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PRIVATE HEALTH INSURANCE ACT 2007 (NO. 31, 2007)
TABLE OF PROVISIONS
Long Title
CHAPTER 1--Introduction
PART 1-1--INTRODUCTION
Division 1--Preliminary
1.1. Short title
1.5. Commencement
1.10. Identifying defined terms
Division 3--Overview of this Act
3.1. What this Act is about
3.5. Incentives (Chapter 2)
3.10. Complying health insurance products (Chapter 3)
3.15. Private health insurers (Chapter 4)
3.20. Enforcement (Chapter 5)
3.25. Administration (Chapter 6)
3.30. Dictionary (Schedule 1)
Division 5--Constitutional matters
5.1. Meaning of insurance
5.5. Act not to apply to State insurance within that State
5.10. Compensation for acquisition of property
CHAPTER 2--Incentives
PART 2-1--INTRODUCTION
Division 15--Introduction
15.1. What this Chapter is about
PART 2-2--PREMIUMS REDUCTION AND INCENTIVE PAYMENTS SCHEMES
Division 20--Introduction
20.1. What this Part is about
20.5. Private Health Insurance (Incentives) Rules
Division 23--Premiums reduction scheme
Subdivision 23-A--Amount of reduction
23.1. Reduction in premiums
23.5. Meaning of incentive amount
23.10. Reduction after a person 65 years or over ceases to be covered by policy
Subdivision 23-B--Participation in the premiums reduction scheme
23.15. Registration as a participant in the premiums reduction scheme
23.20. Refusal to register
23.25. Pre-1999 participants must keep information up to date
23.30. Participants who want to withdraw from scheme
23.35. Revocation of registration
23.40. Variation of registration
23.45. Retention of applications by private health insurers
Division 26--The incentive payments scheme
Subdivision 26-A--Amount of incentive payment
26.1. Payment in relation to premiums
26.5. Payment after a person 65 years or over ceases to be covered by policy
Subdivision 26-B--Claiming payments under the incentive payments scheme
26.10. Claim for payment under incentive payments scheme
26.15. Withdrawal of claim
26.20. Determination of claim and payment of amount
26.25. Reconsideration of decision refusing a claim
26.30. Claimants to keep information up to date
PART 2-3--LIFETIME HEALTH COVER
Division 31--Introduction
31.1. What this Part is about
31.5. Private Health Insurance (Lifetime Health Cover) Rules
Division 34--General rules about lifetime health cover
34.1. Increased premiums for person who is late in taking out hospital cover
34.5. Increased premiums for person who ceases to have hospital cover after his or her lifetime health cover base day
34.10. Increased premiums stop after 10 years' continuous cover
34.15. Meaning of hospital cover
34.20. Meaning of permitted days without hospital cover
34.25. Meaning of lifetime health cover base day
34.30. When a person is overseas
Division 37--Exceptions to the general rules about lifetime health cover
37.1. People born on or before 1 July 1934
37.5. People over 31 and overseas on 1 July 2000
37.10. Hardship cases
37.15. Increases cannot exceed 70% of base rates
37.20. Joint hospital cover
Division 40--Administrative matters relating to lifetime health cover
40.1. Notification to insured people etc.
40.5. Evidence of having had hospital cover, or of a person's age
CHAPTER 3--Complying health insurance products
PART 3-1--INTRODUCTION
Division 50--Introduction
50.1. What this Chapter is about
50.5. Private Health Insurance Rules relevant to this Chapter
PART 3-2--COMMUNITY RATING
Division 55--Principle of community rating
55.1. What this Part is about
55.5. Principle of community rating
55.10. Closed products
PART 3-3--REQUIREMENTS FOR COMPLYING HEALTH INSURANCE PRODUCTS
Division 60--Introduction
60.1. What this Part is about
Division 63--Basic rules about complying health insurance products
63.1. Obligation to ensure products are complying products
63.5. Meaning of complying health insurance product
63.10. Meaning of complying health insurance policy
Division 66--Community rating requirements
66.1. Community rating requirements
66.5. Premium requirement
66.10. Minister's approval of premiums
66.15. Entitlement to benefits for general treatment
66.20. Different amount of benefits depending on where people live
Division 69--Coverage requirements
69.1. Coverage requirements
69.5. Meaning of cover
69.10. Meaning of hospital-substitute treatment
Division 72--Benefit requirements for policies that cover hospital treatment
72.1. Benefit requirements
72.5. Rules requirement in relation to provision of benefits
72.10. Minimum benefits for prostheses
72.15. Ongoing listing fee for prostheses
72.20. Other matters
Division 75--Waiting period requirements
75.1. Waiting period requirements
75.5. Meaning of waiting period
75.10. Meaning of transfers
75.15. Meaning of pre-existing condition
Division 78--Portability requirements
78.1. Portability requirements
Division 81--Quality assurance requirements
81.1. Quality assurance requirements
Division 84--Enforcement of this Part
84.1. Offence: advertising, offering or insuring under non-complying policies
84.5. Offence: directors and chief executive officers liable if systems not in place to prevent breaches
84.10. Injunction in relation to non-complying policies
84.15. Remedies for people affected by non-complying policies
PART 3-4--OBLIGATIONS RELATING TO COMPLYING HEALTH INSURANCE PRODUCTS
Division 90--Introduction
90.1. What this Part is about
Division 93--Giving information to consumers
93.1. Maintaining up to date standard information statements
93.5. Meaning of standard information statement
93.10. Making standard information statements available
93.15. Giving information to newly insured people
93.20. Keeping insured people up to date
93.25. Giving advance notice of detrimental changes to rules
93.30. Failure to give information to consumers
Division 96--Giving information to the Department, the Council and the Private Health Insurance Ombudsman
96.1. Giving standard information statements on request
96.5. Giving standard information statements for new products
96.10. Giving updated standard information statements
96.15. Giving additional information on request
96.20. Failure to give information to Department, Council or Private Health Insurance Ombudsman
96.25. Giving information required by the Private Health Insurance (Complying Product) Rules
Division 99--Transfer certificates
99.1. Transfer certificates
Division 102--Private health insurers to offer cover for hospital treatment
102.1. Private health insurers to offer cover for hospital treatment
CHAPTER 4--Private health insurers
PART 4-1--INTRODUCTION
Division 110--Introduction
110.1. What this Chapter is about
PART 4-2--CARRYING ON HEALTH INSURANCE BUSINESS
Division 115--Introduction
115.1. What this Part is about
115.5. The Private Health Insurance (Health Insurance Business) Rules
115.10. Whether a business etc. is health insurance business
Division 118--Prohibition of carrying on health insurance business without registration
118.1. Carrying on health insurance business without registration
118.5. Injunctions
Division 121--What is health insurance business
121.1. Meaning of health insurance business
121.5. Meaning of hospital treatment
121.7. Conditions on declarations of hospitals
121.10. Meaning of general treatment
121.15. Extension to employee health benefits schemes
121.20. Exception: accident and sickness insurance business
121.25. Exception: liability insurance business
121.30. Exception: insurance business excluded by the Private Health Insurance (Health Insurance Business) Rules
PART 4-3--REGISTRATION
Division 126--Registration
126.1. What this Part is about
126.5. The Private Health Insurance (Registration) Rules
126.10. Applying for registration
126.15. Requesting further information
126.20. Deciding the application
126.25. Notifying the decision
126.30. Council can be taken to refuse application
126.35. Council to maintain record of registrations etc.
126.40. Changing registration status
126.42. Conversion to for profit status
126.45. Cancellation of registration
PART 4-4--HEALTH BENEFITS FUNDS
Division 131--Introduction
131.1. What this Part is about
131.5. The Private Health Insurance (Health Benefits Fund) Rules
131.10. Meaning of health benefits fund
131.15. Meaning of health-related business
Division 134--The requirement to have health benefits funds
134.1. Private health insurers must have health benefits funds
134.5. Notifying the Council when health benefits funds are established
134.10. Inclusion of health-related businesses in health benefits funds
Division 137--The operation of health benefits funds
137.1. Assets of health benefits funds
137.5. Payments to health benefits funds
137.10. Expenditure and application of health benefits funds
137.15. Effect of non-compliance with section 137-10
137.20. Investment of health benefits funds
137.25. Restriction on restructure, merger, acquisition or termination of health benefits funds
137.30. Operation of health-related businesses through health benefits funds
Division 140--The solvency standard for health benefits funds
140.1. Purpose of Division
140.5. Council to establish solvency standard
140.10. Purpose of solvency standard
140.15. Compliance with solvency standard
140.20. Solvency directions
Division 143--The capital adequacy standard for health benefits funds
143.1. Purpose of Division
143.5. Council to establish capital adequacy standard
143.10. Purpose of capital adequacy standard
143.15. Compliance with capital adequacy standard
143.20. Capital adequacy directions
Division 146--Restructure, merger and acquisition of health benefits funds
146.1. Restructure of health benefits funds
146.5. Merger and acquisition of health benefits funds
146.10. Consent of policy holders not required
146.15. Other laws not overridden
Division 149--Termination of health benefits funds
Subdivision 149-A--Approving the termination of health benefits funds
149.1. Applying for termination
149.5. Requesting further information
149.10. Deciding the application
149.15. Council can be taken to refuse application
Subdivision 149-B--Conducting the termination of health benefits funds
149.20. Conduct of funds during termination process
149.25. Insurers etc. to give reports to Council
149.30. Terminating managers displace management of funds
Subdivision 149-C--Ending the termination of health benefits funds
149.35. Power to end termination
Subdivision 149-D--Completing the termination of health benefits funds
149.40. Completion of the termination process
149.45. Distribution of remaining assets after completion of the termination process
149.50. Liability of officers of insurers for loss to terminated funds
149.55. Report of terminating manager
149.60. Applying for winding up
Division 152--Duties and liabilities of directors etc
152.5. Notices to remedy contraventions
152.10. Liability of directors in relation to non-compliance with notices
152.15. Council may sue in the name of private health insurers
PART 4-5--OTHER OBLIGATIONS OF PRIVATE HEALTH INSURERS
Division 157--Introduction
157.1. What this Part is about
157.5. The Private Health Insurance (Insurer Obligations) Rules
Division 160--Appointed actuaries
160.1. Appointment
160.5. Eligibility for appointment
160.10. Notification of appointment etc.
160.15. Cessation of appointment
160.20. Compliance with the Private Health Insurance (Insurer Obligations) Rules
160.25. Powers of appointed actuary
160.30. Actuary's obligations to report
160.35. Qualified privilege of appointed actuary
Division 163--Prudential standards
163.1. Private Health Insurance (Insurer Obligations) Rules to establish prudential standards
163.5. Compliance with prudential standards
163.10. Notice of breaches of prudential standards etc.
163.15. Directions to comply with standards
163.20. Failure to comply with directions
Division 166--Disqualified persons
166.1. Private health insurers not to allow disqualified persons to act as directors
166.5. Disqualified persons must not act for private health insurers
166.10. Effect of non-compliance
166.15. Who is a disqualified person?
166.20. Council may disqualify persons
166.25. Council may determine that persons are not disqualified
Division 169--Reporting and notification requirements
169.1. Copies of reports to policy holders
169.5. Information to be given to the Council annually
169.10. Private health insurers to notify any changes to rules
169.15. Private health insurers to notify Department and Council about current chief executive officer
Division 172--Miscellaneous
172.1. Private health insurers to comply with Council's requirements
172.10. Private health insurers to give information to Secretary
172.15. Restrictions on payment of pecuniary penalties etc.
CHAPTER 5--Enforcement
PART 5-1--INTRODUCTION
Division 180--Introduction
180.1. What this Chapter is about
PART 5-2--GENERAL ENFORCEMENT METHODS
Division 185--What this Part is about
185.1. Introduction
185.5. Meaning of enforceable obligation
185.10. Meaning of Council-supervised obligation
Division 188--Performance indicators
188.1. Performance indicators
Division 191--Explanation of private health insurer's operations
191.1. Minister or Council may seek an explanation from a private health insurer
191.5. Writer must respond to insurer's explanation
Division 194--Investigation of private health insurer's operations
194.1. Minister or Council may investigate a private health insurer
194.5. Notice to give information
194.10. Notice to produce documents
194.15. Notice to give evidence
194.20. Offences in relation to investigation notices
194.25. Authorisation to examine books and records etc.
194.30. Minister may consult Council
194.35. Minister or Council must notify outcome of investigation
Division 197--Enforceable undertakings
197.1. Minister or Council may accept written undertakings given by a private health insurer
197.5. Enforcement of undertakings
Division 200--Ministerial and Council directions
200.1. Minister or Council may give directions
200.5. Direction requirements
Division 203--Remedies in the Federal Court
203.1. Minister or Council may apply to the Federal Court
203.5. Declarations of contravention
203.10. Pecuniary penalty order
203.15. Compensation order
203.20. Adverse publicity order
203.25. Other order
203.30. Time limit for declarations and orders
203.35. Civil evidence and procedure rules for declarations and orders
203.40. Civil proceedings after criminal proceedings
203.45. Criminal proceedings during civil proceedings
203.50. Criminal proceedings after civil proceedings
203.55. Evidence given in proceedings for penalty not admissible in criminal proceedings
203.60. Minister or Council may require person to assist
203.65. Relief from liability for contravening an enforceable obligation
203.70. Powers of Federal Court
Division 206--Revoking entitlement to offer rebate as a premium reduction
206.1. Revocation of status of participating insurer
PART 5-3--ENFORCEMENT OF HEALTH BENEFITS FUND REQUIREMENTS
Division 211--Introduction
211.1. What this Part is about
211.5. Purpose of this Part
211.10. The Private Health Insurance (Health Benefits Fund Enforcement) Rules
211.15. Limitation on external management and termination of health benefits funds
Division 214--Investigations into affairs of private health insurers
214.1. Investigation of private health insurers by inspectors
214.5. Powers of inspectors
214.10. Person may be represented by lawyer
214.15. Compliance with requirements of inspectors
214.20. Access to premises
214.25. Reports of inspectors
214.30. Dissemination of reports
214.35. Liability for publishing reports etc.
214.40. Delegation by inspectors
214.45. Records not to be concealed etc.
Division 217--External management of health benefits funds
Subdivision 217-A--Preliminary
217.1. Purpose of Division
217.5. The basis of the law relating to external management
Subdivision 217-B--Appointment of external managers
217.10. Council may appoint external managers
217.15. Grounds of appointment of external managers
217.20. External managers to displace management of funds
Subdivision 217-C--Duties and powers of external managers
217.25. Duties of external managers
217.30. Additional powers of external managers
217.35. Protection of property during external management
217.40. Rights of chargee, owner or lessor of property of fund under external management
Subdivision 217-D--Procedure relating to voluntary deeds of arrangement
217.45. Matters that may be included in the Private Health Insurance (Health Benefits Fund Enforcement) Rules
Subdivision 217-E--External managers' reports to Council
217.50. External managers to give reports to Council
217.55. Dealing with reports given to the Council
217.60. Court orders in respect of schemes of arrangement
Subdivision 217-F--Miscellaneous
217.65. When an external management begins and ends
217.70. Effect of things done during external management of health benefits funds
217.75. Disclaimer of onerous property
217.80. Application of provisions of Corporations Act
Division 220--Ordering the termination of health benefits funds
220.1. Applications by external managers to the Federal Court
220.5. Orders made on applications for appointments of terminating managers
220.10. Binding nature of Court orders
220.15. Notice of appointments
CHAPTER 6--Administration
PART 6-1--INTRODUCTION
Division 230--Introduction
230.1. What this Chapter is about
PART 6-2--PRIVATE HEALTH INSURANCE OMBUDSMAN
Division 235--Introduction
235.1. Principal object of this Part
235.5. Private Health Insurance (Ombudsman) Rules
Division 238--Establishment and functions
238.1. Establishment of office of Private Health Insurance Ombudsman
238.5. Functions of Private Health Insurance Ombudsman
Division 241--Complaints
Subdivision 241-A--Relevant complaints
241.1. Who may make a complaint
241.5. Persons against whom complaints may be made
241.10. Grounds for complaint
Subdivision 241-B--Dealing with complaints
241.15. Initial receipt of complaint
241.20. Ways of dealing with complaints
241.25. Referral to the Australian Competition and Consumer Commission
241.30. Referral to other bodies
241.35. Deciding not to deal with a complaint
Subdivision 241-C--Referral to subjects of complaints
241.40. Referral to the subject of the complaint
Subdivision 241-D--Investigation of complaints
241.45. Investigation of complaint
241.50. Minister may direct Private Health Insurance Ombudsman to investigate, or to continue to investigate, a complaint
Subdivision 241-E--Recommendations and reports
241.55. Recommendations as a result of referral or investigation
241.60. Report to Minister on outcome of investigation under Subdivision 241-D
Subdivision 241-F--Miscellaneous
241.65. Complainant to be kept informed
Division 244--Investigations
Subdivision 244-A--Investigations
244.1. Initiating investigations
244.5. Investigations at Minister's request
Subdivision 244-B--Recommendations and reports
244.10. Recommendations as a result of investigation
244.15. Report to Minister on outcome of investigations under this Division
244.20. Consultation with Australian Competition and Consumer Commission
Division 247--Mediation
247.1. Conducting mediation
247.5. Participation in mediation may be compulsory
247.10. Medical practitioners may appoint representatives
247.15. Conduct of compulsory mediation
247.20. Admissibility of things said in mediation
247.25. Appointment of mediators
Division 250--Information-gathering
250.1. Information-gathering
250.5. Limits on information-gathering
250.10. Disclosure of personal information
Division 253--Provisions relating to the Private Health Insurance Ombudsman
253.1. Appointment of the Private Health Insurance Ombudsman
253.5. Validity of appointments
253.10. Acting appointments
253.15. Remuneration and allowances
253.20. Outside employment
253.25. Leave of absence
253.30. Resignation
253.35. Termination of appointment
253.40. Disclosure of interest by Private Health Insurance Ombudsman
253.45. Statutory agency etc. for purposes of Public Service Act
253.50. Annual report
253.55. Delegation
253.60. Private Health Insurance Ombudsman and staff not personally liable
Division 256--Miscellaneous
256.1. Protection from civil actions
256.5. Victimisation
256.10. Giving information about the Private Health Insurance Ombudsman
PART 6-3--PRIVATE HEALTH INSURANCE ADMINISTRATION COUNCIL
Division 261--Introduction
261.1. What this Part is about
261.5. The Private Health Insurance (Council) Rules
Division 264--Continuation, purposes, functions and powers
264.1. Continuation of the Council
264.5. Objectives of the Council
264.10. Functions of the Council
264.15. Report on private health insurers
264.20. Powers
264.25. Directions by Minister
Division 267--Constitution and administration
267.1. Constitution of the Council
267.5. Appointment of members
267.10. Meetings of the Council
267.15. Delegation by the Council
267.20. Modification of the Commonwealth Authorities and Companies Act 1997
Division 270--Members
270.1. Terms and conditions etc.
270.5. Validity of appointments
270.10. Acting Commissioner
270.15. Deputy Commissioner to act as Commissioner in certain circumstances
270.20. Powers and duties of persons acting as Commissioner
270.25. Remuneration and allowances of members
270.30. Leave of absence
270.35. Resignation
270.40. Termination of appointment
270.45. Disclosure of interests
Division 273--Chief Executive Officer and staff
273.1. Chief Executive Officer
273.5. Duties of Chief Executive Officer
273.10. Conflict of interests
273.15. Staff and consultants
273.20. Remuneration and allowances of Chief Executive Officer
273.25. Leave of absence of Chief Executive Officer
PART 6-4--ADMINISTRATION OF PREMIUMS REDUCTION AND INCENTIVE PAYMENTS SCHEMES
Division 276--Introduction
276.1. What this Part is about
Division 279--Provisions applying only to premiums reduction scheme
Subdivision 279-A--Reimbursement of private health insurers for premiums reduced under scheme
279.1. Participating insurers may claim reimbursement
279.5. Participating insurers
279.10. Requirements for claims
279.15. Amounts payable to the private health insurer
279.20. Notifying private health insurers if amount is not payable
279.25. Additional payment if insurer claims less than entitlement
279.30. Additional payment if insurer makes a late claim
279.35. Content and timing of application
279.40. Decision on application
279.45. Reconsideration of decisions
Subdivision 279-B--Powers of Medicare Australia CEO in relation to participating insurers
279.50. Audits by Medicare Australia CEO
279.55. Medicare Australia CEO may require production of applications
Division 282--Provisions applying to premiums reduction scheme and incentive payments scheme
Subdivision 282-A--When and how payments can be recovered
282.1. Recovery of payments
282.5. Interest on amounts recoverable
282.10. Medicare Australia CEO may set off debts against amounts payable
282.15. Reconsideration of certain decisions under this Division
Subdivision 282-B--Miscellaneous
282.20. Notification requirements--private health insurers
282.25. Use etc. of information relating to another person
282.30. Information to be provided to the Commissioner of Taxation
282.35. Delegation
282.40. Appropriation
PART 6-5--EXTERNAL MANAGERS AND TERMINATING MANAGERS
Division 287--Introduction
287.1. What this Part is about
287.5. The Private Health Insurance (Management) Rules
Division 290--Powers of managers
290.1. Powers of managers
290.5. Officers etc. not to perform functions etc. while fund is under management
290.10. Managers act as agents of private health insurers
Division 293--Information concerning, and records and property of, health benefits funds
293.1. Directors etc. to help managers
293.5. Managers' rights to certain records
293.10. Only manager can deal with property of fund under management
293.15. Order for compensation where officer involved in void transaction
Division 296--Provisions incidental to appointment of managers
296.1. Remuneration of managers
296.5. Council may give directions to managers
296.10. Termination of appointments of managers
296.15. Acts of managers valid etc.
296.20. Indemnity
296.25. Qualified privilege
Division 299--Miscellaneous
299.1. Time for doing act does not run while act prevented by this Division
299.5. Continued application of other provisions of Act
299.10. Modifications of this Act in relation to health benefits funds under management
299.15. Order of Court to be binding on all persons
299.20. Jurisdiction of Federal Court
299.25. Private Health Insurance (Management) Rules dealing with various matters
PART 6-6--PRIVATE HEALTH INSURANCE LEVIES
Division 304--Introduction
304.1. What this Part is about
304.5. Private Health Insurance (Levy Administration) Rules
304.10. Meaning of private health insurance levy
Division 307--Collection and recovery of private health insurance levies
307.1. When private health insurance levy must be paid
307.5. Late payment penalty
307.10. Payment of levy and late payment penalty
307.15. Recovery of levy and late payment penalty
307.20. Waiver of late payment penalty for levies other than collapsed insurer levy
307.25. Waiver of collapsed insurer levy and late payment penalty for that levy
307.30. Other matters
Division 310--Returns, requesting information and keeping records
310.1. Returns must be lodged with Council and Department
310.5. Insurer must keep records
310.10. Council may request information from insurer
Division 313--Power to enter premises and search for documents
313.1. Authorised officer may enter premises with consent
313.5. Authorised officer may enter premises under warrant
313.10. Announcement before entry
313.15. Executing a warrant to enter premises
313.20. Identity cards
PART 6-7--PRIVATE HEALTH INSURANCE RISK EQUALISATION TRUST FUND
Division 318--Private Health Insurance Risk Equalisation Trust Fund
318.1. Private Health Insurance Risk Equalisation Trust Fund
318.5. Amounts to be paid into the Risk Equalisation Trust Fund
318.10. Operation of the Risk Equalisation Trust Fund
318.15. Administration of the Risk Equalisation Trust Fund
PART 6-8--DISCLOSURE OF INFORMATION
Division 323--Disclosure of information
323.1. Prohibition on disclosure of information
323.5. Authorised disclosure: official duties
323.10. Authorised disclosure: sharing information about insurers among agencies
323.15. Authorised disclosure: sharing information about insurers other than among agencies
323.20. Authorised disclosure: public interest
323.25. Authorised disclosure: by the Secretary or Council if authorised by affected person
323.30. Authorised disclosure: court proceedings
323.35. Authorised disclosure: Council's public information and agency cooperation functions
323.40. Offence: disclosure of information obtained by certain authorised disclosures
323.45. Offence: soliciting disclosure of information
323.50. Offence: use etc. of unauthorised information
323.55. Offence: offering to supply protected information
Division 328--Review of decisions
328.1. What this Part is about
328.5. AAT review of decisions
PART 6-10--MISCELLANEOUS
Division 333--Miscellaneous
333.1. Delegation by Minister
333.5. Delegation by Secretary
333.10. Approved forms
333.15. Signing approved forms
333.20. Private Health Insurance Rules made by the Minister
333.25. Private Health Insurance Rules made by the Council
333.30. Regulations
SCHEDULE 1 Dictionary
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