Private health funds & compensation

Some private health insurance fund membership rules appear to be taking a more rigorous approach to the potential for compensation recovery by the Fund, and in respect of the potential refusal of benefits for some treatment following receipt of compensation.

One major fund in its current rules addresses (at clause F7, page 40):

  • Keeping the fund informed of the progress of the claim for compensation, including the time and place of negotiations, mediations or hearings;
  • Keeping the fund informed of medical reports prepared for the purpose of assessing the claim;
  •  Ensuring that the member’s legal advisers disclose the above to the Fund;
  • Provision to the Fund of a copy of any judgment or settlement document and if not evident, an explanation as to how the compensation has been calculated (regarding which it is asserted that doing so is not inconsistent with any confidentiality or privilege);
  • Extension of the above obligations to circumstances where the Fund has not paid any benefits in respect of relevant treatment;
  • Assumption of the member’s right to pursue compensation, in respect of benefits paid in some circumstances;
  • Provision to the Fund of evidence of whether a judgment or settlement includes an allocation for future medical expenses.

Another major fund has similar but less extensive provisions (see clause F7, page 24),.


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