Code Highlights

Development of the Code

The Australian Health Insurance Association (AHIA) in conjunction with the Health Insurance Restricted & Regional Membership Association of Australia (HIRMAA) has developed codes of practice called the Private Health Insurance Practice Codes to reinforce existing regulatory obligations and to establish a minimum standard of business practice applicable to all participants in such codes. The first code to be established is the Private Health Insurance Code of Conduct.

Development of the Codes commenced in 2003 with a committee formed by AHIA and HIRMAA. The committee had broad representation from funds, so the development has had detailed and expert input from a cross-section of the industry and from stakeholders. The Code was reviewed by industry and government in 2009.

This code has been endorsed by the Minister for Health and Ageing and the Treasurer.

The code is designed to sit beside the current Government Acts and regulations within which the industry operates and underlines the intent of the industry to show its commitment to consumers.

The Code at a Glance

Internal dispute resolution

The internal dispute resolution process exists to provide a confidential, free and readily accessible system to resolve disputes between you and your health fund.

External dispute resolution

If a dispute cannot be resolved between you and your fund, your fund agrees to provide information to you on external dispute resolution procedures available to you, including providing information on how to contact the Private Health Insurance Ombudsman.

Training of employees

An overriding principle of the Code is that all persons dealing directly or indirectly with consumers will be thoroughly trained and retrained in all aspects of their particular job. Signatories to the Code agree to ensure all individual employees are adequately trained and possess the necessary skills to carry out their duties.

Implementation for Employees

Funds agree to differentiate the tasks of individual employees, ensuring all employees know their own responsibilities and are equipped to handle business with consumers. It will be particularly important for funds to define those employees who normally sell or manage private health insurance and those who do not, and to train employees accordingly. For those with no responsibility or specific training in dealing with consumer questions at any level, they should be instructed not to give advice to you except to inform you where you can obtain advice on private health insurance.

Funds agree to instruct staff to explain consumer choices clearly, to provide policy documentation so that consumers can make informed decisions and to keep appropriate records of advice to consumers.

Agents

Funds agree to ensure that they have appropriate agreements in place with agents and that their agents are appropriately trained in relevant information depending on the scope of duties of the agent.

Funds also agree to ensure agents disclose their relationship with the fund to you, including disclosing that they are acting for the fund and not for you.

Brokers

The provisions in the Code set out the desired minimum principles for brokers. They are only outlined on a recommendatory basis and funds are free to deal with any broker(s) they wish. Funds will, however, be required to request all brokers with whom they deal to comply with the provisions of this section of the Code.

All brokers who wish to act in the private health insurance industry should meet appropriate training and accreditation requirements.

Clear and complete policy documentation and written and verbal communication

Policy documentation must be expressed in plain language and designed with the aim of assisting comprehension by you. This policy documentation must also contain at a minimum the information as specified in the Code.

Funds must ensure that all written and verbal communication with members is accurate and concise and able to be understood by you. Funds should keep accurate records of communications with members.

Upon request of an existing member, funds must provide details of the member's entitlement to benefits in a manner which assists the member to make a decision.

For a consumer changing a policy a fund must provide details of the change in plain language and in a way designed to assist comprehension of the change, and must advise that if, in retrospect, the change is not satisfactory the consumer may revert to the old product within thirty days if no claims against the new product have been made.

On a State-by-State basis (where applicable) funds must produce and maintain, in both written and electronic format, material detailing all tables of benefits or products available to consumers and ensure this is freely available and contains certain specified information.

Detrimental changes to policies

There is a distinction in the code between significant detrimental changes to policies and detrimental changes and in the action funds are required to take with their members when such changes occur.

"Cooling Off" period

The health fund must have a written policy of returning premiums to you in full if a policy is cancelled within 30 days from the commencement date of the policy if you have not made a claim on the fund.

Privacy

Funds must have a formulated and published Privacy Policy and must comply with the Privacy Act 1988 and relevant State privacy legislation.