Policy Design and Meeting

Consumers’ Needs

Presentation to 12th Annual Health

Insurance Summit, 22nd July 2013

Samantha Gavel, Private Health Insurance Ombudsman

0

500

1000

1500

2000

2500

3000

3500

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

Complaints and Disputes

All

Disputes

Top 5 Complaint Issues

2012-13

1. Information Oral [1];

2. Waiting Period - Pre-Existing

Condition [3];

3. Hospital

Exclusion/Restriction [2];

4. Delay in Payment [5]

5. Fund Rule [4].

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

2002-032003-042004-052005-062006-072007-082008-092009-102010-112011-122012-13

Axis

Tit

le

PHIAC Statistics on Growth of Restricted Covers

Policies with full cover (may include anexcess)

Policies with exclusions and or restrictions

Policies with an excess

Policies with an excess < $500/$1000

Open Policies on

PrivateHealth.gov.au

53%

13%

28%

6%

Top

Medium

Basic

Public

Common Restrictions

Psychiatric Treatment

Cardiac Surgery

Joint Surgery

Pregnancy Services

Plastic and Reconstructive Surgery

Obesity Surgery

Cataract and lens surgery

0

100

200

300

400

500

600

700

2008/09 2009/10 2010/11 2011/12 2012/13*

Fund Rule (LC)

General TreatmentRestrictions(LC)

HospitalExclusions/Restrictions (LC)

Level of Cover (LC)

Fund Rule Change

PHIO Complaints re Restrictions &

Exclusions

PHIO Solutions

Consumer Information;

Reviewing fund brochure

and website

information;

Complaint handling

workshops;

Website information.

Auto classification of Policies

Category Number of

Policies

Definition

TOP 14,521 Must cover all

services

MEDIUM 3, 550 Must cover cardiac,

plastic surgery,

psyche, rehab and

palliative care; May

have one or more

other restrictions or

exclusions

BASIC 7, 666 Excludes one or more

of the above

PUBLIC 1,685 Self-Explanatory

TOTAL POLICIES 27,422

Industry Solutions

Clear and simple policy design;

Full disclosure at point of sale (clear, upfront, straightforward);

Ongoing explanation and reminder of restrictions (SIS);

Proactive approach to cover review;

Informed Financial Consent;

Publicise www.privatehealth.gov.au.

Standard Information Statement

Consumer Solutions

Being diligent on our own

behalf;

Using the resources

available to them,

including

www.privatehealth.gov.au;

Reviewing their policy

each year when they

receive their SIS.