Plastic and Reconstructive Surgery: Policy Exclusions and Restrictions

What is Plastic and Reconstructive surgery?

Plastic surgery is a medical specialty concerned with the evaluation and treatment of any physical deformity that can be corrected by surgery, whether acquired or congenital. Reconstructive plastic surgery is usually performed to improve function, but it may be done to approximate a normal appearance.

Cosmetic Surgery is only one aspect of Plastic Surgery. Cosmetic Surgery and non surgical cosmetic procedures are not recognised by Medicare, and health insurers do not pay benefits for these procedures or the hospital costs associated with them.

Consumers should check their health insurance policy to ensure adequate cover for other important Plastic and Reconstructive Surgery Procedures. If the policy excludes or restricts Plastic and Reconstructive Surgery, the exclusion or restriction is likely to apply to the following procedures (this list is indicative and not exhaustive):

  • Surgeries on congenital abnormalities, e.g. repair of cleft palates or cleft lips, nasal deformities causing breathing problems;
  • Surgery following burns e.g. skin grafting and release of skin tightening and scarring (contractures);
  • Surgery following traumatic injuries, e.g. repair of facial bone fractures and breaks;
  • Surgery following removal of cancers or tumours, e.g. breast reconstruction following mastectomy, skin grafts and skin flap surgery following tumour removal;
  • Laceration and scar repair.

 

Exclusions and Restrictions on Plastic and Reconstructive Surgery

Some health insurance policies give you full cover for the costs of most hospital admissions, apart from any excess or co-payment you agree to pay. Other policies restrict or exclude benefits for some treatments, in return for a lower premium:

Exclusions: you agree not to be covered at all for certain services. No benefits are payable for the excluded service by your health fund at all.

Restrictions: you agree to receive only limited benefits for certain services. This is usually enough to cover you as a private patient in a public hospital, but will leave you with large expenses if you are treated in a private hospital.

If your policy excludes or restricts Plastic and Reconstructive Surgery, this means there are over 1600 surgical procedures in the Medicare Schedule under the plastic and reconstructive category which your policy either does not cover or covers only to a limited extent. The procedures which you are not covered for can become clinically necessary at any stage of your life.

 

How can restrictions and exclusions affect you?

We cannot always foresee what services we will need and when we will need them. If you have purchased a policy with Plastic and Reconstructive Surgery exclusions or restrictions and then require these services, you may have to upgrade and complete a 12 month waiting period on pre-existing conditions to be covered for these services, or you may personally have to pay for the procedure or service yourself to be able to access it as a private patient.

The Ombudsman recommends that you review your health insurance policy to see if you have an exclusion or restriction on Plastic and Reconstructive Surgery. The Ombudsman’s advice to consumers is to consider taking a higher level of excess, rather than a restriction or exclusion, to save money on premiums.

 

What you can do

Make sure you understand any restrictions or exclusions applying to your policy. Review your policy every year to ensure it will meet your health needs over the coming year, particularly if you are thinking of starting a family or your health needs are changing as you age.

You can upgrade your private health insurance policy to include the services you require as a private patient. However you will have to wait for 12 months before you are entitled to these services on your new policy if the treatment you require is for maternity services (obstetrics) or a pre-existing condition.

If you need more immediate treatment for an excluded or restricted service, you should discuss your treatment options with your doctor or consider covering the cost of the treatment yourself.

 

More information

For more information on Plastic and Reconstructive Surgery, contact the Australian Society of Plastic Surgeons on 1300 367 446 or www.plasticsurgery.org.au.

To check and upgrade your cover, contact your health insurer. For general information about private health insurance and to compare health insurance policies, contact the Private Health Insurance Ombudsman at www.phio.org.au or www.privatehealth.gov.au, or by phone on 1300 737 299.

 

Making a complaint

If you have a complaint about your health fund which you have been unable to resolve with them, you can contact the Private Health Insurance Ombudsman on 1800 640 695 or www.phio.org.au for assistance.

 

This brochure is issued by the Private Health Insurance Ombudsman

Download the Plastic & Reconstructive Surgery factsheet PDF.