Prosthetic leg

Health Insurance for Prostheses

Does health insurance cover prostheses? Compare cover options from Australian funds. 

Private health insurance provides cover for an extensive range of medical procedures and conditions, including prosthetics. If you’re undergoing surgery to have a prosthesis implanted or applied, and if you have private health insurance with the necessary cover, you can receive some much-needed financial assistance.

However, there are certain terms and conditions that need to be met in order to receive health insurance cover for prostheses, so read on for more details.

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Rates last updated October 21st, 2016
Details Features
Premium hospital cover with complete cover for hospital expenses. Save 4% when you pay for 12 months of your cover upfront.
  • All theatre fees covered
  • Unlimited maternity cover
  • Choose no excess or $200, $400, $500 per admission
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Basic Hospital ($500 excess) & Premium Extras
Basic Hospital ($500 excess) & Premium Extras
$100 gift card for all new members and discount on extras cover when taken out in combination with a hospital.
  • No excess for dependents under 21
  • Excess halved for day surgery
  • 100% back on emergency ambulance transport
  • Optical and dental covered
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High 65 / 75 / 85% - $0/$250/$500 Excess
High 65 / 75 / 85% - $0/$250/$500 Excess
Combines High Hospital Cover with its highest level of extras cover.
  • Cover starting from $44.74 weekly
  • 12 month waiting period for pregnancy
  • 65% back on extras
  • Choice of $0, $250 and $500 excess
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Deluxe flexi
Deluxe flexi
Deluxe flexi provides cover for a range of treatments including hip replacement, spinal fusion, dialysis and major eye surgery.
  • No excess for kids
  • All joint replacements
  • Major eye surgery
  • Rehabilitation
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Smart Combination
Smart Combination
Smart combination provides a high level of cover for both hospital and extras.
  • Claim up to $2725 back on extras
  • Hip and knee replacements
  • General and major dental
  • Physio
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Highest level of combined cover offered by CBHS. Includes the same benefits as Comprehensive Hospital and Top Extras plus more. Restricted fund: Only current or former staff (and their families) of Commonwealth Bank Group and their subsidiaries which include Aussie, Bankwest, Colonial First State and more can join.
  • No excess or co-payments on hospital cover
  • Non-student dependent under 25 can be kept on policy
  • Access to Chronic Disease Management Programs
  • Widest range of extras including orthodontics
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Bronze Hospital (no pregnancy) and Bronze Extras Set Benefits
Bronze Hospital (no pregnancy) and Bronze Extras Set Benefits
High level of hospital cover and extras cover for a range of popular services including knee and should reconstructions.
  • Most comprehensive hospital options
  • Cover for general and major dental
  • Shared or single room in a private hospital
  • Intensive and coronary care
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Premium Hospital and Silver Extras Cover
Premium Hospital and Silver Extras Cover
Comprehensive hospital cover including pregnancy cover. Also included affordable mid-level extras cover for dental, optical and therapies.
  • Cover from $39.50 per week
  • Pregnancy and birth-related services cover
  • Heart surgery cover
  • 100% cash back on two dental check per year
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Top Hospital with Top Extras
Top Hospital with Top Extras
Get comprehensive hospital and extras cover and tailor your policy to your needs.
  • Pregnancy and birth services cover
  • Back surgery cover
  • $1000 general dental annual limit
  • $600 physiotherapy annual limit
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Young Couples Combined Cover
Young Couples Combined Cover
Mid-level hospital and basic level Extras package with an excess for young, healthy couples that are not quite ready to start a family.
  • Emergency ambulance cover
  • Cancer-related surgery cover
  • 70% back on extras
  • $300 dental annual limit per person
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Private health insurance and prostheses

As soon as you find out that you will be undergoing surgery to apply or implant a prosthesis, get in touch with your private health insurer. You’ll need to check with your fund to find out whether you will be covered for the cost of the surgery.

Certain treatments such as joint replacement therapy are commonly restricted or excluded on many policies, so it’s worth reading the fine print of your policy documents and contacting the insurer directly if you have any questions. If your surgery is excluded, you won’t receive any cover. If restricted cover is available, you’ll receive a private health insurance benefit for the prosthesis but you may only receive limited cover for other aspects of your treatment and for your stay in hospital.

It’s also essential that you consult with your treating doctor and find out whether the prosthesis you will receive is included on the Prostheses List. If it’s not, check with your doctor to see if there is a prosthesis included on the list that may be able to be used.

Next, check with the hospital for details about the cost of the procedure, the cost of your hospital accommodation and any other out-of-pocket expenses you may have. You can then compare the costs with the benefits available from your policy and work out how much will be covered by your insurer and how much you will have to pay.

What is the Prostheses List?

The Prostheses List is a list of more than 10,000 surgically implanted prostheses, human tissue items and other medical devices. Private health insurers must pay a benefit for the items on the list when they are provided to a patient with the appropriate private health insurance cover in place, and the Prostheses List details the minimum benefit amount payable for each individual item.

The list is updated twice each year and under Australian law, private health insurers must pay at least the minimum benefit listed for each item.

What items are on the Prostheses List?

The types of surgically implanted prostheses, human tissue items and other medical devices on the Prostheses List are broken up into several cover areas including:

  • Cardiac
  • Cardiothoracic
  • Ear, nose and throat
  • General/miscellaneous products (prostheses not included in other categories)
  • Hip
  • Knee
  • Neurosurgical
  • Ophthalmic
  • Plastic and reconstructive
  • Specialist orthopaedic
  • Spinal
  • Urogenital
  • Vascular

The latest version of the Prostheses List is available from the Department of Health website.

Do Australian health funds provide health insurance for prostheses?

FundProstheses conditionsMore info about fund
  • Except for excluded services, ahm will cover you up to the minimum benefit listed on the Government’s Prostheses List.
  • Australian Unity will cover 100% of the minimum cost for government approved surgically implanted items. Non-admitted prosthesis requests are subject to prior application and approval.
  • If you're planning on claiming for appliances, blood glucose monitor, extremity pump, GMHBA approved orthopaedic appliances, nebuliser pump,non surgical prostheses,  pressure garments, sleep apnoea monitor or tens monitor, you'll require a doctor’s letter of recommendation.
  • Government approved, non-cosmetic prostheses that have been surgically implanted are covered by your HCF hospital product.
  •  Government approved prosthetic devices.
Transport Health
  • Government approved, non-cosmetic prostheses that have been surgically implanted are covered by the fund.

What isn’t listed on the Prostheses List?

Each item must satisfy a range of criteria in order to be included on the list, such as being entered on the Australian Register of Therapeutic Goods. Items such as external limb prostheses, external breast prostheses and implants used solely for cosmetic purposes are not included on the Prostheses List.

Out-of-pocket expense for a prosthesis

Whether or not you will have any out-of-pocket expenses will depend on the level of private health cover you have and the prosthesis you receive. If the minimum benefit outlined on the Prostheses List covers the cost of the procedure to the hospital, you won’t have to pay for any expenses out of your own pocket.

But if the minimum benefit isn’t enough to cover the full cost of the prosthesis to the hospital, you might need to cover all or a portion of the ‘gap’ between the minimum benefit payable and the total cost of the prosthesis - this will depend on the hospital where the procedure is performed.

What do I do if my insurer won’t pay?

If your private health insurer refuses your claim for a prosthesis, you are well within your rights to ask for an explanation why. If your claim was refused because the surgically implanted prosthesis, human tissue item or medical device you received was not included on the Prostheses List, the insurer is not required by law to pay a benefit.

However, you could ask the insurer to pay the claim on an ex gratia basis (out of kindness rather than due to any legal requirement), although this is entirely up to their discretion.

Are there no-gap options for prothesis?

A no-gap prosthesis is an item included in the Prostheses List that has no maximum benefit listed. Instead, only a minimum benefit is listed, meaning that patients will not have to cover any out-of-pocket expenses when they have surgery to apply or implant this prosthesis.

Private health insurers are required by Australian law to pay this benefit. There is generally at least one no-gap prosthesis option available for each Medicare Benefit Schedule item.

Compare your cover options with the aid of an adviser

If you need to undergo surgery to receive a prosthesis, make sure you check to see if the device you will receive is included on the Prostheses List, and whether cover is provided by your private health insurance. With the right cover in place, you can receive much-needed financial assistance to cover the cost of your important medical procedure.

Compare your health insurance options today

Picture: Shutterstock

Richard Laycock

Richard is the senior insurance writer at and is on a mission to make insurance easier to understand.

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