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Is plastic surgery covered by your health insurance?

18 August 2016 - 11:32am

Plastic surgery is not, contrary to popular belief, solely about cosmetic surgery. Tummy tucks, face lifts, nose jobs - these are certainly covered under the umbrella of plastic surgery, but surgeries that correct congenital abnormalities, burns, or traumatic injuries are also considered a part of plastic or reconstructive surgery. This could be to retain or create a more regular appearance for the person involved, but is also often performed in order to improve function as well.

Cosmetic surgery, as the Private Health Insurance Ombudsman (PHIO) puts it, is "only one aspect of plastic surgery", but the differences aren't quite so clear cut. What is considered reconstructive surgery by one party may be considered cosmetic or elective surgery by another. That becomes particularly important when considering your health insurance and what precisely you want to be covered for.

What you think of as necessary under Medicare may, in fact, be defined as cosmetic, and must be performed through the private system. 

Are your needs during pregnancy covered by your private health insurance?Are your needs during pregnancy covered by your private health insurance?

It's not always clear-cut

Take the recent example of Kimberlee King. Mrs King, following the birth of triplets, reported that she was in severe pain due to her torn stomach muscles. This is not an uncommon complication with postnatal recovery, and Better Health Victoria recommends soft abdominal exercises as general advice post-pregnancy. 

However, Mrs King's case resulted in extreme, chronic pain, and as such she sought surgery. However, due to recent changes in the definitions of abdominoplasty at the start of 2016, her $16,000 surgery was not covered by Medicare, nor was it a part of her private health insurance plan. As a result, she was required to front the costs herself, creating a significant financial strain on herself and her family.

This circumstance highlights the grey areas that plastic surgery exists within. For some, the above situation should have been covered on some level. For others, muscle repair was classed the same as a "tummy tuck". In fact, the difference between public perception and insurance reality has prompted the Private Health Insurance Ombudsman to conduct an investigation into the handling of reconstructive treatment claims by health insurers. Transparency and understanding is key in ambiguous situations such as these.

Some medical procedures are more likely to be covered than others.Some medical procedures are more likely to be covered than others.

Are you covered?

There are over 1,600 different surgical procedures in the Medicare Schedule.

The situation with Mrs King itself has prompted a number of industrial bodies, including the Australian Society of Plastic Surgeons, to come out in protest of the Medicare changes - but there are lessons for the average Australian here as well. When it comes to plastic surgery, the reality of your coverage may be very different from the reality; another reason to ensure that you check your insurance and coverage regularly, and updating it as necessary.

This may sound simple, but there are a huge number of different insurers and packages available - many with restrictions or exclusions on plastic and reconstructive surgery. In fact, the PHIO explains that there are over 1,600 different surgical procedures in the Medicare Schedule that you would not be covered for if you had complete exclusions on all plastic surgeries.

So, does your health insurance cover medically necessary plastic surgery? Ultimately, it depends on your policy, level of cover and insurer. The Medicare Schedule is sometimes chopped and changed, and this can have unfortunate results such as those that Kimberlee King experienced. Are you covered?

If you are interested in finding out more about policies that cover reconstructive surgery or compare your current package, make sure you get in touch with us here at HICA on 1300 44 22 01.