Relating to the financial year 2019–20

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

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Foreword

I am pleased to present the 16th annual State of the Health Funds Report, relating to the financial year 2019–20. 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.

Mr Michael Manthorpe PSM

Commonwealth Ombudsman

February 2021

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.
  • 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 at 1 December 2020.
  • This report is intended to help consumers decide which health funds to consider, though it won't 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 funds to join or 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 the majority of their business 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 to 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 or have used brand names in the recent past:

Brand name 

Fund

AAMI

NIB

APIA

NIB

Astute Simplicity Health

St Lukes

Australian Health Management

Medibank

Budget Direct

GMHBA

Emergency Services Health

Police Health

Frank

GMHBA

GMF Health

HBF

GU Corporate Health

NIB

Healthguard

HBF

Hunter Health Insurance

CDH

iSelf

Phoenix

Kogan

Medibank

Manchester Unity

HCF

MyOwn Health

AIA Health

NRMA Health

BUPA

Qantas Assure

NIB

Suncorp

NIB

Territory Health

QCH

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, 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 this 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 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 weigh the importance of various indicators, as these are subjective judgements, 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 a 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

Overview of complaints in 2020–21

In 2019–20, the Office received 3,706 complaints about private health insurance, representing an 8.3 per cent decrease in complaints received compared to 2018–19. In the same period we also received 2,049 private health insurance enquiries.[2]

Figure 1—Total complaints and enquiries by year

Complaints

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.

Complaints about delays in benefit payments also represented a significant proportion of complaints received, as did complaints about hospital and medical ‘gaps’ that resulted in an out of pocket expense to patients.

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. This year there was a significant increase in the number of complaints about membership suspensions due to COVID-19—this is discussed in further detail below.

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

COVID-19 complaints

In the February to June 2020 period, the Office received 212 complaints and 43 enquiries related to COVID-19. The majority of these complaints raised issues related to suspension requests, premium costs and the inability to access hospital and general treatment services as planned.

The issue which caused the most COVID-19 complaints was membership suspension (62 complaints) where consumers sought temporary suspensions of membership due to financial hardship.

Almost all insurers postponed their 1 April 2020 premium increases for at least six months to 1 October 2020. The majority of insurers also introduced provisions to provide financial relief to people who have lost their jobs, are underemployed, in hardship or have contracted the virus; and most insurers covered COVID-19 treatment for existing policyholders.

Enquiries

The majority of enquiries received by our Office are general queries about how private health insurance works and Lifetime Health Cover (LHC). Thirty-three per cent of enquiries in 2019–20 fell into the category of private health insurance queries, including queries about what factors consumers should consider when selecting a policy.

Thirty 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 overseas 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.

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 2019–20 we received 1,270 enquiries via the consumer website, which we responded to with information and advice.

Website usage decreased in 2019–20, with 1,098,631 visitors compared to 1,441,712 visits in 2018–19. This is partially a result of the Office’s decision to publish Private Health Information Statement (PHIS) data on data.gov.au, with some visitors now sourcing their information from this secondary source. The website continues to rely on organic growth, with the majority of visitors discovering the website through search engines.

Figure 3—privatehealth.gov.au visitors per year

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 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
AIA HealthAIA Health Insurance, MyOwn Health Insurance1800 333 004www.aia.com.au/health
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-insurance
GMHBAGMHBA Ltd, Frank1300 446 422gmhba.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 246medibank.com.au; ahm.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 415www.queenslandcountry.health
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
NavyNavy Health Ltd1300 306 289navyhealth.com.au
Nurses and MidwivesNurses and Midwives Health Pty Ltd1300 344 000nmhealth.com.au
Police HealthPolice Health Limited1800 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 Federation Health Ltd1300 728 188teachershealth.com.au
TUHTeachers' Union Health Fund1300 360 701www.tuh.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 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 2019 to 30 June 2020. 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

Table 2A includes all funds with a national market share of 0.5 per cent or more.
Fund name (Abbreviated) Member retention (hospital cover) [1] Membership change % (number) [2] Market share Complaints % compared to market share % Code of conduct member
Benefits Service All complaints Complaints investigated
Open membership funds
Australian Unity78%-4.9% (-8,791)2.6%3.7%5.3%4.5%1.8%Yes
BUPA84%-0.8% (-13,816)25.4%18.7%21.5%21.5%27.9%Yes
CUA Health79%1.1% (428)0.6%0.3%1.4%0.8%1.5%Yes
GMHBA71%-8.9% (-13,864)2.1%3.8%2.4%3.3%2.9%Yes
HBF86%-2.3% (-11,395)7.3%4.2%4.3%4.0%2.6%Yes
HCF88%5.9% (43,636)11.7%17.0%13.8%16.4%17.6%Yes
Health.com.au70%-14.4% (-5,648)0.5%1.0%1.0%1.1%3.3%No
Health Partners90%5.1% (2,254)0.7%0.7%0.7%0.7%0.4%Yes
HIF71%-5.8% (-3,120)0.8%1.3%0.7%1.8%2.9%Yes
Latrobe76%-1.7% (-728)0.6%0.9%0.2%0.7%0.4%Yes
Medibank75%0.6% (10,560)26.9%23.4%27.4%22.8%16.5%Yes
NIB78%1.9% (11,690)9.2%10.7%7.9%8.1%4.4%Yes
Peoplecare80%-2.8% (-961)0.5%0.4%0.2%0.5%0.7%Yes
St Lukes86%5.5% (1,843)0.5%0.5%0.5%0.4%1.1%Yes
Westfund85%8.3% (4,435)0.9%1.2%1.0%0.9%1.5%Yes
Restricted membership funds
CBHS91%0.6% (566)1.5%1.0%3.3%2.2%2.9%Yes
Defence Health88%1.0% (1,370)2.1%2.1%1.4%1.8%1.8%Yes
Teachers Health90%2.2% (3,632)2.5%3.0%1.2%2.4%1.8%Yes
TUH84%-9.8% (-301)0.6%0.4%0.0%0.2%0.0%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
AIA Health52%10.1% (1,320)49No12NoNo
CBHS Corporate70%-6.7% (-92)1Yes0YesYes
CDH85%6.9% (191)2Yes0YesNo
HCI83%-6.0% (-374)4No0YesYes
MDHF91%3.1% (513)0Yes0YesNo
Onemedifund91%1.2% (69)0Yes0YesYes
Phoenix85%4.0% (373)6No0YesYes
QCH86%2.1% (569)3Yes0YesYes
Transport Health72%-11.6% (-712)22No1NoYes
Restricted membership funds
ACA91%0.3% (13)0Yes0YesYes
Doctors' Health90%8.8% (1,937)10Yes0YesYes
Navy Health86%4.0% (896)10No1YesYes
Nurses and Midwives68%18.5% (885)8No0YesNo
Police Health91%13.8% (3,212)10Yes0YesYes
Reserve Bank88%-0.5% (-12)2No0YesYes
RT Health Fund86%-4.3% (-1,077)13No3NoYes

[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] Membership change in total policies. The industry experienced a growth of 0.42 per cent or 28,193 memberships overall.

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

In that table each fund's market share (as at 30 June 2020) 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 still 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)

Table 2B—Smaller funds (less than 0.5 per cent national market share)

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 (per cent) 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).

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
AIA Health73.4%85.1%86.8%88.1%88.0%86.3%86.4%83.5%
Australian Unity81.4%88.4%91.3%89.2%89.8%88.9%91.5%87.9%
BUPA84.3%90.1%93.4%91.6%95.2%89.7%93.9%91.7%
CBHS Corporate70.7%86.4%80.9%93.3%95.2%88.5%88.5%N/A
CDH56.6%96.0%89.4%91.8%94.3%95.7%92.2%N/A
CUA Health81.1%90.2%90.3%92.1%90.1%88.6%91.6%80.2%
GMHBA78.0%85.0%92.0%87.3%89.9%91.1%91.6%80.7%
HBF87.8%90.2%93.0%91.9%93.9%95.5%95.4%87.5%
HCF89.4%93.1%93.3%92.3%94.7%90.9%93.5%92.1%
HCI86.1%88.8%92.6%91.4%92.5%95.8%94.3%N/A
Health.com.au74.3%81.6%83.1%83.6%87.1%85.7%85.6%88.0%
Health Partners83.3%91.4%91.1%93.1%95.4%89.7%90.4%84.4%
HIF82.0%88.7%91.3%90.8%91.4%92.5%94.8%84.1%
Latrobe82.7%90.9%92.2%90.3%94.5%93.8%91.9%92.4%
MDHF69.8%94.1%93.5%91.3%93.1%91.8%92.3%99.7%
Medibank84.3%90.1%92.7%90.7%93.1%90.7%93.7%90.9%
NIB78.4%87.9%86.3%84.6%90.9%86.7%90.5%81.6%
Onemedifund76.6%93.6%95.3%95.0%95.8%95.5%95.6%N/A
Peoplecare82.3%92.3%93.3%91.4%94.4%94.1%94.1%86.5%
Phoenix90.1%94.1%92.2%93.3%96.7%92.0%97.6%84.9%
QCH76.4%93.2%92.2%89.2%78.7%92.9%93.6%90.1%
St Lukes84.9%92.3%91.1%91.4%94.7%93.0%93.8%84.2%
Transport Health55.6%85.9%94.1%89.8%88.6%85.3%99.2%N/A
Westfund84.8%93.6%91.7%91.2%93.8%92.0%95.7%92.6%
Restricted membership funds        
ACA92.7%95.0%97.0%96.1%95.0%95.7%95.6%N/A
CBHS86.6%90.7%94.0%92.8%95.4%92.7%93.9%96.2%
Defence Health84.8%90.0%92.9%91.7%94.3%92.1%92.2%90.6%
Doctors' Health91.5%92.6%93.6%93.2%92.1%88.5%90.2%89.0%
Navy Health83.7%91.3%92.4%91.3%94.1%94.3%93.5%92.4%
Nurses and Midwives83.4%92.0%90.7%90.8%92.8%91.6%93.4%93.7%
Police Health82.8%88.8%93.3%92.6%97.0%92.6%94.5%94.4%
Reserve Bank88.1%93.7%97.6%97.6%97.9%98.1%98.1%99.8%
RT Health Fund83.6%92.6%91.6%93.5%95.9%90.9%96.3%84.5%
Teachers Health86.6%92.3%92.9%92.9%94.3%92.3%94.6%89.4%
TUH90.6%91.1%89.5%92.4%93.8%93.0%95.0%90.3%
Industry average84.7%90.8%92.4%91.1%94.6%93.5%93.7%91.2%

[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, 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 accounting for 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
AIA Health73.9%84.9%86.8%87.7%85.8%83.0%78.7%72.2%
Australian Unity79.6%91.9%91.9%91.5%91.8%87.4%92.6%95.1%
BUPA85.0%92.0%93.0%94.3%94.2%88.8%93.4%91.3%
CBHS Corporate68.4%85.4%92.1%91.3%98.7%81.6%72.3%N/A
CDH52.9%87.5%60.5%72.6%63.4%42.9%68.1%N/A
CUA Health79.3%92.4%90.5%94.3%87.9%87.3%90.2%77.5%
GMHBA55.0%78.0%86.9%81.9%85.4%80.0%74.4%79.3%
HBF82.5%85.3%85.8%88.6%90.5%91.7%93.3%86.8%
HCF82.4%91.4%88.6%90.9%88.9%86.1%91.7%88.2%
HCI71.7%87.4%89.1%91.2%89.3%90.2%92.5%N/A
Health.com.au79.1%86.4%84.8%88.5%87.9%86.8%86.5%86.9%
Health Partners76.0%91.1%89.2%92.4%93.2%80.6%87.8%85.2%
HIF73.4%88.6%89.5%91.3%88.5%87.5%89.6%91.7%
Latrobe55.5%79.8%78.6%83.1%87.0%75.7%75.2%50.0%
MDHF30.8%84.3%78.5%80.1%80.9%61.5%70.8%85.7%
Medibank77.3%86.9%87.0%86.6%86.2%74.8%90.6%87.7%
NIB69.9%93.1%91.1%87.8%95.3%89.1%88.4%80.7%
Onemedifund87.2%91.8%90.2%94.6%91.1%80.4%90.9%N/A
Peoplecare76.3%93.3%91.4%92.2%91.4%86.3%93.1%89.8%
Phoenix86.8%92.9%89.6%92.8%93.7%88.2%92.7%89.8%
QCH79.4%94.9%91.4%91.4%89.4%85.9%81.8%82.2%
St Lukes72.2%80.4%84.7%80.0%84.6%67.9%90.6%83.3%
Transport Health33.3%86.0%91.8%90.5%88.4%88.9%100.0%N/A
Westfund71.7%92.4%88.5%90.1%90.6%85.8%79.2%69.4%
Restricted membership funds
ACA78.5%92.7%94.1%94.7%93.0%83.2%92.4%N/A
CBHS82.4%90.1%90.5%92.3%91.7%86.0%91.2%95.2%
Defence Health80.2%90.0%90.6%92.5%91.4%85.9%90.1%87.0%
Doctors' Health90.0%91.6%92.7%94.2%91.0%89.2%91.7%90.6%
Navy Health77.1%91.6%90.8%92.2%92.5%87.1%89.8%93.5%
Nurses and Midwives72.5%91.4%86.3%91.9%91.0%83.5%89.1%84.8%
Police Health76.4%85.6%84.7%89.0%90.2%83.2%87.2%85.9%
Reserve Bank72.8%90.3%94.0%95.8%93.9%91.8%95.0%92.8%
RT Health Fund73.8%93.0%90.6%93.6%90.6%86.3%93.0%96.5%
Teachers Health82.9%91.4%90.0%92.7%91.2%84.6%91.2%87.9%
TUH87.6%90.5%88.5%92.6%87.4%88.6%93.1%81.6%
Industry average79.6%90.5%89.0%90.8%92.0%87.5%91.3%88.9%

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
AIA Health90.5%95.2%97.7%96.8%99.1%95.3%91.6%88.9%
Australian Unity91.8%96.9%98.1%96.8%98.2%97.4%98.4%97.9%
BUPA94.5%96.8%99.0%98.3%99.7%96.8%99.3%97.7%
CBHS Corporate84.2%95.1%97.5%95.6%100.0%95.2%89.2%N/A
CDH52.9%96.9%78.0%91.3%90.3%100.0%100.0%N/A
CUA Health93.7%97.9%98.8%98.5%98.7%96.7%97.2%96.1%
GMHBA78.9%91.9%96.7%93.3%97.9%93.6%86.1%92.4%
HBF99.8%99.5%99.9%99.6%100.0%99.8%99.9%99.4%
HCF97.1%98.9%99.5%99.3%99.9%98.5%99.6%98.9%
HCI98.8%97.0%99.0%97.9%97.9%97.6%99.1%N/A
Health.com.au92.7%95.8%97.5%97.6%98.7%98.5%99.7%97.5%
Health Partners95.4%97.1%98.6%97.5%99.8%97.4%97.4%100.0%
HIF92.4%97.5%98.9%98.2%99.0%98.0%99.8%97.2%
Latrobe98.0%97.8%99.9%99.3%99.6%99.6%99.7%100.0%
MDHF100.0%99.6%99.7%98.5%99.5%92.5%93.8%85.7%
Medibank94.0%96.8%97.4%95.2%99.4%89.9%98.5%96.6%
NIB70.1%93.4%92.5%88.2%95.4%91.0%88.8%80.7%
Onemedifund100.0%97.5%99.0%99.0%99.8%96.8%99.7%N/A
Peoplecare94.7%98.3%99.2%98.2%99.7%97.9%99.6%93.5%
Phoenix95.4%98.5%98.9%98.4%99.9%97.6%100.0%95.9%
QCH95.6%98.5%98.9%98.1%97.7%97.2%88.6%90.9%
St Lukes90.3%89.1%93.8%93.9%95.2%77.6%98.6%83.3%
Transport Health100.0%95.9%99.0%97.8%100.0%99.3%100.0%N/A
Westfund84.4%98.0%97.7%98.3%98.3%97.2%87.7%98.0%
Restricted membership funds
ACA98.3%97.7%99.2%98.8%99.4%96.4%99.2%N/A
CBHS95.8%97.0%98.3%97.7%98.7%97.3%98.7%98.2%
Defence Health94.9%97.5%99.0%98.3%99.6%98.0%98.9%95.7%
Doctors' Health97.6%98.2%98.8%98.9%99.2%98.7%98.7%96.2%
Navy Health94.0%97.6%98.8%97.9%99.2%97.5%98.7%97.8%
Nurses and Midwives92.9%97.5%98.2%97.7%98.7%95.9%98.5%100.0%
Police Health93.3%95.3%97.1%97.1%99.6%97.1%98.1%97.0%
Reserve Bank92.2%96.9%99.4%99.1%99.3%98.4%99.4%100.0%
RT Health Fund93.3%98.5%98.9%98.8%99.3%97.1%99.6%98.3%
Teachers Health95.8%97.8%98.9%98.6%99.5%97.7%99.5%96.0%
TUH97.1%97.6%98.0%98.4%100.0%97.9%99.3%86.8%
Industry average92.8%97.0%98.0%97.0%99.5%97.2%98.6%97.0%

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.

Table 5A shows the average proportion of service charges covered by each fund per state for all their policies and services. 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
AIA Health54.5%53.1%54.4%53.7%56.0%57.5%56.3%65.1%
Australian Unity44.7%46.9%49.8%50.2%52.8%49.2%47.0%52.1%
BUPA46.6%50.8%49.7%53.4%56.9%59.3%51.6%60.0%
CBHS Corporate49.8%51.6%52.9%50.6%55.9%52.2%54.2%N/A
CDH37.0%37.1%39.9%36.3%45.2%39.3%34.8%N/A
CUA Health43.9%53.0%48.8%48.6%53.1%48.6%51.5%40.6%
GMHBA50.4%52.2%49.5%53.2%52.4%50.7%48.0%52.0%
HBF44.5%49.0%48.7%48.9%52.0%56.7%48.0%51.7%
HCF50.9%50.5%56.6%57.5%62.4%61.0%53.2%54.3%
HCI50.7%53.7%53.1%49.5%53.0%48.2%46.5%49.0%
Health.com.au50.5%51.2%52.5%51.2%54.1%53.6%53.9%48.7%
Health Partners53.2%54.1%44.6%42.4%58.1%46.6%45.3%43.9%
HIF42.5%46.1%46.4%47.0%49.6%47.5%46.5%46.6%
Latrobe28.1%32.7%36.0%34.6%39.2%43.0%34.6%29.4%
MDHF47.6%54.0%55.1%54.9%51.5%43.7%50.5%45.8%
Medibank48.5%51.7%54.0%55.6%59.6%58.8%53.9%60.7%
NIB55.6%56.0%60.6%56.4%60.9%63.2%56.0%59.6%
Onemedifund52.4%53.4%56.2%53.6%56.0%57.3%56.8%N/A
Peoplecare46.5%49.7%48.9%47.6%51.9%45.9%46.2%48.5%
Phoenix46.7%52.6%52.1%53.9%56.2%52.5%51.6%52.6%
QCH48.2%49.2%49.6%51.7%49.6%48.6%50.6%46.3%
St Lukes55.2%63.0%59.1%60.2%65.3%62.5%60.3%59.1%
Transport Health48.3%47.8%53.0%46.5%50.7%47.6%52.3%41.3%
Westfund40.7%49.4%45.2%51.4%49.5%43.4%40.1%46.4%
Restricted membership funds
ACA57.8%58.4%59.1%59.9%61.6%59.3%54.6%50.1%
CBHS42.6%47.8%48.8%50.2%52.7%49.9%47.8%46.1%
Defence Health42.8%45.9%48.2%47.9%43.3%46.7%46.2%50.4%
Doctors' Health54.4%53.5%55.3%55.8%58.2%59.0%55.7%57.2%
Navy Health45.2%48.4%51.8%50.3%56.2%52.0%47.3%50.0%
Nurses and Midwives42.8%52.1%49.8%51.0%53.7%54.3%46.2%46.0%
Police Health66.7%66.7%67.4%67.8%70.9%69.0%67.4%68.0%
Reserve Bank70.6%73.0%75.7%75.9%81.4%76.7%75.2%90.0%
RT Health Fund37.7%47.7%43.9%46.2%49.4%43.6%41.9%42.1%
Teachers Health42.2%47.7%47.8%47.5%51.5%50.0%47.1%47.2%
TUH45.7%49.1%48.4%54.9%52.6%50.1%53.1%48.4%
Industry average48.0%50.7%52.3%54.1%57.6%57.1%54.3%59.5%

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) per service type
Average amount of costs covered by service
Fund Name (Abbreviated)Dental [1]Optical [1]PhysiotherapyChiropracticPharmacyPodiatryNatural therapiesAmbulanceAcupuncturePsychology/Group therapyPreventative healthHearing aidsOccupational therapy
Open membership funds
AIA Health51.8%54.5%58.1%58.0%27.3%62.8%54.4%100.0%52.4%55.7%76.4%12.5%58.3%
Australian Unity45.2%65.5%60.8%46.9%38.0%45.2%46.8%98.6%38.9%33.2%74.3%16.0%42.5%
BUPA56.0%56.5%47.0%48.3%34.7%48.8%38.3%100.0%38.3%41.2%36.5%18.8%33.9%
CBHS Corporate49.7%56.3%52.6%60.6%41.9%53.8%52.6%96.5%56.9%44.0%N/A31.4%30.2%
CDH37.3%52.7%42.2%39.4%42.0%33.1%25.9%100.0%42.9%17.3%31.4%N/A29.1%
CUA Health51.3%58.8%38.8%42.9%28.6%50.2%38.3%99.5%43.0%34.4%39.4%56.4%38.8%
GMHBA50.4%57.2%47.7%49.5%33.8%48.3%30.4%86.8%46.5%43.8%66.6%27.3%42.2%
HBF56.1%58.1%47.8%52.7%50.4%49.0%50.3%100.0%N/A40.0%94.9%38.2%44.0%
HCF58.5%57.3%44.2%42.3%35.4%39.9%33.7%100.0%31.1%45.7%42.6%30.8%48.3%
HCI51.3%53.0%41.3%50.2%44.6%43.6%51.2%100.0%54.8%29.7%67.4%47.0%38.9%
Health.com.au49.0%49.2%57.8%58.2%28.8%54.2%57.4%100.0%57.0%51.6%na21.1%54.7%
Health Partners61.6%54.4%59.4%43.5%46.4%34.4%27.7%100.0%29.3%35.8%66.3%32.3%46.1%
HIF48.2%58.4%39.0%39.6%40.5%35.0%22.8%99.3%20.9%32.1%33.8%29.5%33.7%
Latrobe33.5%55.2%32.4%36.2%11.7%36.2%23.4%76.4%43.5%28.9%38.1%13.4%35.2%
MDHF61.3%63.0%40.6%43.9%28.6%44.2%36.7%81.0%33.1%26.8%47.8%34.0%32.0%
Medibank53.5%68.9%46.5%51.7%29.5%50.7%52.2%100.0%41.1%32.2%64.1%26.9%35.4%
NIB57.8%54.1%60.7%60.7%43.7%58.1%61.1%100.0%59.2%60.6%47.2%19.3%66.1%
Onemedifund59.3%52.2%52.0%47.2%40.5%44.1%40.6%96.5%35.7%37.1%86.4%34.3%33.5%
Peoplecare48.6%60.3%39.2%41.7%35.3%38.4%37.7%99.6%39.5%37.6%67.3%35.9%39.0%
Phoenix56.7%66.1%43.6%44.9%38.0%48.2%46.6%96.4%40.5%40.1%48.1%42.1%43.2%
QCH51.7%60.1%43.7%55.6%36.8%60.7%33.3%na41.2%42.6%46.1%35.0%38.0%
St Lukes64.5%75.7%50.1%49.7%41.4%46.1%41.5%74.8%44.1%45.5%59.7%45.4%49.1%
Transport Health55.0%57.5%43.6%52.3%30.9%50.2%41.1%100.0%34.6%27.6%59.5%27.4%29.2%
Westfund51.5%56.2%45.2%51.3%38.8%46.1%38.0%100.0%34.8%39.6%82.7%41.0%43.6%
Restricted membership funds
ACA61.7%70.6%40.5%46.7%44.4%72.5%37.6%100.0%34.0%46.6%N/A42.9%65.9%
CBHS49.3%53.3%49.8%59.0%40.8%42.3%44.1%95.0%44.2%38.1%N/A38.5%33.4%
Defence Health46.0%52.5%48.7%40.6%31.5%48.4%35.9%100.0%31.2%43.3%74.7%32.0%44.5%
Doctors' Health59.3%63.5%43.3%0.0%40.7%50.3%40.3%N/AN/A46.8%33.0%21.4%33.7%
Navy Health46.9%58.6%51.5%58.1%44.0%52.0%43.7%98.5%N/A40.2%100.0%30.0%32.9%
Nurses and Midwives52.3%60.4%44.1%58.9%41.8%54.2%44.5%100.0%40.8%39.9%42.4%28.0%54.3%
Police Health69.7%66.8%75.2%76.6%45.3%68.1%39.2%99.9%73.2%76.3%100.0%41.0%67.8%
Reserve Bank74.4%71.0%68.2%71.1%60.9%78.4%76.9%97.8%72.4%74.6%57.6%78.3%66.6%
RT Health Fund44.3%60.2%46.7%47.1%38.1%44.7%42.5%100.0%47.3%17.3%36.6%30.8%31.0%
Teachers Health50.8%49.2%42.8%55.3%38.4%47.4%44.1%99.8%38.5%37.1%37.1%38.9%56.7%
TUH58.4%56.0%49.4%52.8%35.4%56.8%50.5%100.0%42.6%40.2%49.1%45.1%35.8%
Industry average54.4%59.8%48.2%49.9%36.2%49.0%45.0%99.5%40.4%40.5%55.6%28.4%42.4%

[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.[3] Information included in the Financial Performance table (Table 6) is drawn from data collected by APRA.

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 2019–20 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 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
Open membership funds
AIA Health105.6%30.0%$1,076-35.6%-28.7%No
Australian Unity83.0%11.0%$4176.0%4.4%No
BUPA88.3%7.8%$2963.9%3.4%No
CBHS Corporate110.2%37.1%1,273-47.3%-62.2%No
CDH84.9%14.8%$6540.2%0.6%Yes
CUA Health84.7%9.9%$3695.4%4.1% No
GMHBA85.0%12.2%$4452.8%1.8%Yes
HBF88.6%11.6%$383-0.2%2.2%Yes
HCF93.2%11.0%$422-4.2%-2.8%Yes
HCI83.4%11.1%$4775.5%5.1%Yes
Health.com.au90.8%7.1%$2232.1%2.4%No
Health Partners91.9%9.8%$369-1.7%0.0%Yes
HIF86.9%11.9%$3901.2%2.1%Yes
Latrobe94.8%11.7%$467-6.5%-8.4%Yes
MDHF89.0%9.1%$3211.9%0.5%Yes
Medibank85.7%8.0%$2846.3%4.9%No
NIB84.0%10.5%$3555.5%8.3%No
Onemedifund84.4%9.2%$5246.5%5.3%No
Peoplecare87.7%10.0%$4332.3%1.6%Yes
Phoenix90.4%10.1%$482-0.5%0.1%Yes
QCH88.9%11.4%$537-0.3%1.1%No
St Lukes91.3%11.0%$478-2.3%-1.9%Yes
Transport Health84.6%12.7%$4722.7%2.8%No
Westfund87.1%13.9%$562-1.0%-1.7%Yes
Restricted membership funds
ACA88.4%12.2%$654-0.7%-1.0%Yes
CBHS96.2%8.9%$391-5.1%-3.6%Yes
Defence Health92.0%6.5%$2721.4%2.8%Yes
Doctors' Health88.0%10.2%$5351.7%2.4%No
Navy Health90.3%9.7%$4020.0%0.3%Yes
Nurses and Midwives99.8%11.8%$476-11.6%-11.7%Yes
Police Health (1)92.2%9.4%$478-1.6%-1.0%Yes
Reserve Bank86.7%12.8%$8880.5%1.9%Yes
RT Health Fund85.5%16.1%$746-1.5%-3.3%Yes
Teachers Health89.6%8.1%$3652.3%2.8%Yes
TUH86.7%9.2%$4554.1%2.5%Yes
Industry result88.0%9.2%$3432.7%2.9%

(1) these figures are reflective of the Police Health (amalgamated) Group

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.[4]

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 have 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[5]

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).[6]

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 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, 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
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
AIA Health0.2%35.4%8991  
Australian Unity1.4%17.8%9291  
BUPA24.4%31.6%8874Yes 
CBHS Corporate0.0%57.9%9489  
CDH0.1%77.0%7952Yes 
CUA Health0.4%24.8%9287Yes 
GMHBA1.1%16.8%9687  
HBF0.7%3.3%8693  
HCF20.1%56.8%8588Yes 
HCI0.0%11.6%94109  
Health.com.au0.5%34.3%7971  
Health Partners0.1%3.2%9687  
HIF0.3%11.6%9591  
Latrobe0.2%8.0%7956  
MDHF0.1%11.2%7956 Yes
Medibank23.1%28.2%9176Yes 
NIB14.5%51.8%9293Yes 
Onemedifund0.1%41.6%9687  
Peoplecare0.7%47.2%9687Yes 
Phoenix0.2%43.8%9589Yes 
QCH0.0%1.6%9488  
St Lukes0.1%3.3%7855  
Transport Health0.0%12.8%9687  
Westfund1.5%57.0%9692Yes 
Restricted membership funds
ACA0.1%57.2%9289Yes 
CBHS2.2%46.4%9489  
Defence Health1.2%18.3%9292 Yes
Doctors' Health0.4%40.3%9392  
Navy Health0.3%29.1%9591  
Nurses and Midwives0.1%48.9%9291  
Police0.1%4.6%9591  
Reserve Bank0.1%61.0%9687Yes 
RT Health Fund0.7%49.7%9687Yes 
Teachers Health5.1%67.7%9291Yes 
TUH0.1%5.4%9589  

[1] Agreement hospitals data is sourced from privatehealth.gov.au as of 9 October 2020

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
AIA Health0.4%39.0%7669  
Australian Unity6.6%60.9%7672  
BUPA23.0%21.4%7562Yes 
CBHS Corporate0.0%15.3%7272  
CDH0.0%11.7%7463  
CUA Health0.5%18.4%7370YesYes
GMHBA5.7%64.2%7669YesYes
HBF1.1%3.5%6575YesYes
HCF7.6%15.4%6750Yes 
HCI0.1%22.8%7783  
Health.com.au0.7%35.3%6757  
Health Partners0.2%7.9%7669  
HIF0.5%15.4%7672  
Latrobe2.4%87.3%7463YesYes
MDHF0.9%83.3%7463YesYes
Medibank33.0%29.0%7052Yes 
NIB8.6%22.0%7276Yes 
Onemedifund0.1%24.7%7669  
Peoplecare0.7%31.9%7669Yes 
Phoenix0.2%26.2%7472  
QCH0.0%1.0%7570  
St Lukes0.1%4.8%7463  
Transport Health0.3%71.1%7669  
Westfund0.1%4.1%7673  
Restricted membership funds
ACA0.0%13.0%7571  
CBHS1.6%24.2%7272  
Defence Health2.7%29.7%7777YesYes
Doctors' Health0.4%29.3%7673  
Navy Health0.4%27.3%7673Yes 
Nurses and Midwives0.1%25.0%7473  
Police0.1%7.5%7672  
Reserve Bank0.0%23.2%7669  
RT Health Fund0.2%11.9%7669  
Teachers Health1.6%15.3%7473  
TUH0.1%4.1%7472  

[1] Agreement hospitals data is sourced from privatehealth.gov.au as of 9 October 2020

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
AIA Health0.2%16.2%5245  
Australian Unity1.9%12.7%5050  
BUPA30.9%21.3%5045Yes 
CBHS Corporate0.0%11.7%5050  
CDH0.0%9.0%4836  
CUA Health1.7%50.6%5047YesYes
GMHBA1.3%10.8%5149  
HBF0.7%1.7%4551  
HCF8.2%12.4%4938Yes 
HCI0.0%10.0%5761  
Health.com.au0.5%18.5%4238  
Health Partners0.1%3.1%5149  
HIF0.4%8.7%5051  
Latrobe0.1%2.8%4836  
MDHF0.0%2.5%4836  
Medibank31.8%20.8%5044Yes 
NIB6.9%13.1%5248Yes 
Onemedifund0.1%12.9%5149  
Peoplecare0.3%11.2%5149  
Phoenix0.1%14.4%5050  
QCH2.3%94.9%5048YesYes
St Lukes0.1%3.2%4836  
Transport Health0.1%11.2%5149  
Westfund1.7%34.1%5049Yes 
Restricted membership funds
ACA0.1%20.0%5048  
CBHS1.3%15.0%5050  
Defence Health3.5%29.0%4948 Yes
Doctors' Health0.4%20.5%5049  
Navy Health0.4%19.7%5051  
Nurses and Midwives0.0%10.1%5149  
Police0.7%32.9%5051  
Reserve Bank0.0%6.6%5149  
RT Health Fund0.8%33.7%5149Yes 
Teachers Health0.5%3.7%5149  
TUH2.9%89.0%5050Yes 

[1] Agreement hospitals data is sourced from privatehealth.gov.au as of 9 October 2020

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      
AIA Health0.1%2.2%2524  
Australian Unity1.4%4.3%2625  
BUPA46.0%14.1%2627Yes 
CBHS Corporate0.0%3.4%2527  
CDH0.0%1.0%2317  
CUA Health0.1%1.7%2523  
GMHBA0.4%1.5%2328  
HBF0.5%0.5%2523  
HCF8.5%5.7%2220Yes 
HCI0.0%2.3%2833  
Health.com.au0.2%3.2%2722  
Health Partners7.5%84.3%2328YesYes
HIF0.3%2.7%2627  
Latrobe0.1%0.6%2317  
MDHF0.1%2.3%2317  
Medibank22.3%6.4%2522Yes 
NIB4.0%3.4%2327  
Onemedifund0.1%4.8%2328  
Peoplecare0.3%4.7%2328  
Phoenix0.2%11.1%2527  
QCH0.0%0.3%2527  
St Lukes0.1%1.5%2317  
Transport Health0.0%1.9%2328  
Westfund0.2%1.7%2529  
Restricted membership funds      
ACA0.0%3.5%2626  
CBHS0.9%4.6%2527  
Defence Health2.4%8.6%2730 Yes
Doctors' Health0.2%3.5%2628  
Navy Health0.3%5.6%2628  
Nurses and Midwives0.1%6.9%2327  
Police1.6%31.7%2627Yes 
Reserve Bank0.0%3.3%2328  
RT Health Fund0.1%1.7%2328  
Teachers Health2.1%6.5%2327  
TUH0.0%0.4%2527  

[1] Agreement hospitals data is sourced from privatehealth.gov.au as of 9 October 2020

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      
AIA Health0.1%4.6%1921  
Australian Unity0.5%2.4%2122  
BUPA12.1%6.3%2018Yes 
CBHS Corporate0.0%8.3%2122  
CDH0.0%0.4%1814  
CUA Health0.1%2.7%2121Yes 
GMHBA0.7%4.5%2221  
HBF49.9%90.4%2523YesYes
HCF5.0%5.6%1814Yes 
HCI0.0%1.3%2325  
Health.com.au0.2%4.9%1816  
Health Partners0.0%0.5%2221  
HIF3.4%60.1%2123YesYes
Latrobe0.0%0.3%1814  
MDHF0.0%0.3%1814  
Medibank21.0%10.3%2120Yes 
NIB3.7%5.3%2125  
Onemedifund0.1%11.0%2221  
Peoplecare0.1%2.6%2221  
Phoenix0.0%2.6%2122  
QCH0.0%0.5%2122  
St Lukes0.0%0.5%1814  
Transport Health0.0%1.7%2221  
Westfund0.1%1.6%2123  
Restricted membership funds      
ACA0.0%4.0%2121  
CBHS0.8%6.9%2122  
Defence Health0.7%4.4%2023 Yes
Doctors' Health0.1%2.6%2123  
Navy Health0.2%7.1%2123  
Nurses and Midwives0.0%5.0%2123  
Police0.4%12.7%2123  
Reserve Bank0.0%3.0%2221  
RT Health Fund0.1%1.6%2221  
Teachers Health0.6%3.2%2123  
TUH0.0%0.3%2122  

[1] Agreement hospitals data is sourced from privatehealth.gov.au as of 9 October 2020

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      
AIA Health0.1%0.5%53  
Australian Unity1.0%0.8%83  
BUPA31.3%2.5%86Yes 
CBHS Corporate0.0%0.9%84  
CDH0.0%0.5%88  
CUA Health0.1%0.4%83  
GMHBA0.9%0.9%54  
HBF0.8%0.2%45  
HCF5.5%1.0%86  
HCI2.2%51.1%88Yes 
Health.com.au0.2%0.7%83  
Health Partners0.1%0.3%54  
HIF0.2%0.6%84  
Latrobe0.2%0.5%88  
MDHF0.0%0.3%88  
Medibank26.5%2.0%85Yes 
NIB3.3%0.7%59  
Onemedifund0.2%4.8%54  
Peoplecare0.2%0.7%54  
Phoenix0.0%0.6%84  
QCH0.0%0.2%84  
St Lukes22.1%86.4%88YesYes
Transport Health0.0%0.4%54  
Westfund0.2%0.4%84  
Restricted membership funds      
ACA0.0%1.3%83  
CBHS1.1%1.5%84  
Defence Health1.3%1.2%84 Yes
Doctors' Health0.2%0.9%84  
Navy Health0.2%1.3%84  
Nurses and Midwives0.1%1.9%54  
Police0.5%2.7%84  
Reserve Bank0.0%1.3%54  
RT Health Fund0.1%0.5%54  
Teachers Health1.3%1.1%54  
TUH0.1%0.3%84  

[1] Agreement hospitals data is sourced from privatehealth.gov.au as of 9 October 2020

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      
AIA Health0.2%2.0%67  
Australian Unity1.3%1.0%58  
BUPA21.2%1.7%45Yes 
CBHS Corporate0.0%2.4%58  
CDH0.0%0.4%56  
CUA Health0.3%1.1%57Yes 
GMHBA1.3%1.3%58  
HBF0.8%0.2%85  
HCF15.6%2.8%57Yes 
HCI0.0%0.9%69  
Health.com.au0.6%2.5%66  
Health Partners0.2%0.6%58  
HIF0.3%0.8%58  
Latrobe0.1%0.4%56  
MDHF0.0%0.2%56  
Medibank28.1%2.2%55Yes 
NIB15.1%3.4%68  
Onemedifund0.0%0.2%58  
Peoplecare0.4%1.6%58  
Phoenix0.1%1.1%58  
QCH0.0%0.2%58  
St Lukes0.1%0.2%56  
Transport Health0.0%0.7%58  
Westfund0.5%1.1%58  
Restricted membership funds      
ACA0.0%0.8%66  
CBHS1.0%1.3%58  
Defence Health7.6%7.4%68 Yes
Doctors' Health0.4%2.6%68  
Navy Health1.5%8.8%58  
Nurses and Midwives0.1%1.8%58  
Police0.2%0.9%58  
Reserve Bank0.0%1.5%58  
RT Health Fund0.2%0.7%58  
Teachers Health2.7%2.3%58  
TUH0.1%0.4%58  

[1] Agreement hospitals data is sourced from privatehealth.gov.au as of 9 October 2020

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
AIA Health0.1%0.2%21  
Australian Unity0.4%0.1%21  
BUPA36.5%1.1%11Yes 
CBHS Corporate0.0%0.0%21  
CDH0.0%0.0%11  
CUA Health0.2%0.2%21  
GMHBA0.2%0.1%21  
HBF1.6%0.2%12  
HCF6.4%0.4%11  
HCI0.0%0.1%21  
Health.com.au0.4%0.5%11  
Health Partners0.1%0.1%21  
HIF0.1%0.1%21  
Latrobe0.0%0.0%11  
MDHF0.0%0.1%11  
Medibank39.5%1.1%11Yes 
NIB3.8%0.3%12  
Onemedifund0.0%0.0%21  
Peoplecare0.1%0.1%21  
Phoenix0.0%0.2%21  
QCH0.7%1.3%21  
St Lukes0.0%0.0%11  
Transport Health0.0%0.1%21  
Westfund0.1%0.1%21  
Restricted membership funds
ACA0.0%0.1%21  
CBHS0.3%0.2%21  
Defence Health3.8%1.3%21 Yes
Doctors' Health0.2%0.3%21  
Navy Health0.5%1.1%21  
Nurses and Midwives0.0%0.4%12  
Police3.6%7.0%21  
Reserve Bank0.0%0.1%21  
RT Health Fund0.1%0.2%21  
Teachers Health0.9%0.3%12  
TUH0.1%0.1%21  

[1] Agreement hospitals data is sourced from privatehealth.gov.au as of 9 October 2020

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 complaints 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, subject to certain requirements in the Ombudsman Act 1976. 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.

For more information about our complaint process and what information we may need from you, see our Making a complaint checklist.

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.

Otherwise, 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, with most 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 that 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.

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

[2] The methodology for counting private health insurance enquiries changed during 2019–20 so this figure is not directly comparable to the previous year.

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

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

[5] According to privatehealth.gov.au, 9 October 2020, or as supplied by the fund.

[6] 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.