Samanatha Gavel

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Samanatha Gavel

  1. 1. Policy Design and Meeting Consumers’ Needs Presentation to 12th Annual Health Insurance Summit, 22nd July 2013 Samantha Gavel, Private Health Insurance Ombudsman
  2. 2. 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
  3. 3. 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].
  4. 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 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
  5. 5. Open Policies on PrivateHealth.gov.au 53% 13% 28% 6% Top Medium Basic Public
  6. 6. Common Restrictions  Psychiatric Treatment  Cardiac Surgery  Joint Surgery  Pregnancy Services  Plastic and Reconstructive Surgery  Obesity Surgery  Cataract and lens surgery
  7. 7. 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
  8. 8. PHIO Solutions  Consumer Information;  Reviewing fund brochure and website information;  Complaint handling workshops;  Website information.
  9. 9. Auto classification of Policies
  10. 10. 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
  11. 11. 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.
  12. 12. Standard Information Statement
  13. 13. 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.

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