Does health insurance cover cosmetic surgery?

Article was originally published by TJ Ryan on January 31, 2017.

Cosmetic surgery can be a costly exercise, so it’s worth finding out if you’re covered. Canstar investigates private health insurance cover for cosmetic surgery.

Does health insurance cover cosmetic surgery?

It depends on whether the cosmetic surgery is considered medically necessary to maintain your health. Breast prostheses implants after breast cancer removal surgery, skin grafts, or liposuction in the case of obesity or morbid obesity may be covered. However, elective cosmetic surgeries may only be partially covered or not covered at all.

Elective surgeries could include rhinoplasty (a nose job), breast augmentation or reduction or liposuction in non-medically necessary cases.

Some health conditions or treatment services may only be covered to a limited extent, so there is a gap payment between the fees charged and what the insurer will pay. In addition, private health insurance for cosmetic surgery may not cover everything. For example, it may cover the surgeon’s fees but not the surgery theatre fees.

In general, surgeries or treatments not on the Medicare Benefits Schedule (MBS) list are likely to not be covered by health insurance. This includes surgeries such as elective cosmetic surgery and surgeries or treatments that are not necessary to maintain your health.

Unfortunately, it is common for patients to think they may be covered for a treatment or procedure, but when they try to claim the costs with their health insurance provider they are told it is not covered. Terms and conditions may change at any time and so it’s a good idea to contact your health insurance provider to check what is covered, both before you are considering a treatment and before booking the surgery.

The table below features a snapshot of hospital & extras policies on Canstar’s database with links to providers’ websites, sorted by Star Rating (lowest-highest) then by provider name (alphabetically). Please note the results are based on a couple aged under 35 in NSW, with no pregnancy cover.

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Waiting periods with health insurance for cosmetic surgery

If your health insurance provider has advised you that a certain procedure or treatment is covered, ask them what waiting period applies. You may have to wait six months before booking the surgery to make sure that when you make a claim for the cost of the surgery, you are covered.

Best and worst cover for plastic surgery

does private health insurance cover cosmetic surgery

The AMA’s 2016 Report Card assessed private health insurance funds on how much benefit they provided towards the cost of 22 common surgeries. Below, we have summarised what the AMA report card says about which health funds provide the most benefits towards selected plastic surgeries in NSW specifically:

Surgery Name (MBS Item Number) Health Fund offering largest benefit Known Gap
Varicose Veins (32500) St.LukesHealth Within 10% of St.LukesHealth benefits schedule
Tonsil Removal (tonsillectomy) or Tonsils and Adenoids (41789) HBF Varies according to HBF known gap benefits schedule
Carpal Tunnel Release (39331) HBF Varies according to HBF known gap benefits schedule
Haemorrhoidectomy (surgical removal of internal haemorrhoids) (32139) AHSA Varies according to the AHSA access gap benefits schedule
Vasectomy (37623) St.LukesHealth Within 10% of St.LukesHealth benefits schedule
Basal Cell Carcinoma or Squamous Cell Carcinoma removal from nose, eyelid, lip, ear, digit or genitalia (skin cancer removal) (31255) AHSA Varies according to AHSA access gap benefits schedule
Breast, benign lesion surgical biopsy of excision (31500) BUPA Up to $500 per episode of care
Source: AMA 2016 Report Card

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