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.
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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.
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.
How did the funds in the finder.com.au panel fair?
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.
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.
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.
|Fund||Complaints||Percentage of complaints||Disputes||Percentage of disputes||Market share|
|Grand United Corporate||17||0.40%||5||0.70%||0.40%|
|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%|
|Hospitals Contribution Fund (HCF)||406||10.60%||66||9.60%||10.50%|
|National Health Benefits (Onemedifund)||1||0||0||0||0.001|
|Queensland Country Health||2||0.001||0||0||0.003|
|Railway and Transport||15||0.004||1||0.001||0.004|
Source: Commonwealth Ombudsman Annual Report 2015-16