Samantha Gavel, the Private Health Insurance Ombudsman, gave a presentation on policy design and meeting consumers' needs. She discussed the top complaint issues which included information, waiting periods, hospital exclusions/restrictions and payment delays. Her presentation showed that the number of policies with exclusions and restrictions has grown significantly. Common restrictions are psychiatric treatment, cardiac surgery, joint surgery and various other procedures. The PHIO provides solutions like consumer information and complaint handling workshops. The insurance industry needs clear policy design, full disclosure upfront and ongoing explanations of restrictions. Consumers also need to be diligent in reviewing their policies and using available resources.
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Samanatha Gavel
1. Policy Design and Meeting
Consumers’ Needs
Presentation to 12th Annual Health
Insurance Summit, 22nd July 2013
Samantha Gavel, Private Health Insurance
Ombudsman
7. Common Restrictions
Psychiatric Treatment
Cardiac Surgery
Joint Surgery
Pregnancy Services
Plastic and Reconstructive
Surgery
Obesity Surgery
Cataract and lens surgery
8. 0
100
200
300
400
500
600
700
2008/09 2009/10 2010/11 2011/12 2012/13*
Fund Rule (LC)
General Treatment
Restrictions(LC)
Hospital
Exclusions/Restrictions (LC)
Level of Cover (LC)
Fund Rule Change
PHIO Complaints re Restrictions &
Exclusions
9. PHIO Solutions
Consumer Information;
Reviewing fund brochure
and website
information;
Complaint handling
workshops;
Website information.
11. 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
12. 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.
14. 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.