4%76.8%66.7%70.0%67.7%91.8%79.7%72.7%
HCF81.3%91.1%89.1%91.2%87.9%86.9%90.5%84.7%
HCI82.9%89.6%90.8%91.9%79.4%90.3%91.7%N/A
Health.com.au70.1%86.1%85.3%88.2%84.4%83.5%86.0%94.7%
Health Partners74.7%88.1%86.8%92.4%93.0%86.5%91.5%93.8%
HIF65.7%86.7%88.9%89.4%87.2%87.3%88.6%67.7%
Latrobe60.4%77.7%76.7%83.5%88.9%68.9%72.8%74.2%
MDHF45.2%85.1%80.9%79.7%82.0%74.4%75.5%58.8%
Medibank78.3%87.7%84.6%87.1%86.7%73.7%91.1%84.9%
MO Health68.6%82.2%86.0%87.9%79.6%81.0%72.0%70.6%
NIB66.0%92.8%91.5%87.3%93.3%87.2%83.9%78.7%
Onemedifund89.1%89.3%90.4%93.6%90.9%86.5%88.0%N/A
Peoplecare80.4%93.0%90.5%92.0%89.2%83.5%89.9%92.1%
Phoenix63.4%92.0%89.7%92.7%92.3%88.0%91.9%85.7%
QCH64.4%93.9%91.3%91.7%95.7%87.3%88.3%84.9%
St Lukes80.4%86.0%82.1%78.0%90.3%69.5%89.6%82.4%
Transport Health87.3%88.6%92.5%92.4%77.1%77.5%80.0%N/A
Westfund73.5%92.4%90.0%90.1%89.2%79.4%85.4%75.0%
Restricted membership funds
ACA86.8%92.1%93.3%92.9%90.0%90.9%93.1%N/A
CBHS82.4%89.4%90.2%92.4%91.1%86.7%91.0%81.2%
Defence Health 80.3%89.6%90.6%92.6%90.8%85.7%91.3%86.5%
Doctors' Health90.4%92.0%92.5%93.5%91.9%88.2%87.6%86.1%
Emergency Services76.7%90.7%87.5%88.7%91.8%80.8%100.0%62.1%
Navy Health80.3%90.4%91.0%92.3%91.5%88.2%91.9%89.3%
Nurses and Midwives78.4%90.4%84.9%91.6%90.9%83.3%77.7%96.8%
Police Health71.3%87.6%85.0%89.1%89.8%82.8%88.1%87.6%
Reserve Bank87.5%90.2%92.8%94.2%96.4%93.9%89.2%N/A
RT Health Fund83.4%93.8%91.6%93.4%92.0%87.0%91.2%82.3%
Teachers Health83.4%90.5%90.1%93.2%90.1%85.0%91.1%92.2%
TUH81.9%91.2%91.5%93.0%93.8%91.0%96.1%92.8%

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
ACTNSWVICQLDSAWATASNT
Open membership funds
Australian Unity93.7%96.7%97.9%96.5%98.3%96.8%98.5%91.1%
BUPA90.2%91.9%91.6%91.6%91.7%90.1%92.3%91.1%
CBHS Corporate83.3%91.4%96.6%92.2%90.2%95.5%93.6%N/A
CDH100.0%97.4%94.6%94.4%98.7%50.0%92.3%N/A
CUA Health93.9%97.2%98.5%98.4%97.8%98.0%98.9%96.3%
GMHBA74.7%89.2%91.1%94.0%97.0%86.3%90.3%90.7%
GU Health Corporate94.0%91.9%97.2%94.1%96.7%95.0%98.2%93.2%
HBF99.3%99.4%99.8%99.6%99.9%99.8%99.8%98.8%
HCF96.0%98.7%99.5%99.2%99.8%98.3%99.6%98.5%
HCI92.3%97.2%98.6%97.4%99.3%97.2%99.2%N/A
Health.com.au90.5%95.6%97.8%96.6%97.0%95.3%97.7%98.4%
Health Partners90.8%96.2%97.5%96.9%99.7%93.6%99.4%100.0%
HIF89.7%96.1%98.3%97.3%98.8%97.5%98.2%88.7%
Latrobe98.4%98.0%99.9%99.5%99.9%99.6%99.2%100.0%
MDHF88.1%98.8%98.9%94.2%95.8%86.7%92.6%96.1%
Medibank93.3%96.4%94.4%95.5%99.2%89.2%98.3%95.7%
MO Health92.0%93.8%97.2%95.8%97.8%95.4%89.3%100.0%
NIB66.0%92.8%91.5%87.3%93.3%87.2%83.9%78.7%
Onemedifund100.0%97.1%98.5%98.8%99.5%97.1%99.4%N/A
Peoplecare95.3%97.9%98.8%97.8%99.1%97.7%97.7%100.0%
Phoenix84.4%98.1%98.8%98.0%99.4%98.0%99.6%95.2%
QCH94.9%98.7%98.5%98.0%98.3%98.0%98.5%95.4%
St Lukes87.7%93.3%90.3%90.4%96.7%85.5%98.5%100.0%
Transport Health95.2%96.5%99.0%98.3%100.0%100.0%90.0%N/A
Westfund82.7%97.8%98.6%97.4%98.4%96.5%92.8%96.3%
Restricted membership funds
ACA99.3%97.7%99.1%98.1%98.4%97.5%99.6%N/A
CBHS94.4%96.7%98.3%97.3%98.7%96.6%98.2%90.8%
Defence Health 94.5%97.0%98.9%98.1%99.5%97.2%98.6%97.0%
Doctors' Health97.8%98.4%98.8%98.7%99.4%98.4%98.3%99.3%
Emergency Services86.7%96.5%97.8%96.2%98.7%89.5%100.0%89.7%
Navy Health94.8%97.1%98.6%97.9%99.3%97.5%99.3%96.4%
Nurses and Midwives94.6%97.6%97.3%96.3%99.5%96.3%87.3%96.8%
Police Health86.4%96.5%97.6%97.3%99.3%95.9%98.2%97.5%
Reserve Bank94.9%96.9%98.8%98.3%99.6%98.3%97.6%N/A
RT Health Fund93.6%98.4%98.9%98.4%98.9%97.9%98.8%96.8%
Teachers Health95.7%97.5%98.8%98.2%99.4%97.3%99.1%97.7%
TUH96.6%97.9%99.0%98.3%99.0%97.3%99.8%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).

General treatment (extras)

General treatment policies, also known as 'ancillary' or 'extras' 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.

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

General treatment

General treatment policies, 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

This table 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

This additional table 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.

Table 5A—General treatment (extras)
Fund name (Abbreviated)% General treatment (extras) Charges covered
ACTNSWVICQLDSAWATASNT
Open membership funds
Australian Unity45.6%47.0%50.3%50.2%52.8%48.9%48.2%51.2%
BUPA46.8%50.7%49.7%53.7%56.0%59.4%51.8%59.9%
CBHS Corporate43.4%52.3%51.8%53.0%57.3%55.7%45.0%68.8%
CDH34.8%34.1%40.0%41.3%41.0%34.8%45.5%N/A
CUA Health44.2%55.1%50.5%49.0%49.9%50.2%46.4%42.2%
GMHBA52.1%53.7%50.5%54.8%55.5%50.4%48.6%49.2%
GU Health Corporate74.3%74.7%75.7%72.3%74.4%76.7%75.7%77.2%
HBF45.8%49.7%50.4%50.4%52.9%57.9%53.6%53.9%
HCF50.5%50.8%56.8%58.0%61.8%60.5%51.6%52.8%
HCI44.1%53.0%54.8%48.0%52.5%52.2%47.4%46.9%
Health.com.au55.1%55.4%56.8%55.8%57.9%57.3%56.7%56.4%
Health Partners50.3%49.2%46.6%42.8%57.4%44.6%45.5%46.6%
HIF42.2%45.7%46.4%46.9%48.1%47.4%48.0%44.6%
Latrobe26.4%39.5%34.7%33.3%40.3%41.3%33.6%33.8%
MDHF47.8%56.4%56.7%56.3%53.8%53.8%45.2%51.2%
Medibank47.6%50.7%53.3%54.9%58.3%58.2%53.3%59.7%
MO Health54.5%55.7%57.2%56.3%57.9%58.0%56.3%51.0%
NIB54.5%53.7%58.9%55.7%59.5%58.3%48.9%58.3%
Onemedifund47.8%52.7%56.0%53.3%57.9%55.9%54.4%N/A
Peoplecare46.2%49.8%49.5%48.2%51.5%47.3%49.1%51.2%
Phoenix48.7%53.0%52.8%53.2%55.2%52.3%44.0%51.9%
QCH47.8%50.2%51.6%52.4%52.5%48.5%50.0%50.1%
St Lukes59.3%63.4%60.5%60.6%65.9%61.4%61.1%63.9%
Transport Health43.5%47.3%53.0%47.3%51.4%47.5%54.6%43.6%
Westfund43.2%50.1%46.2%52.6%49.3%46.6%44.4%35.8%
Restricted membership funds
ACA51.7%58.5%59.2%61.0%64.5%56.7%59.8%56.1%
CBHS44.4%49.1%50.4%51.8%53.8%51.2%50.4%48.0%
Defence Health 44.0%47.5%50.2%50.3%54.7%50.6%48.4%51.3%
Doctors' Health55.2%54.3%55.7%57.2%58.1%55.4%58.3%58.0%
Emergency Services65.5%62.3%64.3%65.6%67.1%65.3%61.8%67.2%
Navy Health45.2%48.9%53.1%50.2%55.8%53.6%50.0%49.1%
Nurses and Midwives46.8%52.7%50.8%51.7%56.4%51.9%52.4%51.2%
Police Health66.7%66.6%68.2%67.9%70.7%68.9%67.2%68.3%
Reserve Bank68.5%72.7%76.9%76.7%81.4%76.1%75.3%99.4%
RT Health Fund42.3%48.9%45.5%48.1%49.3%45.4%41.3%40.6%
Teachers Health44.2%49.8%50.2%50.4%53.4%52.1%48.5%47.3%
TUH50.0%49.2%49.2%55.4%54.0%49.7%52.9%48.0%

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]PhysiotherapyChiropracticPharmacyPodiatryNatural therapiesAmbulanceAcupuncturePsychology/Group TherapyPreventative healthHearing aids and AudiologyOccupational Therapy
Open membership funds
Australian Unity45.7%65.7%61.7%47.0%37.5%46.1%46.1%99.3%40.0%32.5%77.0%16.2%42.8%
BUPA55.6%57.7%47.9%49.4%35.7%48.9%38.0%100.0%40.2%41.5%33.8%18.6%34.6%
CBHS Corporate50.9%54.4%53.7%60.3%42.9%51.2%51.6%100.0%57.0%47.8%43.1%38.5%26.6%
CDH38.3%32.6%46.8%41.1%40.5%32.9%26.8%100.0%42.0%21.8%N/AN/A28.7%
CUA Health52.1%60.6%38.8%41.5%29.7%55.5%39.3%100.0%46.0%34.9%56.0%50.3%38.7%
GMHBA51.5%58.1%48.8%51.1%32.4%49.5%46.8%87.7%48.1%45.4%61.0%26.8%44.8%
GU Health Corporate79.4%67.6%83.0%79.4%53.5%78.4%81.1%100.0%79.6%77.7%55.4%20.0%86.6%
HBF58.8%59.5%46.3%49.6%50.9%48.0%50.1%99.9%N/A41.7%85.8%32.9%46.0%
HCF58.6%57.6%44.4%42.6%36.2%40.3%33.1%100.0%31.1%45.1%45.9%29.8%46.4%
HCI51.1%52.3%43.2%51.7%49.0%45.0%53.3%100.0%57.5%31.5%64.6%49.0%37.7%
Health.com.au53.9%53.5%61.3%62.2%34.4%57.2%60.7%100.0%59.4%54.6%N/A5.0%57.8%
Health Partners62.8%55.2%59.4%44.4%46.7%35.0%28.2%100.0%30.4%37.5%67.9%31.4%44.4%
HIF48.7%59.4%36.0%36.5%42.0%35.7%23.0%99.2%21.5%32.9%36.8%30.9%32.8%
Latrobe31.9%53.5%32.1%35.0%22.9%35.3%23.0%75.2%43.2%30.5%33.6%13.7%33.8%
MDHF61.4%64.3%41.7%44.9%25.2%45.4%37.0%81.0%33.8%25.2%42.4%20.6%30.8%
Medibank52.7%68.7%47.1%52.2%23.8%50.9%51.7%100.0%42.3%29.4%57.4%26.0%36.9%
MO HealthN/A58.5%84.2%54.4%59.0%60.7%55.9%59.6%100.0%N/A56.0%57.4%60.4%
NIB56.1%53.3%58.3%57.3%39.4%55.8%54.2%100.0%55.1%54.8%47.9%18.2%56.6%
Onemedifund59.7%51.5%52.3%47.4%39.8%44.5%39.4%99.8%36.8%38.2%80.8%34.9%38.2%
Peoplecare49.0%65.7%40.6%41.7%34.4%40.9%42.1%100.0%49.6%38.5%68.3%33.3%42.3%
Phoenix56.0%63.2%47.4%46.0%37.0%50.3%30.5%99.9%44.1%40.6%49.0%44.1%44.5%
QCH51.8%58.0%45.3%57.7%38.0%60.1%39.8%N/A43.4%43.6%45.0%35.1%40.3%
St Lukes65.7%76.4%52.6%51.4%41.2%47.4%43.0%79.3%45.4%47.0%58.4%47.0%49.2%
Transport Health54.6%57.9%45.2%52.6%30.6%50.7%39.8%100.0%35.2%27.8%55.9%29.4%29.1%
Westfund52.9%56.6%47.7%53.4%40.2%47.1%39.2%99.9%35.5%38.7%79.3%39.9%57.7%
Restricted membership funds
ACA62.9%70.5%41.9%48.0%44.0%71.7%38.1%100.0%36.3%44.3%N/A37.2%61.1%
CBHS49.8%53.1%51.0%59.8%41.9%43.2%44.3%94.7%44.8%40.5%43.8%37.8%33.9%
Defence Health 48.0%52.8%52.1%53.9%45.9%50.3%36.6%100.0%32.5%48.7%91.7%30.7%48.8%
Doctors' Health59.7%64.6%44.4%0.0%44.0%49.2%41.8%N/AN/A48.1%32.2%21.2%17.5%
Emergency Services65.3%59.3%72.7%76.1%44.3%68.7%37.2%100.0%71.8%73.5%N/A32.3%69.6%
Navy Health47.2%59.5%53.2%59.9%45.5%53.0%45.2%99.4%N/A41.6%100.0%29.0%34.5%
Nurses and Midwives53.0%61.1%45.9%59.9%42.4%57.3%45.1%100.0%41.2%39.9%46.1%28.5%57.4%
Police Health69.9%66.7%75.5%76.8%44.4%68.1%42.4%99.1%73.8%76.8%100.0%39.1%70.5%
Reserve Bank74.3%71.5%69.8%72.0%61.4%80.1%78.0%99.7%75.6%75.3%58.0%72.4%71.2%
RT Health Fund46.1%61.3%48.8%48.5%38.9%45.9%42.9%100.0%50.3%20.5%45.0%28.3%32.3%
Teachers Health52.5%54.7%44.0%56.5%41.4%55.5%45.2%100.0%41.0%39.0%38.6%37.6%58.7%
TUH59.2%54.6%50.5%54.1%35.9%58.0%50.6%100.0%43.6%42.2%50.4%44.8%36.2%

[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 Supervision) Act 2015 (the Prudential Supervision 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.

APRA produces an annual publication providing financial and operational statistics for the funds for each financial year. [4] Information included in the Financial Performance table (Table 6) is drawn from data collected by APRA for that purpose.

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.

Benefits as a percentage of contributions

This column 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 Surplus (-loss) and Management Expenses.

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 2018–19 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 % contributionsManagement expensesSurplus (- Loss) from health insuranceOverall profit (- Loss) as % total revenueNot-for-profit fund
as % of contribution incomePer average policy (see MREAust Tab)
 
Open membership funds
Australian Unity81.1%10.7% $389 8.2%6.9%No
BUPA86.2%7.8% $293 6.1%5.3%No
CBHS CorporateN/AN/AN/AN/AN/ANo
CDH79.5%14.9% $655 5.7%7.3%Yes
CUA Health85.7%9.3% $347 5.1%5.3% No
GMHBA86.4%11.9% $428 1.7%3.4%Yes
GU Health Corporate74.8%14.2% $892 11.0%9.6%No
HBF87.3%11.3% $372 1.5%5.3%Yes
HCF89.7%9.7% $371 0.6%3.9%Yes
HCI86.5%10.4% $429 3.1%5.4%Yes
Health.com.au88.6%6.2% $199 5.2%4.4%No
Health Partners87.7%10.0% $381 2.3%7.6%Yes
HIF90.8%12.7% $400 -3.5%-0.4%Yes
Latrobe89.4%10.1% $393 0.5%3.0%Yes
MDHF88.8%8.5% $290 2.7%5.8%Yes
Medibank83.6%8.3% $293 8.1%7.2%No
MO HealthN/AN/AN/AN/AN/ANo
NIB81.8%11.2% $362 6.9%6.6%No
Onemedifund78.6%8.7% $482 11.8%9.4%No
Peoplecare89.4%9.7% $407 1.1%4.0%Yes
Phoenix88.2%9.0% $422 2.8%5.6%Yes
QCH87.7%10.5% $491 1.8%2.8%No
St Lukes89.3%11.2% $475 -0.5%3.4%Yes
Transport Health83.7%13.1% $459 3.2%4.3%No
Westfund84.0%12.8% $528 3.2%8.4%Yes
Restricted membership funds
ACA88.5%12.1% $645 -0.6%3.4%Yes
CBHS93.5%8.4% $364 -1.9%1.9%Yes
Defence Health90.6%6.2% $253 3.2%6.5%Yes
Doctors' Health82.0%9.9% $528 8.1%6.9%No
Emergency Services98.4%N/AN/AN/AN/AYes
Navy Health88.4%9.5% $387 2.1%6.8%Yes
Nurses and Midwives125.6%19.2% $763 -44.8%-41.7%Yes
Police Health90.6%6.7% $381 2.7%0.8%Yes
Reserve Bank82.2%12.4% $830 5.4%7.7%Yes
RT Health Fund84.9%13.8% $628 1.2%2.0%Yes
Teachers Health91.0%7.4% $323 1.7%2.5%Yes
TUH88.8%8.7% $427 2.6%4.4%Yes

Note: 'N/A' indicates no data as insurer commenced operations during previous two years.

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 policyholders in each state. Australian health insurance policies are usually priced according to the policyholder's state of residence, but the benefits extend nation-wide.

Health fund operations by state or territory

These 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 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. [5]

Percentage of fund's membership in state

This column 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 hospitals [6]

All health funds establish agreements with 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). [7]

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.

The table indicates whether the fund operates retail offices and/or agencies in the state or territory.

Table 7A—New South Wales

Table 7A—New South Wales
Fund name (Abbreviated)% Fund market share this state% Fund's membership in this stateAgreement hospitals [1]Fund outlets
Private hospitalsPrivate day hospitalsRetail officesAgencies
Open membership funds
Australian Unity1.5%17.9%9087  
BUPA24.7%31.6%8875Yes 
CBHS Corporate0.0%55.7%9692  
CDH0.1%83.1%7655Yes 
CUA Health0.5%25.3%9490Yes 
GMHBA1.2%17.5%9890  
GU Health Corporate0.7%52.3%9694  
HBF0.8%3.5%9586  
HCF19.7%58.7%8587Yes 
HCI0.0%12.4%95110  
Health.com.au0.6%34.4%7972  
Health Partners0.0%2.4%9890  
HIF0.3%11.9%9692  
Latrobe0.2%8.0%7655  
MDHF0.1%10.8%7552 Yes
Medibank23.1%28.3%8681YesYes
MO Health0.20%33.9%9088  
NIB13.7%52.5%9298Yes 
Onemedifund0.1%41.6%9890  
Peoplecare0.7%46.3%9890Yes 
Phoenix0.2%44.3%9590Yes 
QCH0.0%1.6%9189  
St Lukes0.1%3.5%7349  
Transport Health0.0%14.7%7364  
Westfund1.4%58.8%9692Yes 
Restricted membership funds
ACA0.1%57.6%9390Yes 
CBHS2.1%46.0%9692  
Defence Health1.2%18.2%9890 Yes
Doctors' Health0.4%39.8%9493  
Emergency Services0.0%21.8%9692  
Navy Health0.3%29.3%9492  
Nurses and Midwives0.1%47.5%9394  
Police0.0%2.6%9692  
Reserve Bank0.1%61.6%9890Yes 
RT Health Fund0.6%48.7%7674Yes 
Teachers Health5.0%67.9%9394Yes 
TUH0.1%5.1%9692  

[1] Agreement hospitals data is sourced from privatehealth.gov.au as of 13 November 2019

Table 7B—Victoria
Fund name (Abbreviated)% Fund market share this state% Fund's membership in this stateAgreement hospitals [1]Fund outlets
Private hospitalsPrivate day hospitalsRetail officesAgencies
Open membership funds
Australian Unity7.0%60.9%7570Yes 
BUPA23.2%21.3%7562Yes 
CBHS Corporate0.0%16.5%7472  
CDH0.0%8.1%7363  
CUA Health0.4%18.0%7570YesYes
GMHBA6.2%62.7%7869YesYes
GU Health Corporate0.4%22.4%7773  
HBF1.1%3.5%7765  
HCF7.0%15.0%6649Yes 
HCI0.1%23.6%7783  
Health.com.au0.9%34.7%6757  
Health Partners0.2%6.7%7869  
HIF0.5%15.9%7672  
Latrobe2.4%87.6%7363YesYes
MDHF0.9%84.2%7258YesYes
Medibank32.9%28.9%6852Yes 
MO Health0.32%38.8%7469  
NIB7.9%21.7%7474Yes 
Onemedifund0.1%24.7%7869  
Peoplecare0.7%32.6%7869Yes 
Phoenix0.1%25.2%7672  
QCH0.0%0.9%7670  
St Lukes0.1%5.2%7158  
Transport Health0.3%68.9%6945  
Westfund0.1%3.2%7673  
Restricted membership funds
ACA0.0%12.8%7571  
CBHS1.6%24.2%7472  
Defence Health2.7%29.8%7869YesYes
Doctors' Health0.4%29.2%7673  
Emergency Services0.0%25.5%7772  
Navy Health0.4%27.4%7673Yes 
Nurses and Midwives0.1%25.8%7474  
Police0.1%4.8%7772  
Reserve Bank0.0%23.3%7869  
RT Health Fund0.2%13.1%7157  
Teachers Health1.6%15.3%7474Yes 
TUH0.1%4.0%7672  

[1] Agreement hospitals data is sourced from privatehealth.gov.au as of 13 November 2019

Table 7C-Queensland
Fund name (Abbreviated)% Fund market share this state% Fund's membership in this stateAgreement hospitals [1]Fund outlets
Private hospitalsPrivate day hospitalsRetail officesAgencies
Open membership funds
Australian Unity2.0%12.7%5046  
BUPA31.3%21.4%5045Yes 
CBHS Corporate0.0%12.0%5051  
CDH0.0%6.7%5036  
CUA Health1.7%51.2%5048YesYes
GMHBA1.5%11.4%5249  
GU Health Corporate0.2%9.6%5149  
HBF0.7%1.7%5246  
HCF7.6%12.0%4837Yes 
HCI0.1%10.5%5761  
Health.com.au0.6%18.9%4238  
Health Partners0.1%2.7%5249  
HIF0.4%9.3%5051  
Latrobe0.1%2.5%5036  
MDHF0.0%2.1%4532  
Medibank32.0%20.9%5141YesYes
MO Health0.19%17.0%5145  
NIB6.5%13.2%5347Yes 
Onemedifund0.1%12.8%5249  
Peoplecare0.3%11.6%5249  
Phoenix0.1%14.3%4850  
QCH2.2%95.1%4746YesYes
St Lukes0.1%3.1%4632  
Transport Health0.1%11.9%4434  
Westfund1.5%33.8%5049Yes 
Restricted membership funds
ACA0.1%19.8%5048  
CBHS1.3%15.2%5051  
Defence Health3.5%29.1%5249 Yes
Doctors' Health0.4%21.1%5049  
Emergency Services0.0%27.2%5051  
Navy Health0.4%19.2%5049  
Nurses and Midwives0.0%10.0%5246  
Police0.7%34.1%5051  
Reserve Bank0.0%6.2%5249  
RT Health Fund0.7%33.2%4640Yes 
Teachers Health0.5%3.6%5246  
TUH2.9%89.6%5051Yes 

[1] Agreement hospitals data is sourced from privatehealth.gov.au as of 13 November 2019

Table 7D—South Australia
Fund name (Abbreviated)% Fund market share this state% Fund's membership in this stateAgreement hospitals [1]Fund outlets
Private hospitalsPrivate day hospitalsRetail officesAgencies
Open membership funds
Australian Unity1.5%4.2%2523  
BUPA47.3%14.2%2527Yes 
CBHS Corporate0.0%3.4%2527  
CDH0.0%1.0%2118  
CUA Health0.1%1.4%2523  
GMHBA0.5%1.5%2428  
GU Health Corporate0.1%1.7%2427  
HBF0.5%0.5%2425  
HCF7.7%5.4%2320Yes 
HCI0.0%2.4%2733  
Health.com.au0.2%3.2%2622  
Health Partners7.5%86.8%2428YesYes
HIF0.3%2.6%2527  
Latrobe0.1%0.7%2118  
MDHF0.1%2.2%2214  
Medibank22.1%6.4%2423YesYes
MO Health0.1%2.4%2524  
NIB3.7%3.3%2427  
Onemedifund0.1%4.9%2428  
Peoplecare0.3%4.8%2428  
Phoenix0.2%11.5%2527  
QCH0.0%0.3%2524  
St Lukes0.1%1.6%2214  
Transport Health0.0%1.8%2619  
Westfund0.2%1.5%2529  
Restricted membership funds
ACA0.0%3.4%2526  
CBHS0.9%4.6%2527  
Defence Health2.3%8.5%2428 Yes
Doctors' Health0.2%3.6%2528  
Emergency Services0.0%12.6%2428Yes 
Navy Health0.2%5.6%2528  
Nurses and Midwives0.1%7.1%2924  
Police1.5%34.3%2428Yes 
Reserve Bank0.0%3.4%2428  
RT Health Fund0.1%1.8%2621  
Teachers Health2.0%6.4%2924  
TUH0.0%0.3%2527  

[1] Agreement hospitals data is sourced from privatehealth.gov.au as of 13 November 2019

Table 7E—Western Australia
Fund name (Abbreviated)% Fund market share this state% Fund's membership in this stateAgreement hospitals [1]Fund outlets
Private hospitalsPrivate day hospitalsRetail officesAgencies
Open membership funds
Australian Unity0.5%2.4%1920  
BUPA11.8%6.0%2018Yes 
CBHS Corporate0.0%8.9%2123  
CDH0.0%0.3%1831  
CUA Health0.1%2.6%2122Yes 
GMHBA0.8%4.6%2222  
GU Health Corporate0.4%11.6%2323  
HBF51.2%90.1%2324YesYes
HCF4.1%4.9%1814Yes 
HCI0.0%1.2%2325  
Health.com.au0.2%5.1%1816  
Health Partners0.0%0.5%2222  
HIF3.6%58.8%2123YesYes
Latrobe0.0%0.3%1813  
MDHF0.0%0.3%1813  
Medibank20.7%10.1%2120YesYes
MO Health0.08%5.4%1921  
NIB3.1%4.7%2224  
Onemedifund0.1%11.0%2222  
Peoplecare0.1%2.6%2222  
Phoenix0.0%2.8%2123  
QCH0.0%0.5%1921  
St Lukes0.0%0.5%1713  
Transport Health0.0%1.5%1610  
Westfund0.1%1.3%2123  
Restricted membership funds
ACA0.0%4.1%2121  
CBHS0.8%7.0%2123  
Defence Health0.7%4.4%2222 Yes
Doctors' Health0.1%2.5%2123  
Emergency Services0.0%6.6%2123  
Navy Health0.2%7.2%2122  
Nurses and Midwives0.0%5.1%2123  
Police0.4%13.3%2123  
Reserve Bank0.0%2.9%2222  
RT Health Fund0.0%1.7%1816  
Teachers Health0.6%3.2%2123  
TUH0.0%0.2%2123  

[1] Agreement hospitals data is sourced from privatehealth.gov.au as of 13 November 2019

Table 7F—Tasmania
Fund name (Abbreviated)% Fund market share this state% Fund's membership in this stateAgreement hospitals [1]Fund outlets
Private hospitalsPrivate day hospitalsRetail officesAgencies
Open membership funds
Australian Unity1.0%0.8%83  
BUPA32.7%2.6%86Yes 
CBHS Corporate0.0%1.3%84  
CDH0.0%0.4%68  
CUA Health0.1%0.4%83  
GMHBA1.0%0.9%58  
GU Health Corporate0.1%0.5%58  
HBF0.8%0.2%54  
HCF4.5%0.8%55  
HCI2.2%48.7%88Yes 
Health.com.au0.2%0.8%83  
Health Partners0.1%0.3%54  
HIF0.2%0.6%84  
Latrobe0.2%0.5%68  
MDHF0.0%0.2%86  
Medibank27.3%2.1%55Yes 
MO Health0.05%0.5%83  
NIB3.0%0.7%58  
Onemedifund0.2%4.9%54  
Peoplecare0.2%0.7%54  
Phoenix0.0%0.6%84  
QCH0.0%0.2%83  
St Lukes20.9%85.9%86YesYes
Transport Health0.0%0.5%82  
Westfund0.1%0.3%84  
Restricted membership funds
ACA0.0%1.3%83  
CBHS1.1%1.5%84  
Defence Health1.3%1.2%54 Yes
Doctors' Health0.1%0.9%84  
Emergency Services0.0%1.5%84  
Navy Health0.2%1.4%84  
Nurses and Midwives0.1%2.1%54  
Police0.5%2.9%84  
Reserve Bank0.0%1.1%54  
RT Health Fund0.1%0.5%83  
Teachers Health1.3%1.1%54  
TUH0.1%0.3%84  

[1] Agreement hospitals data is sourced from privatehealth.gov.au as of 13 November 2019

Table 7G—Australian Capital Territory
Fund name (Abbreviated)% Fund market share this state% Fund's membership in this stateAgreement hospitals [1]Fund outlets
Private hospitalsPrivate day hospitalsRetail officesAgencies
Open membership funds
Australian Unity1.3%1.0%57  
BUPA21.4%1.7%45Yes 
CBHS Corporate0.0%2.1%58  
CDH0.0%0.4%56  
CUA Health0.3%1.1%57Yes 
GMHBA1.4%1.2%54  
GU Health Corporate0.4%1.6%68  
HBF0.9%0.2%58  
HCF15.2%2.8%57Yes 
HCI0.0%1.0%69  
Health.com.au0.7%2.3%66  
Health Partners0.1%0.4%58  
HIF0.3%0.8%58  
Latrobe0.1%0.4%56  
MDHF0.0%0.1%56  
Medibank28.3%2.2%55Yes 
MO Health0.18%1.9%67  
NIB15.0%3.6%68  
Onemedifund0.0%0.2%58  
Peoplecare0.4%1.4%58  
Phoenix0.1%1.1%58  
QCH0.0%0.2%56  
St Lukes0.0%0.2%56  
Transport Health0.0%0.7%54  
Westfund0.4%1.0%58  
Restricted membership funds
ACA0.0%0.8%66  
CBHS1.0%1.3%58  
Defence Health7.5%7.3%58 Yes
Doctors' Health0.4%2.6%68  
Emergency Services0.0%1.8%58  
Navy Health1.4%8.7%57  
Nurses and Midwives0.1%1.8%58  
Police0.1%0.7%58  
Reserve Bank0.0%1.4%58  
RT Health Fund0.1%0.8%66  
Teachers Health2.6%2.2%58  
TUH0.1%0.3%58  

[1] Agreement hospitals data is sourced from privatehealth.gov.au as of 13 November 2019

Table 7H—Northern Territory
Fund name (Abbreviated)% Fund market share this state% Fund's membership in this stateAgreement hospitals [1]Fund outlets
Private hospitalsPrivate day hospitalsRetail officesAgencies
Open membership funds
Australian Unity0.5%0.1%21  
BUPA37.1%1.1%11Yes 
CBHS Corporate0.0%0.0%21  
CDH0.0%0.0%11  
CUA Health0.1%0.2%21  
GMHBA0.3%0.1%21  
GU Health Corporate0.1%0.2%21  
HBF1.7%0.2%21  
HCF5.6%0.4%11  
HCI0.0%0.1%21  
Health.com.au0.5%0.6%11  
Health Partners0.1%0.1%21  
HIF0.2%0.1%21  
Latrobe0.0%0.0%11  
MDHF0.0%0.1%11  
Medibank39.9%1.1%11Yes 
MO Health0.05%0.2%21  
NIB3.5%0.3%21  
Onemedifund0.0%0.0%21  
Peoplecare0.1%0.1%21  
Phoenix0.0%0.2%21  
QCH0.6%1.1%21  
St Lukes0.0%0.0%11  
Transport Health0.0%0.1%10  
Westfund0.1%0.1%21  
Restricted membership funds
ACA0.0%0.1%21  
CBHS0.3%0.2%21  
Defence Health3.9%1.4%21 Yes
Doctors' Health0.1%0.3%21  
Emergency Services0.1%3.0%21  
Navy Health0.5%1.1%21  
Nurses and Midwives0.0%0.5%12  
Police3.3%7.3%21  
Reserve Bank0.0%0.0%21  
RT Health Fund0.1%0.2%11  
Teachers Health0.9%0.3%12  
TUH0.1%0.1%21  

[1] Agreement hospitals data is sourced from privatehealth.gov.au as of 13 November 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 PHIO is one of the roles of the Commonwealth Ombudsman. 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:

Online: ombudsman.gov.au

Call: 1300 362 072

Write: Commonwealth Ombudsman, GPO Box 442, CANBERRA ACT 2601

Email: phi@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 will let you know if any other information is needed.

What happens after I make a complaint?

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

We might 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 may contact the health fund or other body, to seek further information or to recommend a certain course of action. Your case officer will keep you regularly informed about the progress of your complaint.

What if I just want some information about health insurance?

We can help with information about private health insurance arrangements:

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.

Your health insurance checklist

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.
  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.

Footnotes

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

[4] The ‘Operations of the Private Health Insurers’ report is available on the APRA website: apra.gov.au

[5] Australian Health Service Alliance: ahsa.com.au

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

[7] 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.