What do I do if I have a complaint with my health fund?

27 January 2017
Health insurance complaints on the rise. 

Health insurance is a complicated but often necessary part of life in Australia, covering us for a wide range of treatments and benefits beyond the scope of Medicare. While many Australians have health insurance, the constantly changing premiums, coverage and eligibility mean there are bound to be disagreements between customers and health funds.

Health insurance complaints are on the rise: annual complaints to the Private Health Insurance Ombudsman (PHIO) have increased by a massive 49% over the past five financial years.

So if you have a disagreement or complaint to make with your health fund, what course of action should you take? It may seem somewhat fruitless to try and influence a huge company such as a health insurer, but there are in fact several consumer protection services which ensure you can make a complaint easily and effectively.

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What might I complain about?

Complaints with your health insurer need to be genuine issues regarding the service your fund has given you. It might be an incorrect charge, a failure to cover a medical procedure in time, or poor customer service; all are issues where your health fund has failed to provide what you’re paying them.

The top 5 complaints Australians made about their health insurance in 2016 were:

  1. Service delays in updating membership records, sending tax certificates, or responding to customer service enquiries and complaints
  2. Transfer and clearance certificates upon leaving a fund
  3. Oral advice where advice given to customers over the phone or in person differed from their actual policy cover
  4. Membership cancellation refunds not being processed in a timely fashion
  5. Premium payment problems with incorrectly processed direct debits and the like

Your issue could be with the fund itself, or it could also be with the hospital or medical practitioner who provided you with a service, so long as your complaint is related to your insurance. You shouldn’t direct any complaints about quality of medical service to your health fund – those issues should be brought to the attention of the relevant practitioner or institution.

Health insurance complaints you won’t have grounds for include how high your premium is, what is and what’s not included, or how much money you get back. All of this is laid out in the PDS that you purchased, so unfortunately you’re stuck with it unless you move to a different insurer.

For more information on your rights and whether you may have been wronged, you can read through the government’s Private Patient’s Hospital Charter.

If you’d like to switch insurers, use our website to compare your options when it comes to health funds in Australia:



How do I make a complaint about my health fund?

Just like any complaint with a service provider, your first port of call should always be to contact your health fund itself. Contacting your health insurer’s customer service department and telling them your issue can often help resolve the problem.

If a simple phone call doesn’t help, or you receive an unsatisfactory response, consider emailing or posting a formal complaint that details exactly what has gone wrong with your service.

If contacting the company hasn’t produced satisfactory results, it’s time to kick things up a notch. Perhaps your health fund hasn’t given you a satisfactory offer to resolve the problem, or they’ve simply not gotten back to you in a reasonable timeframe.

You can now choose to make a formal complaint to the Private Health Insurance Ombudsman (PHIO), which handles complaints and disputes relating to private health insurance. PHIO helps consumers resolve complaints and also provides advice to industry, government, and consumers about issues regarding health insurance. You can contact PHIO by the online Commonwealth Ombudsman Complaint Form, over the phone (Hotline 1300 362 072 open 9am-5pm Mon-Fri (Sydney Time)), or via email (phio.info@ombudsman.gov.au).

As a professional dispute resolution service, Ombudsman should be able to help you resolve just about any issue you have with your health fund. Last year, 85% of people who complained to the PHIO were satisfied with how their complaint was handled. Hopefully this government body will be able to solve your dispute as well!

Making a switch if you’re dissatisfied

If you’re still feeling dissatisfied with your health insurer, remember: there are plenty of other providers out there, some of which might offer you a better deal. To compare health insurance providers based on value for money and level of coverage, check out Canstar’s star ratings for health funds and policies:

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