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Private Health Insurance Ombudsman

In 2019–20 we received 3,706 complaints, which represented an 8.3 per cent decrease in complaints received compared to 2018–19. We finalised 3,801 complaints in 2019–20 compared to 4,086 in 2018–19.

In 2019–20, 74 per cent of complaints were finalised as 'assisted referrals'. In these cases we refer a complaint directly to a nominated representative of the insurer or service provider, on behalf of the complainant. Our assisted referral process ensures a quicker resolution of the complaint and client satisfaction survey responses show that complainants have a high satisfaction rate with this method of complaint resolution.

Nine per cent of complaints were finalised through a 'standard referral'—that is, the complainant received advice from our Office and then lodged their complaint directly with the appropriate body themselves.

Approximately five per cent of complaints were classified as 'grievances'. These complaints are finalised by considering the issue and providing more information or a clearer explanation directly to the complainant, without the need to contact or seek additional information from the health insurer or health care provider.

About 11 per cent of complaints were classified as 'disputes' (a slight decrease from 13 per cent in 2018–19). In these cases, we request a detailed report from the health insurer or other subject of the complaint. The report is then reviewed and a decision is made on whether the initial response was satisfactory or if further investigation is warranted.

Of disputes handled by our Office, 89 per cent were resolved by giving a more detailed explanation to the complainant, 6 per cent were resolved by a payment and 5 per cent by another satisfactory outcome (for example, backdating a change to a policy).

No complaints were referred to another body under s 20L in 2019–20.

No inspections or audits were conducted under s 20SA in 2019–20.

No investigations were conducted under s 20T in 2019–20.

More information can be found in our quarterly bulletins1.

Footnotes

  1. https://www.ombudsman.gov.au/publications/industry/private-health-insurance