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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 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 panel fair?

Fund Complaints Percentage of complaints Disputes Percentage of disputes Market share

ahm health fund

1544 40.20% 252 36.80% 28.60%
Australian Unity 195 5.10% 33 4.80% 3.10%
CBHS health fund 35 0.90% 9 1.30% 1.40%
GMHBA health fund 55 1.40% 6 0.90% 2.00%
health-com-au-logo 53 1.40% 13 1.90% 0.60%
HIF Logo 22 0.60% 3 0.40% 0.90%
HCF 406 10.60% 66 9.60% 10.50%
nib 301 0.078 42 0.061 0.079
people care health fund 6 0.002 1 0.001 0.005
Transport Health Logo 8 0.002 1 0.001 0.001

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:
  • 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

Full list of funds

Fund Complaints Percentage of complaints Disputes Percentage of disputes Market share
ACA 0 0.00% 0 0.00% 0.10%
Australian Unity 195 5.10% 33 4.80% 3.10%
BUPA 834 21.70% 196 28.60% 26.80%
CBHS 35 0.90% 9 1.30% 1.40%
CDH (Cessnock) 2 0.10% 0 0.00% <0.1%
CUA 70 1.80% 17 2.50% 0.60%
Defence 26 0.70% 6 0.90% 1.80%
Doctors 11 0.30% 2 0.30% 0.20%
GMHBA 55 1.40% 6 0.90% 2.00%
Grand United Corporate 17 0.40% 5 0.70% 0.40%
HBF 125 3.30% 21 3.10% 7.40%
HCI 1 0.00% 0 0.00% 0.10% 53 1.40% 13 1.90% 0.60%
Health Insurance Fund of Australia 22 0.60% 3 0.40% 0.90%
HealthGuard (GMF/ Central West) 10 0.30% 0 0.00% 0.50%
Health-Partners 13 0.30% 1 0.10% 0.60%
Hospitals Contribution Fund (HCF) 406 10.60% 66 9.60% 10.50%
Latrobe 16 0.40% 1 0.10% 0.70%
Medibank (AHM) 1544 40.20% 252 36.80% 28.60%
Mildura 1 0.00% 1 0.10% 0.20%
National Health Benefits (Onemedifund) 1 0 0 0 0.001
Navy 2 0.001 0 0 0.003
NIB 301 0.078 42 0.061 0.079
Peoplecare 6 0.002 1 0.001 0.005
Phoenix 0 0 0 0 0.001
Police 1 0 0 0 0.003
Queensland Country Health 2 0.001 0 0 0.003
Railway and Transport 15 0.004 1 0.001 0.004
Reserve 0 0 0 0 <0.1%
St Lukes 4 0.001 0 0 0.004
Teachers Health 47 0.012 6 0.009 0.021
Teachers Union 6 0.002 1 0.001 0.005
Transport 8 0.002 1 0.001 0.001
Westfund 10 0.003 1 0.001 0.007

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 Insurance Editor at finder, and has been wrangling insurance Product Disclosure Statements for the last 4 years. When he’s not helping Aussies make sense of the fine print, he can be found testing the quality of Aperol Spritzes in his new found home of New York. Richard studied Journalism at Macquarie University and The Missouri School of Journalism, and has a Tier 1 certification in General Advice for Life Insurance. He has also been published in CSO Australia and Dynamic Business.

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2 Responses

  1. Default Gravatar
    dianneDecember 20, 2016

    in desperatiom, I have contacted you as I have sent 6 emails to Australian Unity regarding a rather urgent request and they are not responding. It is too expensive to call from a mobile as they have extended hold times before answering. I have had problems with the fund since October. Can you please help! thank you Dianne

    • finder Customer Care
      RichardDecember 21, 2016Staff

      Hi Dianne,

      Thanks for getting in touch and I am sorry to hear about your situation. Unfortunately, is a comparison service and is unable to provide personalised financial advice. If you would like to contact Australian Unity, you can do so by heading to their website.

      If you would like to speak with the Private Health Insurance Ombudsman, you can do so my heading to its contact us page.

      You may also find the Insurance Law Service useful.

      I hope this was helpful,

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