I recently received an email from Mandy, upset and distressed over the $8,000 she had been slugged with that was not going to be covered by her health insurer to pay for her cancer treatment.
“I’m 59 years old and I’ve been with these mongrels for 30 years blindly paying for what they told me was ‘top’ hospital and extras cover. Now I’ve been forced to go to my super just to pay for all the gaps that this stupid policy doesn’t cover”.
It makes me wonder about whether health insurers understand the expressions “good will” and “a duty of care”. When you’re sick and believe you have the best health cover you just shouldn’t have to face being brushed off by your insurer. You also shouldn’t cop the additional pressure of finding the money to pay for your recovery. 

However, the sad thing is Mandy is far from alone.
A recent national study by the Consumers Health Forum found many patients were forgoing medical treatment because of unexpected costs, with others dipping into their savings and superannuation to cover the ‘surprise’ medical bills. Mandy noted in her email that there were extra costs for the anaesthetist and bills for scans that were not going to be covered because they were post op. “I received one bill for an MRI. I found I wasn’t covered by Medicare and I was told by my private health insurer ‘you should have read the fine print of your policy’.

Many patients are also not aware that private health insurance does not cover medical services that are provided out of hospital and which are covered by Medicare. These services include GP visits and consultations with specialists, in their rooms, and diagnostic imaging and tests. Unfortunately the low medicare rebates generally don’t even come close to covering half of the cost leaving patients strapped.

As Alan Kirkland from Choice recently stated, 
“It can be completely perplexing and sometimes impossible for patients in need of surgery to work out how much they will be out of pocket”. Kirkland also noted that average prices for procedures such as knee replacements and colonoscopies should be publicly available and easy to access which at present they’re not. Talk about poor disclosure from the funds!

However when it comes to some things, the health funds are not entirely to blame. Present legislation in Australia prevents health funds from covering the gap for outpatient consultations. Until this is addressed by the Government the problem is with the Medicare Benefits Schedule and what doctors charge, rather than the funds.
And don’t some doctors always charge a hell of a lot more than the MBS designated fee.

What can you do if you have a problem with your fund?

Established in 1996, the Private Health Insurance Ombudsman is a nationwide service that assists health fund members to resolve disputes through an independent complaints handling service. Your complaint must be about your health insurance arrangement, meaning its got to be about the policy failing to do something or an area where you feel you were covered but are being told a different story. AMA President Michael Gannon recently commented that patients were not getting value for money and were being left confused by unnecessarily complex policies that often did not provide an acceptable level of cover.
This sort of scenario is where the Ombudsman can help.

Speak to your fund first

The Ombudsman will not, and in some cases cannot, investigate complaints until they have been raised with the agency. Most health funds have internal complaint handling procedures that may be able to sort out the problem to your satisfaction. However it’s often at this point that customers may feel they’re getting the runaround but persist and advise them that you will not be fobbed off, and that the problem will not go away unless it is properly resolved.
Here’s some simple tips when dealing with the your health fund.

Get your communication with the fund in writing

As a lawyer, I can’t state how important it is to get your communication with the fund in writing. Send emails after any initial phone communication detailing what has been discussed and request that they reply and keep you updated about your matter via email, or at worst SMS.
Reliance on phone contact could mean you end up speaking with multiple people all of whom may mean well but information and results always end of getting scrambled. Try and get a case manager or one person to communicate with you on phone but still keep up the written stuff.

What to include in your complaint
Whether you write or telephone, set out your complaint as clearly and briefly as possible. Be specific rather than general. Stick to the main facts, and don’t go into excessive detail. If detail is necessary, it is useful to set it out in a logical order including your name and contact details; relevant dates and times; a description of the incident or decision; details of telephone conversations, meetings and any steps you may have taken to sort out the problem already; and any explanations you think are important. Attach copies of relevant documents to your covering letter, and sign and date it.
It’s important to be organised!

And don’t forget, if you are unable to sort out the matter after making all reasonable efforts to do so, you should then contact the Ombudsman and make a complaint.
They also have a range of tools for consumers, including the consumer website PrivateHealth.gov.au

If you are looking at changing funds I recommend you check out the reviews by verified customers on productreview.com.au 
There’s one fund that surprisingly stands head and shoulders above all the others when it comes to customer service and performance.





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Written by The Legal Eagle