Private Health Insurance Act 2007

CHAPTER 3 - COMPLYING HEALTH INSURANCE PRODUCTS  

PART 3-2 - COMMUNITY RATING  

Division 55 - Principle of community rating  

SECTION 55-5   PRINCIPLE OF COMMUNITY RATING  

55-5(1)    
A private health insurer must not:

(a)    take or fail to take any action; or

(b)    in making a decision, have regard or fail to have regard to any matter;

that would result in the insurer ^[*]

To find definitions of asterisked terms, see the Dictionary in Schedule 1 .

improperly discriminating between people who are or wish to be insured under a ^[*]

To find definitions of asterisked terms, see the Dictionary in Schedule 1 .

complying health insurance policy of the insurer.

55-5(2)    
Improper discrimination is discrimination that relates to:

(a)    the suffering by a person from a chronic disease, illness or other medical condition or from a disease, illness or medical condition of a particular kind; or

(b)    the gender, race, sexual orientation or religious belief of a person; or

(c)    the age of a person, except to the extent allowed under:

(i) Part 2-3 (lifetime health cover); or

(ii) subsection 63-5(4) ; or

(iii) section 66-5 , because of the reason mentioned in paragraph 66-5(3)(ea) ; or

(d)    where a person lives, except to the extent allowed under subsection 66-10(2) or section 66-20 or 66-25 ; or

(e)    any other characteristic of a person (including but not just matters such as occupation or leisure pursuits) that is likely to result in an increased need for ^[*]

To find definitions of asterisked terms, see the Dictionary in Schedule 1 .

hospital treatment or ^[*]

To find definitions of asterisked terms, see the Dictionary in Schedule 1 .

general treatment; or

(f)    the frequency with which a person needs hospital treatment or general treatment; or

(g)    the amount or extent of the benefits to which a person becomes entitled during a period under a ^[*]

To find definitions of asterisked terms, see the Dictionary in Schedule 1 .

complying health insurance policy, except to the extent allowed under section 66-15 ; or

(h)    any matter set out in the Private Health Insurance (Complying Product) Rules for the purposes of this paragraph.

55-5(3)    
Despite subsection (2) , discrimination by a ^[*]

To find definitions of asterisked terms, see the Dictionary in Schedule 1 .

restricted access insurer is not improper discrimination to the extent to which the insurer:

(a)    takes or fails to take an action; or

(b)    in making a decision, has regard or fails to have regard to a matter;

only to ensure that its ^[*]

To find definitions of asterisked terms, see the Dictionary in Schedule 1 .

complying health insurance products are not made available to persons to whom its constitution or ^[*]

To find definitions of asterisked terms, see the Dictionary in Schedule 1 .

rules prohibits it from making the products available.

55-5(4)    
Despite subsection (2) , discrimination by a private health insurer is not improper discrimination to the extent to which:

(a)    the insurer:

(i) takes or fails to take an action; or

(ii) in making a decision, has regard or fails to have regard to a matter; and

(b)    taking or failing to take the action, or having regard or failing to have regard to that matter, has the effect of the premiums payable under an insurance policy that covers a person who is:

(i) employed by a particular person or body; or

(ii) under contract to provide services to a particular person or body;

being the subject of a discount or discounts (whether or not the policy also covers one or more persons who are not so employed and are not under such a contract); and

(c)    the premiums meet the premium requirement in section 66-5 .

55-5(5)    
To avoid doubt, subsection (4) does not apply if taking or failing to take the action, or having regard or failing to have regard to that matter, has the effect of an insurance policy being cancelled because a person ceases to be an employee of, or ceases to be under contract to provide services to, a particular employer.