What are the waiting periods for prostheses cover?

Standard private health insurance waiting periods apply for treatments involving prostheses. Generally, you will need to serve a 2 month waiting period for most hospital treatments or 12 months for pre-existing conditions. For more complex treatments such as joint replacements or cataract surgery, the waiting period is typically 12 months. Always check with your health fund for the specific waiting periods that apply to your policy and planned treatment.

Does private health insurance cover external prostheses?

Generally, private health insurance hospital cover primarily focuses on surgically implanted prostheses that are listed on the Australian government's Prostheses List. External prostheses, such as artificial limbs not surgically attached, may be covered under certain extras policies or through other government schemes like Medicare or the NDIS, depending on your circumstances. It is important to review your extras policy for specific benefits related to external medical appliances or ask your health fund directly.

What if my prosthesis needs replacing or repairing?

If a surgically implanted prosthesis needs replacing or repairing due to malfunction, wear and tear or a change in your medical condition, your private health insurance will typically cover the cost if the original implant was also covered under your policy and the replacement device is on the Prostheses List. Standard waiting periods may apply if the replacement is for a new condition or if you have recently upgraded your cover.

Are dental prostheses covered by private health insurance?

Dental prostheses, such as crowns bridges or dentures, are generally not covered under hospital policies. Instead, they are typically covered under extras health insurance policies that include major dental benefits. The level of cover for dental prostheses can vary significantly between different extras policies so it is important to check your policy's limits and exclusions.

How do I make a claim for a prosthesis?

To make a claim for a prosthesis, your doctor will generally submit the hospital admission and treatment details directly to your health fund and Medicare. Ensure your doctor uses a device from the Prostheses List for covered treatments. Any out-of-pocket expenses or gaps will be clearly outlined to you before your procedure. For external prostheses or specific consultations, you may need to submit an itemised receipt or doctor's letter to your health fund.

Does health insurance cover consultations with a prosthetist?

Consultations with a prosthetist for the assessment, fitting or adjustment of a prosthesis may be covered depending on your health insurance policy. If the consultation is part of a hospital admission for a surgically implanted device, it might be included in your hospital cover. For external prostheses, some extras policies may offer benefits for allied health services or medical appliances that could include prosthetist consultations.

Can I get cover for a prosthesis if it relates to a pre-existing condition?

Yes, you can get cover for a prosthesis related to a pre-existing condition but you will need to serve a 12 month waiting period before your health insurance benefits become active. A pre-existing condition is generally defined as an illness, ailment or condition that you had signs or symptoms of in the six months before taking out or upgrading your hospital cover, regardless of whether you or a doctor knew about it.