25 September 2023

Health complaints attract Ombudsman

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The Commonwealth Ombudsman has responded to recent media reports relating to private health insurers and pre-existing conditions (PEC), setting out the rules and regulations in place to protect consumers.

In his role as Private Health Insurance Ombudsman (PHIO), the Ombudsman, Michael Manthorpe said that while his usual practice was to investigate in private and not comment on individual matters, he would make an exception this time.

“Our function is to protect the interests of private health consumers,” Mr Manthorpe said.

“This includes investigating complaints from consumers about PEC decisions and ensuring the PEC rules have been correctly applied by the insurer.”

He said the PHIO investigates 4,000 private health insurance matters a year, 300 of which involve PEC decisions by insurers.

“The office regularly publishes information about complaint issues for the industry and consumers,” Mr Manthorpe said.

“When the office receives a complaint about the application of PEC waiting periods, our process is to request copies of relevant documentation.”

He said the office’s PHIO case officer would then assess the information provided by the insurer and would either finalise the complaint assessment; seek guidance on the complaint, or escalate the complaint.

“While the office is confident that PEC matters referred to in recent media articles have been appropriately dealt with in accordance with our processes, we continue to monitor PEC matters with interest and investigate complaints,” Mr Manthorpe said.

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