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The guide · receipt 06 of 06
Complaints about a health fund
Take a complaint to your health insurer first; if it isn’t resolved, or you get no response, you can take it to the Private Health Insurance Ombudsman, through the complaint form on ombudsman.gov.au or by phone. Disputes about a doctor’s in-hospital fees can go there too, while practitioner standards and the provision of care go to other bodies.
The order of steps
Your insurer, first
The Private Health Insurance Ombudsman asks that a problem with your health insurance be raised directly with the insurer or provider first. Each insurer’s contact details are on its page at privatehealth.gov.au.
Then the Ombudsman
If you can’t resolve it, haven’t had a response, or need advice, you can contact the Private Health Insurance Ombudsman through the Ombudsman complaint form on ombudsman.gov.au.
You can also lodge a complaint by phone on 1300 362 072, choosing option 4 for private health insurance.
A referral back to the insurer
If the issue hasn’t already been escalated within the insurer, the Ombudsman’s usual process is to refer your complaint to the insurer for a quicker response, usually within three business days of contacting it. The point is to give the insurer a chance to review its decision at a higher level.
Investigation, if it is still unresolved
Only after that review does the Ombudsman proceed with any investigation.
For a question rather than a complaint, privatehealth.gov.au has an online ‘Ask a question’ form with topics including gap payments, waiting periods and complaints about an insurer. If you can’t use the online forms, its phone line is 1300 737 299, 10am to 4pm Australian Eastern Time, Monday to Friday.
Who handles what
Not every problem with a health bill belongs to the Ombudsman. privatehealth.gov.au sorts them this way.
| The problem | Who to contact |
|---|---|
| A private health insurance matter, including a dispute over a doctor’s fee for in-hospital treatment or a private patient hospital gap fee | Private Health Insurance Ombudsman |
| A competition or fair trading issue | Australian Competition and Consumer Commission |
| A complaint about a health practitioner’s standards | Australian Health Practitioner Regulation Agency |
| The provision of healthcare, public or private, including disputes about medical bills | Your state or territory’s health complaints body (below) |
- ACT: Health Services Complaints Commissioner
- NSW: Health Care Complaints Commission
- NT: Health and Community Services Complaints Commissioner
- Qld: Office of the Health Ombudsman
- SA: Health and Community Services Complaints Commissioner
- Tas: Health Care Complaints Commissioner
- Vic: Health Complaints Commissioner
- WA: Health and Disability Services Complaints Office
When the complaint is a bill
For a doctor’s or provider’s bill that is much higher than you expected, the Ombudsman’s site suggests contacting the doctor’s office first, to check whether you agreed to the charges and to discuss the reasons for them. If the charge still seems unfair, it suggests paying at least part of it, such as the amount you expected or the MBS fee, with a letter that covers these points:
- the amount you are paying, and why you are paying that amount for now
- what you expected to pay, and why
- whether any procedures were performed other than the ones you expected, or whether there is a case for the unexpected charge
- any personal circumstances that affect your ability to pay the higher fee
- what further amount you would be prepared to pay, if any, and how
- a request for a written response
If that doesn’t resolve it, the table above shows where it can go next. The gap receipt explains how the bill was built in the first place.
When the complaint is a change to your policy
Some complaints begin with a letter from the fund. Your insurer must tell you in advance about changes to your premiums or cover; and if it discontinues your policy, it must explain what won’t be covered, any change to excesses or co-payments, the waiting periods that will apply and the new premium. You don’t have to accept the replacement it offers. The premium receipt covers the yearly price change.
What the Ombudsman publishes
The Private Health Insurance Ombudsman describes itself as an independent service that helps consumers with health insurance problems and enquiries, and it publishes reports and consumer information. Two of those reports are useful before a complaint arises:
- an annual performance report for each insurer in each state, on that insurer’s page on privatehealth.gov.au
- the State of the Health Funds Report, an annual report on insurer performance and service delivery, on the Ombudsman’s website