Complaints

Complaints Overview

Introduction

The role of the Private Health Insurance Ombudsman (PHIO) is to protect the interests of people covered by private health insurance. PHIO carries out this role in a number of ways, including our independent complaints handling service, our education and advice services for consumers and our advice to industry and government about issues of concern to consumers. 

The focus of PHIO’s complaints handling service is on ensuring we are independent, objective, accessible, effective and timely. In dealing with complaints, we assist people to resolve disputes and act as an umpire in dispute resolution at all levels within the private health insurance industry.

What can I complain about?

Complaints need to be about private health insurance or a related matter. They can be about a private health fund, a broker, a hospital, a medical practitioner, a dentist or other practitioners (as long as the complaint relates to private health insurance).

However, complaints about the quality of service or treatment provided by a health professional or a hospital should be directed to the health care complaints body for your state or territory.

The Ombudsman cannot deal with complaints about Medicare. Complaints about Medicare should be directed to the Commonwealth Ombudsman.

Who can make a complaint?

Generally, anyone can make a complaint, as long the complaint is relevant to private health insurance. The objective of the Private Health Insurance Ombudsman is to "protect the interests of people who are covered by private health insurance". The Ombudsman will look into complaints that concern private health insurance consumers but the office may not investigate complaints of a purely commercial nature that do not have a significant impact on the rights of consumers.

What should I do if I want to make a complaint?

You should first contact your health fund or the body you are complaining about. They may be able to resolve your complaint for you.

Then if you are not satisfied, or if you have any questions, please contact us.

What information does the Ombudsman need?

When you contact the Ombudsman you should provide the following information:

  • a clear description of your complaint;
  • the name of your health fund and your membership number; and
  • what you think would resolve the matter for you.

The Ombudsman’s staff will let you know if any other information is needed.

What can happen after I make a complaint?

Many complaints result from misunderstandings. The Ombudsman’s staff may be able to explain what has happened and why, and this often solves the complaint.

Otherwise, the Ombudsman’s staff will contact your health fund or the body you are complaining about to get their explanation and any suggestions they have for fixing the problem.

The Ombudsman will deal with most complaints by phone, email and fax and most can be settled quickly.

Where complaints are more complex, the Ombudsman will write to the health fund or other body, seeking further information or recommending a certain course of action.

The Ombudsman’s staff will keep you regularly informed, usually by telephone and will give you their name and contact number, in case you need to contact them.

What if I just want some information about health insurance?

We can help with information about private health insurance arrangements if you want to phone, email or contact us by fax.

We also have a number of brochures and publications about private health insurance arrangements such as:

  • State of the Health Funds Report - which compares different health funds across a number of performance criteria; 
  • Individual Health Fund Report Cards - summarising each health fund's details as provided in the State of the Health Funds Report; 
  • Annual Reports - providing information about the office and our annual performance, including complaint statistics;
  • Quarterly Bulletins - listing health fund complaints and issues for each quarter and providing updates on industry related matters;
  • Facts and Advice - factsheets about a range of health insurance topics such as obstetrics (pregnancy) and the pre-existing conditions rule.

All our brochures and publications are available on our website or can be provided on request.