Who must comply with Private Health Insurance Act 2007 + APRA rules?

Private health insurers regulated by APRA + PHIO; community rating, complaints + claims rules apply.

The Private Health Insurance Act 2007 sets community rating, lifetime health cover loading, product disclosure + complaint-handling rules. APRA supervises prudential aspects; the Private Health Insurance Ombudsman handles individual complaints.

Applies when the business has industry: Private health insurers.

How the regulator frames it: Private health insurers.

What triggers it: Carrying on private health insurance business.

Jurisdiction: Commonwealth law, so the test is the same in every state and territory.

Outcome across the 35 industries Rules Mate maps (1 of 35: yes; 34 of 35: no).

Structure does not change the answer in private health insurers: for every structure the answer is "yes".

Size does not change the answer in private health insurers: at every size band the answer is "yes".

Each line is one run of the Rules Mate applicability engine for a single business profile, with the reason the engine gives:

• Pty Ltd company in private health insurers with 6–19 employees, turnover $1M–$3M: applies. Industry: Private health insurers.
• Pty Ltd company in real estate agents with 6–19 employees, turnover $1M–$3M: does not apply. Requires industry: Private health insurers.

When due

Continuous.

Frequency

Ongoing

Evidence to keep

Product disclosure statements, complaint records, APRA reporting, PHIO engagement.

Status

Current

Priority

High

Maximum penalty: APRA enforcement, civil penalties under PHI Act, registration consequences.

Rules Mate has not yet classified the audit or assurance level for this obligation. Any audit, review or certification requirement is set by the regulator source listed below.

If this obligation applies to you, so does this one: the engine uses the same rule for each.

• PHI Prudential Standards (APRA)

• Comply with claims handling + settling as a financial service (s 766A): From 1 January 2022, insurance claims handling is a financial service requiring AFSL authorisation.
• Comply with General Insurance Code of Practice (ICA): ICA Code binds member insurers on conduct + claims + complaints.
• General Insurance Code of Practice 2020: ICA member insurers bound by service standards + claims handling timeframes.
• Life Insurance Code of Practice 2.0: FSC member life insurers bound by Code 2.0 (commenced 1 July 2023).
• Manage business interruption claim definitions (post-pandemic precedent): BI insurance policies must clearly define pandemic exclusions per Federal Court guidance.

Across the 1,890 business profiles Rules Mate evaluates, these obligations apply to most of the businesses this one applies to, and are far more common among them than among businesses generally:

• Design and Distribution Obligations (DDO) — RG 274: applies to 100% of the same businesses (11.7× the overall rate)
• Comply with APRA CPS 220 (Risk Management): applies to 100% of the same businesses (11.7× the overall rate)
• Comply with APRA CPS 230 (Operational Risk Management): applies to 100% of the same businesses (11.7× the overall rate)
• Comply with APRA CPS 234 (Information Security): applies to 100% of the same businesses (11.7× the overall rate)
• Comply with Design and Distribution Obligations (DDO): applies to 100% of the same businesses (11.7× the overall rate)

Rules Mate tracks 8 published obligations tagged "insurance", 1 of them rated critical. For a professional services Pty Ltd company with 6–19 employees operating in every state, 0 of those apply outright. This obligation is rated high priority, and is an ongoing duty.

Regulated by Australian Prudential Regulation Authority.

APRA: Prudential regulator of banks (ADIs), insurers (general, life, private health), and superannuation funds. Sets and enforces CPS standards including CPS 234 (information security) and CPS 230 (operational risk).

• Australian Prudential Regulation Authority

Free tools that help with this obligation:

• Compliance calendar builder