Mistakes, Disputes and Official Sources
How to complain about a health insurer: the Private Health Insurance Ombudsman
The steps for disputing a refused claim, a pre-existing condition decision or a billing problem, from the insurer's own process to the Private Health Insurance Ombudsman.
If you have a problem with your private health insurance, complain to the insurer first and ask for its internal dispute resolution process. If that does not resolve it, take the complaint to the Private Health Insurance Ombudsman (PHIO), a function of the Commonwealth Ombudsman. The service is free and independent, and it handles complaints about insurers, private hospitals, doctors and brokers on health insurance matters, including refused claims, pre-existing condition decisions, waiting periods, gap fees, transfers and premium or rebate problems. The Ombudsman can investigate and help resolve disputes, but it is not a court and cannot award compensation the way a tribunal can.
This guide is part of private health insurance mistakes.
What the Ombudsman deals with
| Problem | Example |
|---|---|
| Claims | A benefit refused because the insurer says a category is excluded |
| Pre-existing conditions | Disagreement with the insurer's medical adviser |
| Waiting periods | An insurer not recognising time served with a previous fund |
| Informed financial consent | A gap fee you were not told about |
| Policy changes | A product closed or changed without adequate notice |
| Membership | Problems with cancellation, refunds, transfer certificates or Lifetime Health Cover calculations |
| Sales | Being told a policy covered something it does not |
Complaints about the standard of clinical care go to the health care complaints body in your state or territory, or to Ahpra for a practitioner's conduct. Tax questions about the surcharge go to the ATO.
Step 1: gather the evidence
- Your policy number and the Private Health Information Statement in force at the time
- Letters or emails from the insurer, especially its reasons for any decision
- Bills, receipts and MBS item numbers
- Any written estimate (informed financial consent) you received from doctors
- Notes of phone calls: date, time, who you spoke to and what was said
- For pre-existing condition disputes, a letter from your treating doctor about when symptoms started
Step 2: complain to the insurer
Write to the insurer's complaints team. Say clearly:
- what happened, with dates
- what you think is wrong, quoting the policy wording if relevant
- what outcome you want, such as payment of a claim or recognition of waiting periods
Ask for a reference number and a written decision. Insurers are expected to handle complaints promptly; if you hear nothing in a reasonable time, follow up in writing.
Pre-existing condition decisions: the insurer's medical practitioner must consider information from your treating practitioners. Ask for a review and supply a letter from your GP or specialist about the timing of signs and symptoms.
Step 3: go to the Ombudsman
If the insurer's response does not resolve it, lodge a complaint with the Commonwealth Ombudsman, online or by phone. Include the insurer's response and your evidence. The Ombudsman may:
- give you information that clarifies your rights
- refer the complaint back to the insurer for a senior review
- investigate and ask the insurer, hospital or doctor to respond
- recommend an outcome
You can also use the "ask a question" form on privatehealth.gov.au for general questions before a dispute arises.
Other avenues
| Body | When |
|---|---|
| ACCC | Misleading advertising or conduct in breach of Australian Consumer Law |
| Australian Financial Complaints Authority (AFCA) | Not usually for health insurance; it handles general and life insurance |
| State health care complaints commissioner | Quality of care in a hospital or by a practitioner |
| Ahpra | Concerns about a registered practitioner's conduct |
| Civil and administrative tribunal or court | Legal claims for money, usually after other avenues |
Illustrative dispute
A member has knee surgery after joining Bronze cover nine months earlier. The insurer refuses the claim, saying knee pain was pre-existing based on a physio note from before joining. The member's GP writes that the earlier issue was a different injury that fully resolved, and that the current condition began with a fall after joining. The member asks the insurer for a review with the letter attached. If the insurer maintains its position, the Ombudsman can examine whether the decision followed the pre-existing condition rules. Outcomes depend on the facts; this is a pattern, not a guarantee.
When to get professional help
For a large disputed amount or a complex legal question, a community legal centre or a lawyer can advise. For health concerns arising from the dispute, keep seeing your treating doctor; care should not wait for an insurance decision.
FAQ
Does it cost anything to complain?
No. Both insurer complaint processes and the Ombudsman are free.
Is there a time limit?
Complain as soon as you can while records are available. Check the Ombudsman's website for any current guidance on timing.
Can the Ombudsman make an insurer pay?
It can investigate and recommend, and insurers usually respond to its findings, but it is not a court. For binding orders you would need a tribunal or court.
Can I complain about premium increases?
Increases are approved by the Health Minister each year. The Ombudsman can help if your insurer failed to notify you properly, but not with the approved increase itself.
Sources
- Commonwealth Ombudsman — Private Health Insurance Ombudsman complaints
- PrivateHealth.gov.au — ask a question and consumer information
- ACCC — misleading conduct and consumer law
- Ahpra — concerns about registered health practitioners
