Helping Consumers to Navigate

Change

Presentation to 13th Annual Health Insurance Summit

28th July 2014

Samantha Gavel, Private Health Insurance Ombudsman

Private Health Insurance in Australia

Over 10 million privately insured members;

34 private health insurers (12 are restricted

access insurers);

5 largest insurers account for 82.3% of policies

nationally;

552 private hospitals; 762 public hospitals;

17,675 health insurance policies available for

sale (25,709 policies in total);

$13.16 billion in benefits in 2010/11.

Standard Information Statement

Complaints and Disputes

0

500

1000

1500

2000

2500

3000

3500

4000

2007-08 2008-09 2009-10 2010-11 2011-12 2012-13 2013-14

All Complaints vs Disputes

All complaints

Disputes

Complaint Issues

0

200

400

600

800

1000

1200

Complaint Issues, 2011-12 to 2013-14

2011-12

2012-13

2013-14

Value of Complaints

Most dissatisfied customers don’t complain;

Satisfied complainants become greater advocates than those who’ve never complained;

Costs of complaints include loss

of loyalty, negative opinions and damage to reputation;

Value of good complaints handling not just to customers, but also to staff.

Good Complaints Handling

An organisational culture that values feedback and

complaints;

A complaints handling system that is accessible and

responsive to customers;

Proper resourcing, recruitment and staff training;

Good complaint handling processes that facilitate timely

investigation and resolution of complaints;

Analysis to identify and address systemic issues;

Regular review of the effectiveness and efficiency of the

complaints handling process.

Unreasonable Complainant

Conduct Any behaviour by a current or former

complainant which, because of its

nature or frequency, raises substantial

health, safety, resource or equity

issues for the parties to a complaint.

UCC can happen anywhere. It is not

limited to telephone communications

or face-to-face interactions with

complainants.

It can occur over the internet or on

social networking websites, in a public

location or in written correspondence.

Inappropriate and Unreasonable

Online Conduct

1. Monitor;

2. Evaluate;

3. Act;

4. Follow up and follow through;

5. Support affected staff members.