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Last Updated on 17 November 2018

Will Private Health Insurance Cover My Cosmetic Surgery?


Thinking of undergoing cosmetic surgery? You may be wondering whether you’ll receive any assistance from your health insurance provider. This depends on your insurance policy (or plan), and the purpose for your surgery.

Your answer will largely depend on whether you are undergoing surgery for cosmetic or reconstructive purposes.

Key Points
  • When determining whether cosmetic surgery is covered under your private health insurance policy, ask yourself whether the surgery is essential (medically necessary) or elective. Also check with your health insurer to determine whether it is listed as a surgery they cover.
  • The type of surgery you need will also impact on the available assistance from your health insurer. Is your surgery cosmetic or medically necessary.
  • Even though a policy states it covers ‘reconstructive surgeries’, this does not mean it covers every type. Always double check your policy covers the specific surgery you want/need, and if it doesn’t, consider making the switch.

Thinking of undergoing cosmetic surgery? You may be wondering whether you’ll receive financial assistance from your health insurer. This depends on your insurance policy (or plan), and the purpose for your surgery.

Your answer will largely depend on whether your surgery is cosmetic or medically necessary.

Cosmetic vs. Medically Necessary

In most cases, cosmetic surgery is not needed to improve health or maintain the body’s normal functioning. Patients will elect to have the surgery done – it is an option rather than a necessity.

A patient may feel unhappy with a particular feature of their appearance and wish to change this via surgical intervention. The end goal is to improve a patient’s self-esteem and/or subjective appearance.

Medically necessary surgery, on the other hand, may be required to maintain a patient’s health and/or normal functioning. Medically necessary surgery may also seek to preserve or improve a patient’s quality of life through ‘fixing’ abnormal structures.

Abnormal bodily structures requiring say, reconstructive surgery may be caused by one of the following factors:

  • Trauma or disease
  • Infections
  • Developmental abnormalities

Key Differences Between Cosmetic and Reconstructive Surgery

Difference Between Cosmetic and Reconstructive Surgery

Cosmetic Surgeries Covered By Insurance

Your surgeon will determine if your surgery is purely cosmetic or if it is medically necessary

For this reason, it’s always best to check with your surgeon and your health fund to determine whether financial assistance will be available for your procedure. If you are currently shopping around for a policy, and have cosmetic or reconstructive surgery in mind, it’s a good idea to check your policy has the inclusions you are after.

Surgeries that may be covered by Medicare and private health insurance include:

  • Skin grafting
  • Cleft lip palate
  • Eyelid lift
  • Breast reduction
  • Breast reconstruction
  • Repair of facial bone structures
  • Abdominoplasty (tummy tuck)

What Surgeries Are Not Likely to Be Covered?

If your surgery is elective rather than medically necessary, it is not likely to be covered by Medicare orr health insurance. Some of these procedures include:

  • Rhinoplasty (nose job)
  • Botox/fillers
  • Breast augmentation
  • Liposuction
  • Face lift

Exceptions to the Rule

There are exceptions to nearly everything in life, and that includes cosmetic surgery.

For example, consider the following case:

Elise gets a nose job as she has a deviated septum, causing difficulty in her breathing, sleeping and ability to exercise. Her doctor has advised her health fund that having the surgery carried out will improve Elise’s breathing and quality of life. After having the surgery done, Elise will be able to sleep and exercise more comfortably. Even though Elise’s nose shape may change, thereby altering her physical appearance, the primary goal of the surgery is to correct Elise’s breathing. Therefore, the surgery is classified as reconstructive, rather than cosmetic.

In some circumstances, breast reductions may also be necessary in order to reduce back pain and improve quality of life. In these cases, your health fund may cover the surgery in part or full.

Restrictions and Exclusions

It’s important to note that not all medically necessary surgeries are covered by your private health insurer. That’s why it’s important to check your policy restrictions and exclusions before you purchase a policy.

If you have a policy that does not cover the surgery you need, you may want to shop around for a new one and compare current policies out there. Keep in mind that even if a policy claims to cover reconstructive procedures, some specific surgeries may be excluded. If you are unsure, contact the health fund to find out more.

If you do switch policies, you may have to reserve waiting periods before you are able to make a claim and have your surgery performed.

Frequently Asked Questions About Health Insurance

There are three types of health insurance in Australia. They are:

  • Hospital Cover
  • Extras Cover (also known as general or ancillary cover)
  • Ambulance Cover

Hospital cover can ensure any unexpected surgeries, treatments or hospital stays you may require will be covered. With appropriate cover you will have the flexibility to choose your own doctor and the option of receiving treatment in a private hospital.  Most hospital covers allow you to stay in a private room. One other perk is skipping the public hospital systems’ waiting list, which can be lengthy for non emergency treatment.

Extras cover pays benefits for a a range of services, often including treatments and procedures related to the fullowing:

  • Dental/oral health
  • Glasses and contact lenses
  • Podiatry
  • Physiotherapy
  • Psychulogy
  • Acupuncture
  • Remedial massage
  • Chiropractic
  • Hearing aids
  • Travel vaccinations

Ambulance cover, as the name suggests, will cover you should you require emergency ambulance transport. In an emergency, there is enough to worry about. Having the expenses covered for provides security and peace of mind. Many hospital covers include emergency ambulance transport If yours doesn’t, you will need to shop for this separately.

Life is unpredictable. You never know when you might need cover. No matter what life stage you’re in, there’s a policy out there for everyone. You can select as much or as little cover as you want, depending on your health needs and requirements. It’s a small price to pay for the peace of mind health cover provides.

There is no one answer here. Costs vary across providers and policy types. Just because a policy is cheap, that does not mean it is ‘value for money’ and vise versa. Make sure you check what’s included and excluded in a policy before signing up, as you want to purchase a policy that best fits your specific needs.

Premium: A premium is the price you pay for your insurance policy (it may be paid annually or on an ongoing basis).

Policy: An insurance plan. In other words, it is the type of insurance you choose to select.

Policy Holder: The owner, or ‘holder’ of a policy.

Claim: In the event that you require treatment for a service covered by your policy, you can lodge a claim for reimbursement of all or part of the cost of that treatment.. These days, most claims are submitted electronically by the health care provider (dentist, physio etc)

Lifetime Health Cover: Lifetime Health Cover was put in place to encourage young Australians to seek out and maintain ownership of private health insurance early in their lives. If you do not take out a policy before you turn 31, extra charges will be applied should you take out a policy at a later time.

This means you will pay a 2% loading on top of your premium for every year that passes after you turn 30. For example, if you take out a policy for the first time at age 32, you will be charged 4% of your premium as an extra, then at age 40, 20% and so on, up to a maximum loading of 70%.

The loading is payable for 10 consecutive years of cover - after which it is removed and you premiums will be reduced.

Pharmaceutical Benefits Scheme (PBS): Medicare offers assistance for Australians with many of their their prescribed medication costs through the PBS. This assistance is in the form of subsidies towards the cost of many medications. You can check if your prescribed medication is on the list of subsidised items here.

Medicare Levy Surcharge: The Medicare Levy Surcharge is an additional charge (tax) applied to single Australian taxpayers who earn over the income threshold of $90,000 per year, or families/couples who earn over $180,000 per year. This surcharge is only applied to those who choose not to have a private health insurance policy.

The surcharge is designed to reduce pressure on the public health system by encouraging those with higher incomes to invest in private health cover.

Private Health Insurance Rebate: The government’s Private Health Insurance rebate lowers premiums for most Australians with private health insurance Older Australians may enjoy an even higher rebate. Our calculator can help you estimate the Government health insurance rebate you may receive.

Disclaimer: The above information is correct and current at the time of publication


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