Does Private Health Cover Reconstructive Surgery?
Most health funds cover reconstructive surgery as a non-elective plastic surgery. Contact us to find out if you are covered or read more.
by Gary Andrews
Last update 15 Apr 2021
Plastic surgery encompasses a wide range of procedures -- many of which are cosmetic.
Health funds usually won't cover such surgeries, but often do cover reconstructive plastic surgery.
Ahead, we'll take a closer look at reconstructive surgery as it relates to private health insurance.
Reconstructive surgery falls under the "plastic surgery" umbrella.
Most people tend to think of plastic surgery as cosmetic surgery, but that's not always the case.
Cosmetic surgery is elective surgery designed to enhance the patient's appearance in one way or another.
While there's an element to this in reconstructive surgery, these procedures are considered to be medically necessary rather than cosmetic.
Medicare and private health funds do not pay benefits for cosmetic surgery.
They often recognise the difference between cosmetic plastic surgery and reconstructive surgery, which means some policies will cover these procedures.
Where Medicare pays a benefit so will the health insurer, so long as reconstructive surgery is included on the policy.
Reconstructive surgery is plastic surgery to correct abnormalities in the body.
These will either be developed, acquired by trauma, or congenital.
Here are some of the more common procedures that are considered reconstructive surgery.
As you can see, these procedures might be cosmetic, but they're also medically necessary as they can improve the patient's quality of life outside of their appearance.
These are the kinds of procedures we're talking about when we discuss reconstructive surgery.
These all have an item number in the Medicare Benefits Schedule, which means Medicare and private health funds will usually cover them.
Some require you to meet specific criteria to receive plastic surgery as well.
If a plastic surgery procedure doesn't have an MBS number, it likely won't be covered by a health fund.
As we've discussed, reconstructive plastic surgery is different from elective plastic surgery.
More health funds cover procedures like skin grafts in their basic coverage than procedures like breast or lip augmentation.
Some surgeries -- such as rhinoplasty (a nose job) -- fall into a grey area.
This procedure is typically seen as cosmetic, but can sometimes be medically necessary to correct a deviated septum or other abnormality.
When a doctor decides you need the procedure, health funds will usually provide benefits depending on your level of cover.
The procedures we included in the infographic above are the most commonly covered reconstructive surgeries.
These are procedures you might find in your current policy already without even knowing.
Medicare will even cover some of them if you don't have private health insurance.COMPARE & SAVE
Reconstructive surgery is one of the areas of private health insurance that needs a closer look.
Sure, you might have coverage for some reconstructive surgeries, but there are probably some hidden exclusions and restrictions you should be aware of.
Exclusions mean that your health fund won't cover particular procedures. Restrictions mean that they'll cover a portion of the cost, but leave the rest up to you.
It's important to know these things, so you aren't caught with a high bill you didn't expect.
Health funds may group all plastic surgery procedures into one category. You might see coverage for plastic surgery with some exclusions on cosmetic surgery.
This is normal, and will often still result in coverage for the necessary procedures we listed above.
You should take a closer look at the exclusions list, though, because it could cost you some money if you end up needing one of the procedures.
A health fund might only cover particular methods of the procedure but charge you if the doctor performs it in a different way.
There are several ways to complete some of these procedures, but your health fund might restrict a doctor to just one.
One way to avoid this confusion is by getting a clear picture from the fund on what's covered, and talking to your surgeon about the ins and outs of the procedure.
Another common way health funds provide limited coverage is through failing to pay for your hospital stay.
They might only pay for certain elements of the treatment rather than the whole thing.
You might be inclined to disregard coverage for plastic surgery to save money on premium payments.
Lower premiums are undoubtedly attractive, but they aren't the only factor to consider -- your level of cover matters, too.
Reconstructive surgery encompasses hundreds of procedures that you might need throughout the course of your life.
Unplanned accidents happen, and having cover through your health fund can be invaluable at these times.
If your current policy doesn't cover much in the way of reconstructive surgery, you can easily switch to one that does.
And it's a good idea to do this as soon as possible, because waiting periods may apply.
As we've discussed, changing your health fund won't always solve your problems.
You can compare health funds and switch at any stage, but there will be waiting periods for upgraded benefits.
Waiting periods for reconstructive surgery are generally around 12 months if there is a pre-existing condition, meaning you'll have to wait a year before you can make a claim for the reconstructive surgery.
Such policies protect health funds from policyholders who purchase or upgrade their health insurance right before they need a procedure.
If you need reconstructive surgery following an accident there are generally no waiting periods.
The good news is that once you've served a waiting period for hospital cover, you won't have to repeat waiting periods for the same level of benefits when you switch funds.
You should also stay up to date with all of the procedures that your health fund covers.
These procedures can change from year to year, so it's not as simple as making sure your health fund covers certain procedures when you first sign up.
Every year comes with some new policy changes, so stay informed about what your health fund covers.
If you encounter a surprise change to your health fund coverage, you can take a look at some competing offers through our comparison tool.
There are three options when it comes to choosing a health fund with reconstructive surgery in mind.
You can choose a policy with the top level of cover for reconstructive surgery, one with limited coverage, or one with no coverage.
Weigh up your options against your budget to decide what's the best fit for your situation.
It's a lot to think about, so it helps to shop around to see what's out there.
Our Melbourne-based team of insurance experts is always on hand to help explain the ins and outs of any cover you're considering, including cover for reconstructive surgery.COMPARE & SAVE
This guide is opinion only and should not be taken as medical or financial advice. Check with a financial professional before making any decisions.