Last Updated on 13 February 2020

Private Health Insurance for Reconstructive Surgery

Do you, or one of your loved ones, need reconstructive surgery? Have you considered how your health insurance may help with the costs? Here are some basic points to think about.

What is Reconstructive Surgery?

Reconstructive surgery is a specialized medical field that serves to correct physical function and appearance that has been deformed due to congenital abnormalities, disease, injury or infection. While it is typically performed to improve normal function for the patient, it can also be undertaken to provide for a more normal appearance. It is a subset of plastic surgery.

While cosmetic surgery, which is only done to enhance natural appearances, is generally not covered by health insurance policies, reconstructive surgery cover may be offered. However, not all procedures and components are covered, and every private health insurance policy is different.

Reconstructive Surgery Cover

These are some of the surgical procedures that may be covered in your policy:

  • Surgeries on congenital abnormalities. These are abnormal physical defects that developed in utero. Examples are cleft palates or cleft lips and nasal deformities, all of which can cause breathing problems.
  • Surgery to correct the soft tissues and appearance after burns. These procedures could involve skin grafting as well as cosmetic adjustments and skin tightening.
  • Surgery to mend traumatic injuries. For example, resetting bone fractures in the face or other places in the body.
  • Surgery to repair soft tissues after a surgery to remove a tumour, such as breast reconstruction after a mastectomy. This can also include skin grafts needed to replace skin in areas where a tumour was removed.
  • Surgeries to repair injured skin for example after suffering lacerations or detrimental scarring.

Other factors

Many private health funds cover reconstructive surgery as a field but have major exclusions or restrictions. An exclusion means that an entire procedure may be left out of coverage and you will not be covered or reimbursed for any part of it. A restriction means that the coverage only extends to a specified limit or type of treatment, or only if performed in a particular way. An example of a restriction would be that a procedure is covered, but the hospital stay is only fully covered as a private patient in a public hospital.

Even if your health fund covers the full cost of treatment, or part of the treatment for your basic procedure, it may not cover other services such as a hospital stay. You may also be required to pay an excess to cover the initial treatment as laid out by your policy. A private health insurance comparison will help you get some clarity about what may work best for you and your family.

If your policy does not cover reconstructive surgery at all, that means that it does not offer benefits for sixteen hundred listed treatments that may not affect you now, but could become necessary at various points in your life. The average Australian does not require any reconstructive surgery, but it is also not uncommon and can become necessary for anyone at any point in time.

Another factor to consider is that health plans cannot be changed simply in a moment. Although you can change your policy fairly easily, there are usually waiting periods of up to twelve months before you can access certain parts of your plan, depending on when you registered for them.

If you need reconstructive surgery and subsequently discover that your required procedure is not covered under your current policy, you may need to wait for the predetermined period of time before having the surgery performed, or elect to pay completely out of pocket.

While rechecking your policy annually can ensure that you know what benefits your insurance covers, it makes sense to check it at least whenever there are expected to be significant changes in your life, such as before a marriage or birth.

Depending on the cost stated by your private health insurer, you may decide to extend coverage to these procedures given the possibility that they may become necessary at any time, and as surgical procedures, can be quite costly if it becomes necessary to pay for them out of pocket. When you compare private health insurance, keep all of this in mind.


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