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Private Health Insurance Ombudsman

Not sure what role the Private Health Insurance Ombudsman (PHIO) plays? Keep reading.

An Ombudsman represents the interests of the public by investigating and addressing complaints of maladministration or violations of consumer rights. This guide looks at the Private Health Insurance Ombudsman (PHIO) in Australia, including what it is, what it does and what it can do for you if you have a complaint about a private health insurance matter.

What is the Private Health Insurance Ombudsman?

The Private Health Insurance Ombudsman (PHIO) is an independent body set up to protect the interests of private health insurance consumers. Its functions include:

  • To assist health fund members with dispute resolutions through an independent complaints-handling service
  • To identify and advise the government of any problems in the administration of private health insurance by health funds or healthcare providers
  • To provide advice and recommendations to government and industry regarding the performance of private health and the nature of complaints
  • To provide information and advice to consumers via the PrivateHealth.gov.au website and through regular bulletins, reports, brochures and fact sheets

Anyone can lodge a complaint about a health insurance matter with the Private Health Insurance Ombudsman including consumers, health funds, private hospitals and healthcare providers.


What types of complaints does the PHIO handle?

As long as a complaint is about a private health insurance matter, the PHIO will consider it and will investigate those it believes are impacting on the rights of consumers. Common complaints about health funds received by the PHIO include:

  • Restrictions and exclusions. Consumers unhappy with terms and conditions they were unaware of in private hospital policies.
  • Rule changes to existing policies. Consumers not understanding benefit reductions made to their cover.
  • Oral advice. Members misunderstanding oral advice provided by health fund staff, without records being kept of what was said.
  • Membership service. Complaints about administrative inefficiencies with regard to membership cancellations, clearance certificates and arrears.
  • Premium increases. Members unhappy with higher than average premium rises and slow or no notification of such increases.
  • Pre-existing medical conditions. Members unhappy with claims being denied due to pre-existing conditions.

In the majority of cases, the PHIO determined these problems were largely due to ambiguous information and poor communication on the part of certain health funds.


Complaints per insurer for 2015-16

How did the funds in the finder.com.au panel fair?

FundComplaintsPercentage of complaintsDisputesPercentage of disputesMarket share
ahm

154440.20%25236.80%28.60%
Australian Unity1955.10%334.80%3.10%
CBHS health fund350.90%91.30%1.40%
GMHBA551.40%60.90%2.00%
health.com.aulogo531.40%131.90%0.60%
HIF Logo220.60%30.40%0.90%
HCF40610.60%669.60%10.50%
nib3010.078420.0610.079
people care health fund60.00210.0010.005
Transport Health Logo80.00210.0010.001

Source: Commonwealth Ombudsman Annual Report 2015-16

Want to see how the rest of the market did? Check out the full list at the end of this article.

What do you need to do before contacting the PHIO?

Before contacting the Private Health Insurance Ombudsman with a complaint about a health fund, you should first approach the health fund to see if they can offer a resolution. It is in their best interests to maintain a satisfied customer base and most funds have a department dedicated to dealing with member complaints.

Australian Unity, for example, views member feedback as an opportunity to improve their services, products and policies and they invite you to contact them if you are dissatisfied with any aspect of their service or the cover they provide.

You can do so by phone, email or post and they will endeavour to respond within 48 hours. You can first discuss your issue with a customer service representative and if you are not satisfied with their response, your complaint will be escalated to their manager for further review.

If you still don’t feel your complaint has been fully resolved, you can then have your case escalated to a case manager within the customer relations department, who will investigate your complaint and attempt to resolve it within five business days.


Making a complaint?

If you are not satisfied with the response from your health fund, you can make an official complaint to the Private Health Insurance Ombudsman. This is now part of the Commonwealth Ombudsman, which is also the Ombudsman for government departments and agencies, overseas students, the Defence Force, immigration, law enforcement and the postal industry.

You can make a complaint to the Commonwealth Ombudsman in the following ways:

  • By phone. Call 1300 362 072 Monday to Friday during office hours
  • Online. You can fill in the online complaint form on their website at: http://www.ombudsman.gov.au/making-a-complaint
  • By mail. Post the details of your complaint to Commonwealth Ombudsman, GPO Box 442, Canberra ACT 2601

When writing your complaint, you should keep it simple and stick to the facts including:

  • What happened?
  • Where and when did it happen?
  • Who was involved?
  • Were there any witnesses?
  • Do you have any relevant evidence?
  • Have you already complained to your health fund and if so, what was the outcome?
  • What result would you like to see from your complaint?

The Ombudsman will endeavour to deal with your complaint as quickly as possible and keep you informed of its progress. If your complaint cannot be resolved through contact with the health fund and the Ombudsman feels it should be taken further, they may undertake an investigation and may recommend the fund make changes to its policies or compensate you for your loss. Fortunately, most complaints are resolved quickly and without the need for such measures.

Compare your health insurance options

Details Features
High 65 / 75 / 85% - $0/$250/$500 Excess
High 65 / 75 / 85% - $0/$250/$500 Excess
Combines High Hospital Cover with its highest level of extras cover.
  • Cover starting from $44.74 weekly
  • 12 month waiting period for pregnancy
  • 65% back on extras
  • Choice of $0, $250 and $500 excess
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Premier Package
Premier Package
Top tier combined hospital and extras policy that covers you for an extensive range of hospital and general treatment services.
  • All the benefits of HCI's Premier Hospital policy
  • All the benefits of HCI's Premier Extras policy
  • Cover for pregnancy and IVF treatment
  • Cover for general and major dental
Get Quote More info
Deluxe flexi
Deluxe flexi
Deluxe flexi provides cover for a range of treatments including hip replacement, spinal fusion, dialysis and major eye surgery.
  • No excess for kids
  • All joint replacements
  • Major eye surgery
  • Rehabilitation
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GoldStar
GoldStar
Premium hospital cover with complete cover for hospital expenses. Save 4% when you pay for 12 months of your cover upfront.
  • All theatre fees covered
  • Unlimited maternity cover
  • Choose no excess or $200, $400, $500 per admission
Get Quote More info
Smart Combination
Smart Combination
Smart combination provides a high level of cover for both hospital and extras.
  • Claim up to $2725 back on extras
  • Hip and knee replacements
  • General and major dental
  • Physio
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Prestige
Prestige
Highest level of combined cover offered by CBHS. Includes the same benefits as Comprehensive Hospital and Top Extras plus more. Restricted fund: Only current or former staff (and their families) of Commonwealth Bank Group and their subsidiaries which include Aussie, Bankwest, Colonial First State and more can join.
  • No excess or co-payments on hospital cover
  • Non-student dependent under 25 can be kept on policy
  • Access to Chronic Disease Management Programs
  • Widest range of extras including orthodontics
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Bronze Hospital (no pregnancy) and Bronze Extras Set Benefits
Bronze Hospital (no pregnancy) and Bronze Extras Set Benefits
High level of hospital cover and extras cover for a range of popular services including knee and should reconstructions.
  • Most comprehensive hospital options
  • Cover for general and major dental
  • Shared or single room in a private hospital
  • Intensive and coronary care
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Premium Hospital and Silver Extras Cover
Premium Hospital and Silver Extras Cover
Comprehensive hospital cover including pregnancy cover. Also included affordable mid-level extras cover for dental, optical and therapies.
  • Cover from $39.50 per week
  • Pregnancy and birth-related services cover
  • Heart surgery cover
  • 100% cash back on two dental check per year
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Top Hospital with Top Extras
Top Hospital with Top Extras
Get comprehensive hospital and extras cover and tailor your policy to your needs.
  • Pregnancy and birth services cover
  • Back surgery cover
  • $1000 general dental annual limit
  • $600 physiotherapy annual limit
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Young Couples Combined Cover
Young Couples Combined Cover
Mid-level hospital and basic level Extras package with an excess for young, healthy couples that are not quite ready to start a family.
  • Emergency ambulance cover
  • Cancer-related surgery cover
  • 70% back on extras
  • $300 dental annual limit per person
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Full list of funds

FundComplaintsPercentage of complaintsDisputesPercentage of disputesMarket share
ACA00.00%00.00%0.10%
Australian Unity1955.10%334.80%3.10%
BUPA83421.70%19628.60%26.80%
CBHS350.90%91.30%1.40%
CDH (Cessnock)20.10%00.00%<0.1%
CUA701.80%172.50%0.60%
Defence260.70%60.90%1.80%
Doctors110.30%20.30%0.20%
GMHBA551.40%60.90%2.00%
Grand United Corporate170.40%50.70%0.40%
HBF1253.30%213.10%7.40%
HCI10.00%00.00%0.10%
Health.com.au531.40%131.90%0.60%
Health Insurance Fund of Australia220.60%30.40%0.90%
HealthGuard (GMF/ Central West)100.30%00.00%0.50%
Health-Partners130.30%10.10%0.60%
Hospitals Contribution Fund (HCF)40610.60%669.60%10.50%
Latrobe160.40%10.10%0.70%
Medibank (AHM)154440.20%25236.80%28.60%
Mildura10.00%10.10%0.20%
National Health Benefits (Onemedifund)10000.001
Navy20.001000.003
NIB3010.078420.0610.079
Peoplecare60.00210.0010.005
Phoenix00000.001
Police10000.003
Queensland Country Health20.001000.003
Railway and Transport150.00410.0010.004
Reserve0000<0.1%
St Lukes40.001000.004
Teachers Health470.01260.0090.021
Teachers Union60.00210.0010.005
Transport80.00210.0010.001
Westfund100.00310.0010.007

Source: Commonwealth Ombudsman Annual Report 2015-16

Interested in private health insurance? Compare your options today

Picture: Private Health Insurance Ombudsman (PHIO)

Richard Laycock

Richard is the senior insurance writer at finder.com.au and is on a mission to make insurance easier to understand.

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