Private Health Insurance – exclusions and restrictions

Private Health Insurance – exclusions and restrictions

Many members of the public are unaware that the term plastic surgery encompasses both reconstructive and cosmetic plastic surgery.

“Reconstructive plastic surgery” is usually an operation, treatment or procedure performed on an abnormal structure, deformity or tissue of the body arising as a consequence of congenital defects, developmental or acquired abnormalities, trauma, disease, tumour, including surgery or other treatments for such conditions or defects. The definition also includes gender reassignment surgery.

“Cosmetic plastic surgery” is an operation, treatment or procedure undertaken to improve appearance where no prior injury from trauma, disease, congenital disorder, congenital or acquired deformity exists.

Some private health insurance policies exclude all plastic surgery procedures. Some examples of medically necessary reconstructive plastic surgery procedures include, but are not limited to:

  • 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.

Consumers should check their health insurance policy to ensure adequate cover for Plastic and Reconstructive Surgery Procedures.