Cosmetic Surgeries and Private Health Insurance in Australia

Can Private Health Insurance Cover Some of the Costs of Plastic Surgery?

In Australia, private health insurance gives you access to private patient treatment in hospitals, and it also covers health care costs for procedures that don’t fall under Medicare, one good example being physiotherapy.

While these things often get complicated right at the first step, acquiring private health insurance is as simple as buying a policy from a registered entity in the country and continuing to pay for the regular premiums to stay covered at all times.

Depending on which policy you opt for, your insurer will pay for treatment in public hospitals as well as certain health services that Medicare doesn’t cover, including but not limited to dental, optical, and physiotherapy.

Users of private health insurance are often entitled to faster access to certain hospital services, although this only applies in fringe cases and will not prioritise you over a patient whose life is in danger. It’s important to add that even if you have private health insurance, you can still choose to be treated as a public patient in the hospital you’re assigned to.

In stark contrast to other insurance policies, private health insurance is community rated, rather than risk rated, meaning that everyone pays the same premium for a particular policy and that the insurer cannot refuse to sell the said policy.

Even though the majority of health procedures are covered by Medicare in Australia, certain health services are still not included and it’s exactly why more people are opting for private insurers. Additionally, you’re always guaranteed to have the right to renew your policy, so long as you are able to pay for it, and if you wish to avoid paying for the higher premiums, you should look into taking out a hospital cover before turning 31.

This will make you eligible for the Lifetime Health Cover Government initiative, which was put in place to help adults remain insured for the rest of their lives.

Is Cosmetic Surgery Covered by My Private Insurance?

However, not every visit to the hospital is strictly health-related, and cosmetic surgery has grown in popularity in the past years, with the most common procedures being:

When it comes to nonsurgical interventions, different procedures from anti-wrinkles injections to nonsurgical fat removal are popular nowadays.

The Cosmetic Physicians College of Australasia attributes this spike to the effects of the COVID-19 pandemic, aptly naming it the “Zoom Boom” in demand for cosmetic surgeries, the theory is that increased exposure to our own face on zoom may have helped many cast a critical eye on themselves.

With all that attention shifted towards our facial and body features, it’s no surprise that we’re all considering how we’d look with a tummy tuck or without some of the wrinkles, prompting the phenomenon to be known as “Lockdown Face” across the globe.

Unfortunately, cosmetic surgery, one undertaken solely for the purpose of altering one’s appearance is highly unlikely to be covered by your private health insurer, according to the Commonwealth Ombudsman.

This also applies to Medicare, although Medicare does cover some or all of the costs of reconstructive surgery, meaning that if you’re looking for cosmetic surgery, chances are you’ll be paying out-of-pocket, or if you’re lucky enough to come to an agreement with your private insurer, they’ll cover some of the surgery costs.

This usually applies in cases when altering one’s appearance is deemed to be necessary for one’s health, and if you’re not already claiming it on Medicare, your private health insurer will partake in paying for the surgery costs.

More often than not, the procedures that fall under this include burn surgeries, tumour removals, and plastic surgeries following traumatic injuries, and even if your insurer does approve your claim, prepare for some significant out-of-pocket costs.

Plastic Surgery and Medicare Cover

Some examples of reconstructive surgery that IS covered by Medicare include:

Repairs of congenital abnormalities (nasal deformation, cleft lip)
Reversing the damage of traumatic injuries to an extent
Skin grafts for burn victims
Scar repair
Skin flap and breast reconstruction in the case of tumour removal

Every single one of these procedures has an item number in the Benefits Schedule and will be covered by Medicare and most private health insurers, although some of them will require you to meet a specific criterion if you wish to receive surgery.

On the other hand, if a procedure doesn’t have a number in the Medicare Benefits Schedule, chances are that it won’t be covered by any private health funds either unless an agreement is made between the policy buyer and the insurer.

Even if you do have access to coverage for certain reconstructive procedures, there are always some exclusions and restrictions that hide in the fine print, and looking into them on time is crucial if you don’t wish to be paying for any unnecessary costs.

Certain private health funds have exclusions for particular reconstructive procedures, and they won’t cover any of the costs for them, whereas those that are restricted won’t be covered in full and you’ll be forced to cover the rest.

Being aware of your insurer’s restrictions can help you avoid an unnecessarily high bill that you won’t see coming, and that’s not the position you want to be putting yourself in.

It’s entirely up to you whether you want to be able to claim cosmetic procedures on your private health insurance policy or not, but before you make that decision, you must first understand the different levels of coverage that insurers provide.

In general, hospital policy tends to fall into one of these three categories:

A comprehensive policy that fully covers reconstructive plastic surgery
A mid-tier policy that offers limited or restricted coverage for plastic surgery
A low-tier policy that doesn’t provide cover for reconstructive procedures

Each of these levels of coverage has its own pros and cons, and weighing them up is crucial to deciding your approach to said procedure, one example being that opting for a comprehensive policy does provide you with coverage for any medically-necessary procedure, with the downside being the higher premiums you’ll be paying.

On the other hand, if you take out a lower level of cover, you’ll be able to pay less on your premiums, but in the case of cosmetic procedures, you’ll be risking having to pay for them out-of-pocket.

Out-of-Pocket Costs You Should Expect

There’s a common misconception that “fully covered” means that there will be no out-of-pocket costs for the surgery, and this being categorically untrue is why plastic surgery patients are often confused with how insurance works.

There are always incidental expenses such as post-surgery garments, antibiotics, and other medicine that you’re given, and these can and will stack up to quite a sizeable amount that you surely won’t be expecting.

Moreover, being “fully covered” means that Medicare or your private health insurer will cover the recommended Government Fee, which tends to fall short of what private practices usually charge for cosmetic surgeries.

If a surgery costs $10k, you’re likely to be rebated anywhere between $2k and $3k, leaving you the rest to pay out of your own pocket, and that’s if your insurance policy was even applicable to the procedure in question.

FAQs about Cosmetic Procedures and Private Health Insurance

How do I know whether my cosmetic surgery will be covered by my private health insurance?

If the procedure’s number is in the Medicare Benefits Schedule, your insurance provider will cover it.

How many levels of coverage does my private insurance fund provide?

Private Health Insurance provides up to 3 levels of coverage, ranging from comprehensive to low-tier.

What will my out-of-pocket costs be?

You may end up paying for up to 80% of the hospital costs yourself.