Printable version of 18/12 (PDF 20 KB)
21 March 2012
Information Regarding Health Insurance Business
The Department is aware that some private health insurers are paying benefits for the liability to pay fees or charges for the provision of goods and services such as ‘learn first aid’ and ‘learn to swim’ classes as part of their health insurance business. The purpose of this circular is to clarify that health insurance benefits can only be paid for hospital and/or general treatment.
In accordance with section 121-1 of the Private Health Insurance Act 2007
(the Act), health insurance business is defined as the business of undertaking liability by way of insurance that relates to hospital treatment or general treatment.
Under section 121-5 of the Act, hospital treatment is the provision of goods or services that is intended to manage a disease, injury or condition, which is provided either at a hospital or with the direct involvement of a hospital. Section 121-10 of the Act provides general treatment as treatment that is intended to manage or prevent a disease, injury or condition and is not hospital treatment.
Therefore, the payment of health insurance benefits for fees or charges related to services such as ‘learn to swim’ classes can only occur in circumstances where the class is for the purpose of managing or preventing a diagnosed disease, injury or condition. An example of this is where a medical practitioner has prescribed swimming as a part of a health management program to ameliorate a specific condition, such as chronic asthma.
Health insurance benefits cannot be paid for classes or courses undertaken solely for the purpose of learning new skills or acquiring new information in the absence of the participant requiring specifically recommended treatment for the purpose of managing or preventing a disease, injury or condition.
The Department will be scrutinising the payment of health insurance benefits for goods and services other than hospital treatment and general treatment to ensure that the requirements of the Act are complied with.
For further information about this circular, please contact Mr Stephen Lewis on (02) 6289 8283
If you require further information please telephone: (02) 6289 9853/24 hr answering machine or email the enquiry to Private Health Insurance Branch
For more information visit 2012 Private Health Insurance (PHI) Circulars
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