Health insurance reforms: Strengthening the powers of the Private Health Insurance Ombudsman

The health insurance reforms will help you get the care and answers you deserve.

Private health insurance (PHI) can sometimes be a little confusing. Whether it's an unexpected out-of-pocket expense or your coverage doesn't correspond to what you believe was outlined in a letter or phone call, it often feels like there is nobody to turn to.

As part of a range of reforms being rolled out in 2019, the government is strengthening the powers of the Private Health Insurance Ombudsman (PHIO), helping to address and resolve more customer complaints.

What's changing for the PHIO in 2019?

The PHIO represents the interests of the public by investigating and addressing complaints of unfair treatment, sometimes known as maladministration. Throughout 2019, the ombudsman will obtain increased powers, allowing it to conduct more-thorough investigations in order to resolve more consumer complaints.


  • The ombudsman will be able to conduct inspections and regular audits of private health insurers to address various customer complaints. This means having full access to the insurer's records, including supplementary records like phone calls, letters and emails.
  • The government is providing the PHIO with additional staff members, employed mainly in investigatory roles, allowing it to answer customer complaints faster and more efficiently.
  • Investigators will focus on verifying customer activity records and addressing complaints by consumers regarding their private health insurer and private hospital contractual arrangements, including prostheses.

How will changes to the PHIO impact you?

The PHIO's primary role is to protect your interests as a private health insurance customer. However, it doesn't just deal with complaints from health fund members, it deals with grievances made by health funds, private hospitals, health insurance brokers and medical practitioners, improving services for a wide range of people.

In the 2017–18 period, the PHIO received 4,553 complaints. Providing more staff and better powers will help it deal with complaints quicker than before and get you the answers you need. As anyone will tell you, if you've ever had to make a complaint, it's often a very stressful period and you want it resolved quickly.

The move will also increase pressure on insurance companies to provide clear and consistent information. With the increase of the PHIO's powers, insurers will have to make sure they don't make mistakes, or risk alienating some of their customers.

Will it impact your healthcare costs?

While the changes are likely to increase transparency in the private health insurance sector, it'll only put money in your pocket if an insurance provider is found to have treated you unfairly or misled you. Although it's rare that insurers are found to have misled their customers, there are occasions where it has happened, which is why it helps to know you have the backing and protection of the PHIO.

Why is it changing?

The move comes as part of an attempt by the government to simplify private health insurance and improve transparency. Private health insurance is an integral part of Australian society and grows in size each year, with over 13 million of us holding some kind of PHI. That's why it's important to have an independent regulatory body capable of adequately dealing with such a big industry.

While health insurers have a good track record in voluntarily providing full records to the ombudsman during complaint investigations, there are some instances where further investigation has revealed additional records like phone calls, letters or emails have been overlooked. It's important then that we have a strong ombudsman, which is why increasing its resources benefits us all as customers.

Similarly, by accessing a health insurer's records within its premises, investigation officers will be able to make sure that nothing is being hidden or overlooked. This is helpful as it allows the PHIO to assure you about the accuracy of the information provided by insurers.

When will these changes happen?

Legislation regarding the increase to the PHIO's powers was introduced in March 2018. Legislation for the Increased Complaints Levy funding, which is needed to boost the PHIO workforce, was passed in June 2018. The ombudsman's role will continue to be expanded throughout 2019.

What else is changing in healthcare this year?

These reforms are part of a systemic overhaul by the government that targets a whole range of issues in private health insurance.

Picture: Unsplash

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