Mistakes, Disputes and Official Sources
How to read a Private Health Information Statement, plus the official sources to check
A section-by-section guide to the standard policy statement, and which government site to use for tiers, the surcharge, the rebate, Medicare, MBS fees and complaints.
The Private Health Information Statement (PHIS) is a standard summary that every registered insurer must publish for every policy, in the same format, on privatehealth.gov.au. It shows the hospital tier, which clinical categories are covered, restricted or excluded, the excess and co-payments, the extras benefits and limits, ambulance cover and the premium for your state and policy type. Reading the PHIS is the fastest way to compare policies like for like. For the rules behind the policy, use the official sources listed below rather than advertising or comparison websites.
This guide is part of private health insurance mistakes.
Reading a PHIS: what each part tells you
| Section | What it shows | What to check |
|---|---|---|
| Policy name, insurer, state and type | Single, couple, family, single parent, extended family | Quote is for your state and the right people |
| Hospital tier | Gold, Silver, Bronze, Basic, or a Plus | Plus means at least one extra category |
| Covered categories | Paid as a private patient | Every category you need appears here |
| Restricted categories | Paid at public shared-ward rate only | Rehab, psychiatric and palliative are often listed here |
| Excluded categories | Not covered | No category you need is here |
| Excess and co-payment | Amount, how often, waivers | Within the surcharge limit; per admission or per year |
| Waiting periods | Any shorter than the maximums | Note anything unusual |
| Ambulance | Emergency, non-emergency, limits | Interstate cover |
| Extras | Services, benefit examples, annual limits | Matches what you actually use |
| Premium | Before rebate, usually monthly | Convert to annual, then apply loading and rebate |
Turning the PHIS into a real price
Example (illustrative). A PHIS shows a monthly premium of $210 for a single in Victoria, of which $160 is hospital and $50 extras. Annual: $2,520, hospital $1,920. You have a 6% loading and are in tier 1 (16.079%).
- Loading: $1,920 × 6% = $115.20
- Rebate: $2,520 × 16.079% = $405.19
- Annual cost: $2,520 + $115.20 − $405.19 = $2,230.01
Some PHIS documents show a single combined premium; ask the insurer for the hospital component to calculate the loading. The rebate calculator handles the rebate part.
Official sources and what each is for
| Source | Use it for |
|---|---|
| privatehealth.gov.au (run by the Commonwealth Ombudsman) | Every policy's PHIS, product tiers and clinical categories, surcharge and rebate tables, Lifetime Health Cover rules, registered insurers, gap cover doctors and agreement hospitals |
| ato.gov.au | Income for surcharge purposes, how the surcharge and rebate appear in your tax return, exemptions |
| servicesaustralia.gov.au | Medicare enrolment, Medicare card, Safety Net, Medicare Entitlement Statements, Child Dental Benefits Schedule |
| health.gov.au (Department of Health, Disability and Ageing) | Policy changes, premium round announcements, Medical Costs Finder, Prescribed List of medical devices |
| mbsonline.gov.au | MBS item numbers and schedule fees, to understand what Medicare pays |
| ombudsman.gov.au | Complaints to the Private Health Insurance Ombudsman |
| apra.gov.au | Statistics on the private health insurance industry and insurers' prudential supervision |
| accc.gov.au | Misleading advertising and consumer law; reports on the private health insurance industry |
| healthdirect.gov.au | Free health information and the 1800 022 222 nurse advice line |
Commercial comparison sites and brokers
Commercial comparison sites can be convenient, but they are usually paid by insurers and may not list every fund or every policy. If you use one:
- ask which insurers it compares and how it is paid
- check the policy's PHIS on privatehealth.gov.au before buying
- do not rely on a "recommended" label without understanding why
How rules change during the year
| Date | What usually changes |
|---|---|
| 1 April | Approved premium increases; rebate percentages; some policy changes |
| 1 July | Surcharge and rebate income thresholds; your LHC base day if you turned 31 in the past year; new tax year |
| Any time | Insurers closing or changing products, with notice |
Because of this, an article, quote or calculator from last year may already be out of date. Check the date and the official source.
FAQ
Is the PHIS the full policy?
No. It is a summary. The fund rules and policy terms are the full contract; ask the insurer for them if something is unclear.
Why does the premium differ from the advertised price?
Advertised prices may be for a different state, a higher excess or include a temporary discount. The PHIS shows the standard premium for that policy and state.
Where do I find my LHC loading?
Your insurer's member statement or annual tax statement; privatehealth.gov.au explains how it is calculated.
Can I get a PHIS for my current policy?
Yes. Your insurer must provide it, and it is also on privatehealth.gov.au.
Sources
- PrivateHealth.gov.au — policy statements and rules
- Australian Taxation Office — surcharge and rebate
- Services Australia — Medicare
- Department of Health, Disability and Ageing — private health insurance policy
- APRA — industry statistics
- Commonwealth Ombudsman — complaints
