Can you claim Cosmetic Surgery on your Private Health Insurance?

By Guest Blogger, Richard Laycock, Insurance Expert at finder.com.au.

Cosmetic Surgery is becoming increasingly popular among Australians and with so much interest in these kinds of procedures, many people are rightly asking, “Will this be covered by Medicare or my Private Health Insurance?”

The answer is not quite as simple as a “yes” or a “no”. Instead, it’s a “sometimes”. Whether or not your private health insurance will cover you will depend on a couple of factors.

First and foremost, you will need your doctor to tell you if there is a Medicare Item Number for the procedure you’re contemplating:

  • If there’s no Medicare Item Number for it, no Private Health Insurance will apply.
  • If there is a Medicare Item Number, and you satisfy the criteria to be eligible for it, the next step is to ask your Private Health Insurance if they’ll contribute towards the cost and if so, how much.
  • And, if your Medicare-eligible procedure is to be done in a hospital, does your Private Health Fund have a contract with the hospital in question.

These are the questions you need to ask to determine if and how much your Private Health Insurance will pay.

As a general rule:

“If the treatment is medically required and has a Medicare Benefit Schedule (MBS) number, your Fund will pay a benefit towards your cosmetic surgery.”

The key term here is “medically required”. Your private health insurance won’t cover you for elective cosmetic surgery. However, if you can prove that the procedure is medically necessary, then you can claim cosmetic surgery on your Private Health Insurance.

Procedures that you can often claim for include:

  • Surgeries to remedy congenital abnormalities such as a cleft palate
  • Surgeries, such as a skin graft, to remedy a serious burn
  • Facial reconstructive surgeries following traumatic events
  • Breast reconstruction following a mastectomy
  • Breast revision surgery for implant complications
  • Restorative procedures to treat scarred skin

What are your options for Private Health Insurance that covers cosmetic procedures?

Whether or not you want to be able to claim for cosmetic procedures on your private health insurance policy is up to you, but it’s good to understand the different levels of cover available.

Generally, your hospital policy will fall into one of three categories:

  • It will be a comprehensive hospital policy that covers reconstructive plastic surgery
  • It will be a mid-tier policy that offers limited or restricted cover for reconstructive plastic surgery
  • It will be low-tier policy that excludes cover for reconstructive plastic surgery

You should weigh up the pros and cons of each level of cover. For example, taking out a comprehensive policy will provide you with cover for medically-necessary procedures but the premiums will be higher.

If you take out a lower level of cover, you will be paying less on your premiums but you risk having to pay out-of-pocket for cosmetic procedures.

At the end of the day, it’s up to you what level of cover you take out, and you’ll need a medical specialist to advise you on whether or not you’ll be eligible for cover. But sometimes, it’s nice to have the peace of mind.

Richard Laycock is an Insurance Expert at finder.com.au.

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