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.

1. Policy Design and Meeting
Consumers’ Needs
Presentation to 12th Annual Health
Insurance Summit, 22nd July 2013
Samantha Gavel, Private Health Insurance
Ombudsman

3. 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

4. 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].

5. 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
AxisTitle
PHIAC Statistics on Growth of Restricted Covers
Policies with full cover (may include an
excess)
Policies with exclusions and or restrictions
Policies with an excess
Policies with an excess < $500/$1000

6. Open Policies on
PrivateHealth.gov.au
53%
13%
28%
6%
Top
Medium
Basic
Public

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.

10. Auto classification of Policies

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.

13. Standard Information Statement

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.