STATUTORY INTERPRETATION — Construction — Private Health Insurance (Benefit Requirements) Rules 2011 (Cth) sch 5 cl 3 — Proper construction of cl 3(6) — Where a private health insurer had no negotiated agreement with plaintiff second tier private hospitals — Where private hospitals provided insured patients with episodes of hospital treatment and sought minimum benefits from insurer calculated under the Rules — Where insurer required to calculate minimum benefit
Quick Take
1The word 'relevant' in sch 5 cl 3(6) qualifies 'insurer's negotiated agreements' (not 'insurer'), so that only those negotiated agreements containing an equivalent episode of hospital treatment form the pool from which the 'majority' is determined for identifying the episode's patient classification system and payment structure.
2Clause 3(6) is a mechanism for identifying the episode of hospital treatment and the methodology for calculating the minimum benefit; it is not a threshold barrier that excludes episodes from minimum benefit entitlements where fewer than a majority of all comparable agreements include that episode type.
3The purpose of the second-tier default benefit regime is to incentivise accreditation of private hospitals and ensure minimum benefits are payable for episodes of hospital treatment provided to insured consumers, even absent a negotiated agreement — a construction that treats cl 3(6) as a bar to benefits is inconsistent with that purpose.
