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Last Updated on 26 September 2018

Private Health Insurance Ombudsman PHIO


When purchasing private health insurance, you have certain consumer rights. If your insurance company fails to follow the laws or engages in dishonest or unfair behavior, you can make a compliant to your insurer. If you are not able to resolve your disagreement, the Private Health Insurance Ombudsman (PHIO) can step in and help you to deal with your insurance fund.  It is important to understand when you can make a complaint to the PHIO, and to take the proper steps to notify the PHIO of problems.

What is the PHIO?

The Private Health Insurance Ombudsman is an independent agency of the Australian Government. The job of the PHIO is to protect consumers who have purchased private health insurance coverage. The PHIO investigates consumer complaints, interfaces with insurance companies to help resolve complaints, and publishes information about health funds that consumers can use to comparison shop.

Although the PHIO is a government agency, it acts independently of the government. The agency is fully funded by levies collected from private health insurers, but is also independent of any insurer, hospital, or health provider.

What Does the PHIO Do?

The Private Health Insurance Ombudsman carries out the task of protecting private health insurance consumers in a number of different ways. Some of the different tasks the PHIO carries out include:

  • Helping members of health funds to resolve disputes with insurers. An independent claims handling service manages consumer complaints.
  • Identifying private health insurance fund providers who engage in problematic behavior or inappropriate practices related to the provision and administration of private health insurance.
  • Advising the Government and health insurance industry on issues that affect the industry’s relations with consumers.
  • Providing recommendations and advice to the insurance industry and the government related to the administration and management of private health insurance.

The Private Health Insurance Ombudsman addresses issues with private health funds only, including those providing extras coverage and hospital coverage. PHIO does not address complaints about care offered by providers, and it does not address complaints about Medicare coverage.

What are Your Rights as a Consumer of Health Insurance?

The Private Health Insurance Ombudsman enforces the consumer protection rules that exist in the Private Health Insurance Act, as well as other consumer protection laws related to private health insurance coverage. Some of the different rights that consumers have related to health insurance include:

  • The right to change providers without losing coverage. The Private Health Insurance Act 2007 created portability rules protecting consumers who want to change hospital cover. When a consumer changes products or funds, the law prohibits an insurer from making the consumer re-serve waiting periods for the same level of benefits. These rules apply to hospital cover only, not extras cover. Most insurers voluntarily provide the same coverage for extras benefits, but consumers will need to check policy terms.
  • The right to a cooling off period. When a consumer takes out a new policy or joins a health insurance fund, the insurer must provide details about the policy in writing. Consumer generally have a 30-day cooling off period after signing up for a new fund. Consumers can cancel and get their contributions refunded if they have not used any benefits within this period.
  • The right to limited waiting periods. There are maximum waiting periods set by law for certain kinds of cover, including a 12-month waiting period for obstetrics benefits; a 12-month waiting period for pre-existing conditions; and a general two month wait for psychiatric care, rehabilitation, palliative care, and most other general benefits. While some funds can waive the waiting periods, a fund cannot require longer waiting periods than permitted by law.

Consumer protection laws also prohibit insurers from making any false or misleading statements in advertising materials related to health funds. This includes brochures, oral statements and written statements.

What if You Need to Make a Complaint to the PHIO?

Complaints can be made to the PHIO about any matter related to private health insurance. You can make a complaint by calling the complaint hotline (1800 640 695) or by contacting the PHIO via telephone at (02) 8235 8777.  Complaints may be faxed to (02) 8235 8778 or sent via email to info@phio.gov.au.  A complaint lodgement form is also available on the website of the PHIO and complaints may be submitted via mail.

Template letters are available for common complaints including:

You should generally try to resolve the issue by speaking with a representative of your insurance company first. If you are unable to do so, reaching out to the PHIO may provide you with options for resolving the problems you are having with your insurance provider.

What to Include in a Complaint

When you make a complaint to the PHIO, you need to provide:

  • A description of the complaint. Provide enough details that the PHIO is able to act.
  • The name of your health fund
  • The membership number of the health fund
  • Details about the desired resolution of your complaint.

Using a template letter like those provided above can be a good way to ensure your complaint includes everything you need to help the private health insurance ombudsman act on your behalf.

How Does the Complaint Process Work?

After you have made a complaint to the PHIO, the Ombudsman staff can reach out to you and to the insurer to try to resolve the issue. Many complaints are based on misunderstandings and having a third party act as a go-between may be enough to allow for a successful resolution.

If this first step is not enough, the Ombudsman will explore other options with the health insurance fund to try to provide a satisfactory resolution. When the insurer is not responsive, the Ombudsman will reach out to other agencies or regulators as appropriate to try to resolve the issue.  The PHIO will recommend a course of action and will keep you informed via telephone about the dispute resolution process.

What if the PHIO Cannot Help?

If the private health insurance ombudsman cannot provide you with the necessary assistance, there may be other consumer protection agencies that can provide assistance.  There is a long list of complaint bodies that may be able to provide help to consumers including:

  • The Australian Competition & Consumer Commission.
  • The Queensland Office of Consumer Affairs.
  • The South Australian Office of Consumer and Business Affairs.
  • Victorian Consumer Affairs.

If the PHIO is not able to help you, the agency may be able to offer advice on other regulatory bodies you can reach out to.

Get Help with Your Insurance Issues

Do not hesitate to act if you need help resolving problems with your health insurance fund. Contact the PHIO for assistance and consider using the template letters for help making an effective claim.

Frequently Asked Questions About Health Insurance

There are three types of health insurance in Australia. They are:

  • Hospital Cover
  • Extras Cover (also known as general or ancillary cover)
  • Ambulance Cover

Hospital cover can ensure any unexpected surgeries, treatments or hospital stays you may require will be covered. With appropriate cover you will have the flexibility to choose your own doctor and the option of receiving treatment in a private hospital.  Most hospital covers allow you to stay in a private room. One other perk is skipping the public hospital systems’ waiting list, which can be lengthy for non emergency treatment.

Extras cover pays benefits for a a range of services, often including treatments and procedures related to the fullowing:

  • Dental/oral health
  • Glasses and contact lenses
  • Podiatry
  • Physiotherapy
  • Psychulogy
  • Acupuncture
  • Remedial massage
  • Chiropractic
  • Hearing aids
  • Travel vaccinations

Ambulance cover, as the name suggests, will cover you should you require emergency ambulance transport. In an emergency, there is enough to worry about. Having the expenses covered for provides security and peace of mind. Many hospital covers include emergency ambulance transport If yours doesn’t, you will need to shop for this separately.

Life is unpredictable. You never know when you might need cover. No matter what life stage you’re in, there’s a policy out there for everyone. You can select as much or as little cover as you want, depending on your health needs and requirements. It’s a small price to pay for the peace of mind health cover provides.

There is no one answer here. Costs vary across providers and policy types. Just because a policy is cheap, that does not mean it is ‘value for money’ and vise versa. Make sure you check what’s included and excluded in a policy before signing up, as you want to purchase a policy that best fits your specific needs.

Premium: A premium is the price you pay for your insurance policy (it may be paid annually or on an ongoing basis).

Policy: An insurance plan. In other words, it is the type of insurance you choose to select.

Policy Holder: The owner, or ‘holder’ of a policy.

Claim: In the event that you require treatment for a service covered by your policy, you can lodge a claim for reimbursement of all or part of the cost of that treatment.. These days, most claims are submitted electronically by the health care provider (dentist, physio etc)

Lifetime Health Cover: Lifetime Health Cover was put in place to encourage young Australians to seek out and maintain ownership of private health insurance early in their lives. If you do not take out a policy before you turn 31, extra charges will be applied should you take out a policy at a later time.

This means you will pay a 2% loading on top of your premium for every year that passes after you turn 30. For example, if you take out a policy for the first time at age 32, you will be charged 4% of your premium as an extra, then at age 40, 20% and so on, up to a maximum loading of 70%.

The loading is payable for 10 consecutive years of cover - after which it is removed and you premiums will be reduced.

Pharmaceutical Benefits Scheme (PBS): Medicare offers assistance for Australians with many of their their prescribed medication costs through the PBS. This assistance is in the form of subsidies towards the cost of many medications. You can check if your prescribed medication is on the list of subsidised items here.

Medicare Levy Surcharge: The Medicare Levy Surcharge is an additional charge (tax) applied to single Australian taxpayers who earn over the income threshold of $90,000 per year, or families/couples who earn over $180,000 per year. This surcharge is only applied to those who choose not to have a private health insurance policy.

The surcharge is designed to reduce pressure on the public health system by encouraging those with higher incomes to invest in private health cover.

Private Health Insurance Rebate: The government’s Private Health Insurance rebate lowers premiums for most Australians with private health insurance Older Australians may enjoy an even higher rebate. Our calculator can help you estimate the Government health insurance rebate you may receive.

Disclaimer: The above information is correct and current at the time of publication


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