1. Purpose
The purpose of this policy is to:
-
ensure that complaints received by The Doctors' Health Fund ('The Fund'), are resolved in an efficient and professional manner, and in accordance with the Private Health Insurance Code of Conduct and as per Australian Standard AS ISO 10002 – 2006 ‘Customer Satisfaction – Guidelines for complaints handling in organisations.
- improve the standard of service for our members by ensuring that all complaints are addressed and, where relevant, used to improve processes,
- provide assistance to Fund staff in dealing with complaints by establishing procedures for making complaints, and
- advise complainants of their rights with respect to the handling of their complaint.
2. Definition
2.1 A complaint can be received from a number of sources including:
- members,
- providers,
- agents, or
- consumers.
The above are all referred to as complainants.
2.2 A complaint is an expression of dissatisfaction with a product or service provided by the Fund. There are 3 levels of complaint:
- Level 1 – a grievance or concern which can usually be immediately addressed by the employee dealing with the matter. In these cases, the complainant agrees that the matter has been dealt with in accordance with current Fund rules or standards, or with health insurance regulations as the case may be.
- Level 2 – the complainant is not satisfied with the response they have received and the matter is escalated to the receiving staff member's manager.
- Level 3 – complaints that escalate to the level of a dispute have not been adequately dealt with by a staff member or their manager and are referred to the CEO. The CEO might refer the matter to the Board. For unresolved Level 3 complaints, the complainant must be made aware that they can approach the Private Health Insurance Ombudsman (PHIO) with their complaint. Contact details for PHIO are provided with this policy.
3. Principles
The Fund applies the following principles in this policy:
3.1 Commitment: The Fund is committed to the efficient and fair resolution of complaints by staff at all levels, including the Chief Executive Officer and the Board of Directors.
3.2 Right to complain: the Fund acknowledges consumers' right to complain and encourages feedback from consumers.
3.3 Fairness: The Fund recognises the need to be fair and objective in its assessment of the complaint and to manage the process in an unbiased manner. Fairness applies to all parties, including the complainant, the Fund membership as a whole and any individual against whom a complaint may be raised. Each complaint shall be addressed in an equitable, objective and unbiased manner through the complaints-handling process.
3.4 Resources: The Fund will maintain adequately trained staff to handle the complaint procedures.
3.5 Visibility: The Fund will make the Complaints Handling Policy publicly available in plain language on its website and to anyone who requests it.
3.6 Responsiveness: The Fund will deal with complaints quickly and treat complainants courteously.
3.7 Costs: The Fund will not apply a charge where the complaint is dealt with internally. Where the complaint is referred to an external mediator, The Fund reserves the right to recover costs of defending the claim where the ultimate finding is in The Fund's favour.
3.8 Remedies: The Fund has the capacity to determine and implement remedies as set out in this policy.
3.9 Data collection: The Fund will record and monitor the status of complaints.
3.10 Continual improvement: The Fund will review its processes or products or retrain staff as appropriate and where the complaint involves a systemic or recurring issue.
3.11 Accountability: The Fund will apply appropriate reporting on the operation of the complaints handling process against documented performance standards.
3.12 Confidentiality: Personally identifiable information (as per the Privacy Act 1988) concerning the complainant shall be actively protected from disclosure, unless the customer or complainant expressly consents to its disclosure.
3.13 Review: The Fund will review this policy annually.
4. Complaints-handling framework & process
4.1 The Fund has systems and procedures in place to log, monitor and report complaints. Management reviews level 2 and 3 complaints and involves the Board as and when required.
4.2 Complainants may make complaints in whichever way they feel most comfortable: by e-mail, letter, fax, face-to-face or telephone. In order to clarify the exact nature of the grievance, it is usually preferable for the complainant to put the complaint in writing. All complainants must be sent an acknowledgment of receipt of their complaints.
4.3 Management and /or the CEO are to be advised immediately where:
- The complaint is identified by the staff member as significant, or
- The complaint has potentially serious impact on the operations of the Fund.
4.4 Where unresolved immediately, the complainant should be advised that they will be contacted within three working days of receiving the complaint, of the progress of their complaint.
4.5 The Fund will contact the complainant within three working days of receiving the complaint to advise of progress.
4.6 The complaint must, where practicable, be resolved within 10 business days.
4.7 Where the complaint cannot be resolved within 10 business days, the client must be contacted and the delay explained. In any event, the complaint must be resolved within 45 days from the date of receipt of the complaint. (ASIC Policy Statement 139).
4.8 The complainant must be informed of the criteria and complaints-handling process, including the avenuesfor further review through the PHIO. Contact details for the PHIO are provided at the end of this policy.
4.9 Where the matter involves a medical issue, such as the determination of a pre-existing condition, the complainant is to be made aware that the Fund has a Clinical Advisory Policy for handling such matters.
4.10 Where possible, complaints should be reviewed by a staff member who has not been involved in the matter. Ideally, if the complaint is about the quality of service, the CEO should independently review the complaint.
4.11 All Fund employees are to be patient and courteous and empathise with the complainant's circumstances. This does not mean admitting any fault or liability but understanding that, for whatever reason, they have encountered an issue causing them a level of distress or grievance.
4.12 Ensure that the complainant is familiar with the complaints procedure. The complainant is entitled to receive a copy of the Fund's complaints-handling procedure should they request it or if they are unfamiliar with the process.
4.13 The complainant must be advised that they have a right to be heard and must be supplied with material in support of their complaint, if so they desire.
4.14 The complainant must be informed of the Fund's policies, procedures or Rules applicable to the complaint.
4.15 In dealing with the complaint, the Fund's employees must:
- identify themselves, actively listen, record details and determine what the complainant wants;
- confirm the details received;
- explain the courses of action available;
- not attempt to lay blame or be defensive;
- resolve the complaint if possible or commit to doing something immediately, irrespective of who will ultimately handle the complaint;
- ensure that the complainant is informed that the complaint is receiving attention, without creating false expectations, and
- check whether the complainant is satisfied with the proposed action and, if not, advise alternative courses of action.
4.16 Details of the complaint are to be recorded in the appropriate place. It is preferable that for level 2 and 3 complaints, the complainant is requested to put the complaint in writing. The application of the Fund's Privacy policy is to be taken into consideration when compiling this information. The correspondence is to be copied and stored in the Fund's computer system against the membership record. The information can include the following:
- copies of background information eg, account opening forms, all correspondence and transaction listings;
- file notes of interviews with relevant staff;
- copies of all correspondence sent to the client in relation to the complaint;
- file notes of all telephone conversations between the client and DHF; and
- an action plan to resolve the complaint.
4.17 Responses to the complaint must:
- include the decision and reason/s for the decision;
- address the issue raised in the initial complaint;
- refer to applicable provisions in legislation, codes, standards, Fund rules, Fund constitution or procedures; and
- advise the complainant that, if they are not satisfied with the outcome of their complaint, they may refer their complaint to the CEO and if necessary, to the PHIO.
4.18 If applicable, the CEO is to advise the Fund's insurers where a claim might be made.
4.19 Staff should, at all times, keep the complainant informed in writing of the status of their complaint. Wherever possible, work to the agreed timeframes and, if there are any delays, advise the complainant promptly and inform them of when they can expect to hear additional information.
5. Remedies available
Possible remedies for resolving complaints include:
- apology
- financial assistance
- provision of free services
- reduction or refund of fees paid
- compensation
- disciplinary action against staff member
- mediation
- refund
- replacement
- repair
- substitute
- technical assistance
- additional information
- other assistance
- goodwill gift or token
The Operations Manager and/or CEO must approve, within their delegations limits, remedies before any of these are offered to the complainant. Proposed remedies outside of these delegations must be approved by the Board of Directors. The principle of fairness to all members is paramount in any decision regarding remedies.
Fund Contact Details:
Operations Manager
The Doctors' Health Fund Limited
P O Box 482
St Leonards NSW 1590
6. PHIO Contact details
Where complaints cannot be resolved internally, complainants retain the right to refer the complaint to:
The Private Health Insurance Ombudsman (PHIO)
Freecall Complaints Hotline: 1800 640 695
Email: info@phio.org.au
Website: www.phio.org.au
2202 / 580 George St, Sydney NSW 2000
Telephone: (02) 8235 8777
Facsimile: (02) 8235 8778