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Private Health Insurance Code of Conduct

Private Health Insurance Code of Conduct

The Private Health Insurance Code of Conduct is a self-regulatory code to promote informed relationships between Private Health Insurers, consumers, Agents, Brokers and Corporate Brokers.

The private Health Insurers with which we work require Health Insurance Consultants Australia Pty Ltd (HICA) to meet minimum principals and obligations in the way we work and deal with clients.

TRAINING AND ACCREDITATION REQUIREMENTS

HICA meets all training and accreditation requirements set out by all the Private Health Insurers with which it deals. This training allows HICA to provide clients with sufficient information to be in a position to make an informed choice as to their health insurance purchase.

RESPONSIBILITIES OF HICA ACTING AS AGENT OF INSURED

As a minimum, HICA when acting as the agent of a client in relation to a PHI contract is required to:
(a) discharge its responsibilities and duties competently and with integrity and honesty;
(b) act in the best interest of its principal (the company it is representing);
(c) exercise reasonable care and skill;
(d) ensure clients are able to make an informed decision about their health insurance purchase by clearly explaining all options and providing all relevant information;
(e) develop and maintain an internal complaints handling procedure including information on external processes available to the consumer such as the PHIO;
(f) comply with its fiduciary obligations to its principal, including:

(i) avoiding conflicts of interest;
(ii) if a conflict of interest occurs, disclosing that conflict as soon as is reasonably practicable;
(iii) disclose fees, commissions or other remuneration or benefits to the consumer;
(iv) maintain the confidentiality of its principal’s records and other information;

(g) comply with the provisions of all relevant laws, including the Private Health Insurance Act 2007, the Trade Practices Act 1974 and the State Fair Trading Acts;
(h) maintain all records required by law and comply with all requirements for the production of, access to, or copying of, such records;
(i) provide such information as may be legally required by any regulatory or other authority;
( j) comply where relevant with the Code;
(k) assist the consumer in all ways to comply with the Private Health Insurer’s requirements of the consumer;
(l) promptly provide the consumer’s proposal information to the Private Health Insurer;
(m) not engage in any non-disclosure or misrepresentation; and
(n) when drafting proposal forms ensure they identify the usual information the Private Health Insurer ordinarily requires to be disclosed and are in plain language and provide instruction where necessary on how the questions should be answered.

DISCLOSURE REQUIREMENTS

HICA is required to inform clients of our status and identify the Private Health Insurers whose products we are presenting to a company or to clients. HICA is also required to inform clients and the corporate entity for whom they are acting of any associations between HICA and Private Health Insurers.

Internal Dispute Resolution Procedure

We have a fully documented internal process for resolving a dispute between a client and us and the client and any of the Health Insurers with which we deal. This process is accessible to clients without charge.

Where we receive from a client a request, whether written or oral, for the resolution of a dispute or a request for a response in writing in relation to the dispute, we will promptly reply to the client. If the dispute is not resolved in a manner acceptable to the client, we will provide:
(a) where appropriate, the general reasons for that outcome; and
(b) information on the further action that the client can take.

In the event that a dispute is considered by the client to be unresolved internally, we will
advise the client of the available external dispute resolution procedures by providing information regarding the Private Health Insurance Ombudsman.

Private Health Insurance Ombudsman

The Private Health Insurance Ombudsman (PHIO) provides an independent service to help clients with health insurance problems and enquiries.

The Ombudsman can deal with complaints from health fund members, health funds, private hospitals or medical practitioners. Complaints must be about a health insurance arrangement.
Complaints need to be about private health insurance or a related matter. They can be about a private health fund, a broker, a hospital, a medical practitioner, a dentist or other practitioners (as long as the complaint relates to private health insurance).

What should I do if I want to make a complaint?
You should first contact your health fund or the body you are complaining about. They may be able to resolve your complaint for you.

What information does the Ombudsman need?
When you contact the Ombudsman you should provide the following information:
•    a clear description of your complaint;
•    the name of your health fund and your membership number; and
•    what you think would resolve the matter for you.

What can happen after I make a complaint?
The Ombudsman’s staff will contact your health fund or the body you are complaining about to get their explanation and any suggestions they have for fixing the problem.

The Ombudsman will deal with most complaints by phone, email and fax and most can be settled quickly.

Where complaints are more complex, the Ombudsman will write to the health fund or other body, seeking further information or recommending a certain course of action. The Ombudsman’s staff will keep you regularly informed, usually by telephone and will give you their name and contact number, in case you need to contact them.

Private Health Insurance Ombudsman contact details
Telephone (02) 8235 8777
Facsimile (02) 8235 8778
Email on info@phio.org.au