Looking for health insurance that will cover plastic surgery? Know your options first.
When you hear the words plastic surgery, most people start thinking about nose jobs, breast enhancements and tummy tucks. But plastic and reconstructive surgery can actually cover many essential medical procedures, from repairing cleft palates to reconstructive surgery following traumatic injuries and severe burns.
While many plastic and reconstructive surgery procedures are covered by Medicare and private health funds, some procedures are not.
How is plastic and reconstructive surgery defined?
Reconstructive plastic surgery is performed to correct abnormalities, whether they are congenital or acquired, and repair damage as a result of trauma. Reconstructive plastic surgery usually refers to essential medical procedures rather than elective ones, and many procedures are covered by Medicare and Australian health funds.
Reconstructive plastic surgery is different to cosmetic plastic surgery, which is typically carried out to improve appearance and refers to elective procedures.
Which health funds cover medically necessary plastic surgery?
| Health fund | Which funds cover cosmetic and plastic surgery? | Find out more |
|---|---|---|
 | Benefits for cosmetic surgery are only payable if it is for a medical purpose and if it's a treatment for which Medicare benefits are payable. | More info |
 | Depending on your level of hospital cover you may have exclusions or limited cover for cosmetic surgery when not deemed medically necessary. | More info |
 | Depending on your level of hospital cover you may have exclusions or limited cover for cosmetic surgery when not deemed medically necessary. | More info |
 | Benefits are only payable for cosmetic surgery or services when it is required for medical purposes and if the surgery or service has a Medicare benefit attached. | More info |
| Health fund | Which funds cover cosmetic and plastic surgery? | Find out more |
|---|---|---|
| Bupa | Depending on your level of hospital cover, you may be able to receive a benefit for this type of treatment if it's deemed medically necessary. | More info |
 | CDH Gold Hospital policy will cover cosmetic surgery only if it is a procedure for which Medicare pays a benefit. | More info |
 | While elective cosmetic surgery is completely excluded, you may be able to receive a benefit if the treatment is medically required. | More info |
 | If the treatment is medically required and has a Medicare Benefit Schedule number, GMF will pay a benefit towards cosmetic surgery such as rhinoplasty. | More info |
 | Medibank Top Hospital and Overseas Student Health Cover policies include a benefit for medically required plastic surgery. | More info |
 | Peoplecare Mid and Premium Hospital policies cover plastic surgery providing the treatment or service has an attached Medicare Benefits Schedule number. | More info |
 | Cosmetic surgery and related services that Medicare pays a benefit towards may be covered. | More info |
 | Medically required plastic surgery is covered by Queensland Country Health Fund hospital policies. Please note that if you are covered by its public hospital policy and are an inpatient in a private hospital or day surgery you will only be eligible for a minimum benefit for accommodation costs. | More info |
 Restricted fund* | Although not included in any of ACA's covers, under exceptional circumstances you may be able to receive a benefit for cosmetic surgery. This requires the procedure to have prior approval from the fund committee and be recommended by a Registered Medical Practitioner. | More info |
 Restricted fund* | Benefits for plastic surgery and related services will only be paid if they are also eligible for Medicare benefits. If chosen for cosmetic reasons only a minimum benefit to cover accommodation will be paid. | More info |
 Restricted fund* | Some benefits may be paid for hospital treatments required following cosmetic surgery. Police Health Fund requires you to contact them directly to see if you will be covered. | More info |
 Restricted fund* | Some plastic surgery procedures will be covered providing they are deemed medically necessary and have a Medicare Benefits Schedule number. | More info |
 Restricted fund* | Provides restricted cover for plastic surgery. The procedure must be medically required and have an attached Medicare Benefit Schedule number. | More info |
*Restricted funds only provide cover to members of specific industries, groups and organisations. In some cases family members may also be eligible to join.
What is generally covered by private health insurance?
If you need to undergo reconstructive plastic surgery, you may be able to receive cover for the following types of procedures from Medicare and your health fund:
- Surgeries on congenital abnormalities. A congenital abnormality is a condition that exists at or before birth, such as a cleft palate or a nasal deformity that results in breathing difficulties.
- Surgeries following burns. Skin grafts, reduction of skin tightening and treatment of scarring are all covered.
- Surgeries following traumatic injuries. For example, facial bone fractures that need to be repaired or reset.
- Surgeries following the removal of cancers or tumours. Some common examples of covered procedures include breast reconstruction following a mastectomy, and skin grafts following the removal of a tumour.
- Surgeries to repair scars. This refers to procedures to repair skin injured by lacerations or scarring.
Health Insurance Reforms coming April 2019
As part of the reforms to the Australian health insurance system, we will see hospital policies placed in four categories: gold, silver, bronze and basic.Each of these tiers includes cover for a minimum number of clinical categories. If you wish to continue to claim benefits for cosmetic surgery, you will need a policy of Bronze tier or higher. Keep in mind that this will only cover medically necessary cosmetic surgery, such as breast implants following a mastectomy or required skin grafts.
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How can restrictions and exclusions affect you?
Some health funds will provide full cover for all costs associated with your hospital admission for reconstructive plastic surgery, although you may have to pay an excess or co-payment as part of your policy arrangement. However, other policies will restrict or exclude certain services in return for offering lower premiums, so this may affect the level of cover available to you.
Exclusions refer to services that are not covered at all by your health insurance, while restricted services are those for which you will receive only a limited benefit. If restrictions or exclusions apply to the reconstructive plastic surgery cover offered by your private health insurance policy, there are more than 1,600 procedures listed on the Medicare schedule for which you will not be able to receive full coverage.
Don’t be so quick to exclude plastic surgery cover from your policy
While you may wish to exclude or restrict your plastic surgery coverage in order to save on premiums, remember that it’s impossible to predict what the future holds and what sort of medical treatment you may require. If reconstructive plastic surgery is excluded from your cover, you may have to pay significant out-of-pocket costs if you require an excluded service. And even if you have restricted cover in place, this may only cover the treatment itself and no other expenses, so you may be left with sizeable bills to cover the cost of your hospital accommodation.
What are your options?
Your options when it comes to private health insurance for plastic and reconstructive surgery are simple. You can:
- Choose a comprehensive policy that covers reconstructive plastic surgery
- Choose a policy that offers restricted cover for reconstructive plastic surgery and pay lower premiums
- Choose a policy that excludes reconstructive plastic surgery altogether
The option you choose is entirely up to you, but be aware that not having any cover in place could lead to significant out-of-pocket expenses if you require plastic reconstructive surgery. Consult your health fund for further details about the type and level of cover it offers.
It’s vital that you fully understand your options when it comes to private health insurance and plastic surgery. Consider your cover needs and discuss the policies available with your health fund before deciding on the right policy for you.
Picture: Shutterstock
Query: re:Breast reduction surgery when medically needed for health reasons, how does this work regarding costs? I have HAD hospital cover?
Hi Karren,
Thank you for your comment.
Generally, health insurance covers surgical and accommodation costs under the hospital cover policy if the breast reduction surgery is medically necessary and not only for cosmetic purposes. You may learn more on how health funds work with breast reduction surgery if you check our guide here. To compare the policies, you may fill out the form on the page provided and click Search Policies button. Once done, you’ll see the quotes from different health insurance providers with the list of detailed benefits.
Please make sure to read the eligibility criteria, features and details of the policy, as well as the relevant Product Disclosure Statement PDS/T&C’s of the policy before making a decision and consider whether the product is right for you. If necessary, speak to the insurance brand to verify any details.
Regards,
Jhezelyn