Private Health Insurance Hospital Coverage and Plastic Surgery: Terminology


Health Insurance, Hospital Coverage and Plastic Surgery, Cosmetic Surgery (Part 1 of 2) – Terminology.

Health Insurance, Hospital Coverage and Plastic Surgery is a confusing topic for most patients.  Health Fund coverage has a tendency to change rapidly and without notification to its members. This can be a result of Medicare Rebate criteria changing which usually happens once a year. When these changes occur, it can also effect your ability to apply for early release of Super for surgery procedures, based on compassionate grounds.

So when you’re about to have Plastic Surgery, and you know you’ll be dealing with your Private Health Fund, we hope this BLOG helps you prepare for what to expect.

I thought ‘fully covered’ meant no out of pocket expenses for my surgery.”

How to understand what the “fully covered” means in terms of your Private Health Insurance Fund.

hospital coverage plastic surgery, cosmetic surgery - health-cover-fully-cover-plastic-surgery_preview

Here, we are going to explain what the health fund term ‘fully covered’ actually means.

We also highlight how important it is to have your paperwork in order if you’re planning to phone your Private Health Insurance Fund to discuss your health insurance hospital coverage and medical insurance policy restrictions, or waiting times.

Private Health Insurance, Hospital Coverage and Plastic Surgery – Terminology used by some Private Health Insurance companies in Australia (Part 1 of 2)

Australian Health Insurance or Private Health Fund Terminology 

Will I have any out of pocket costs for surgery if I am “fully covered”?

Health Funds are very strict about what they cover.

Waiting times, certain criteria and exclusions in cover can take up multiple pages in a Health Insurance Policy and/or paperwork.  Consumer groups are pushing for greater transparency and plain language for easier understanding.

  • When your Private Health Insurance says you are“Fully covered”, this usually means you will still have some out of pocket costs for surgery.  There are fees for more than just the surgeon such as, anaesthetist, assistant, theatre fee, bed fee and pathology.
  • There are typically incidental expenses involved with having surgery (post-surgery garments, antibiotics and other medicines).
  • “Fully Covered” means that Medicare and the Health Fund will cover you to the recommended Government Fee on a particular surgery. This fee often falls far short of what a Private Practice charges.

For example:  On a $10,000 surgery, you may be rebated $2,000 therefore leaving $8,000 out of pocket (for you to pay yourself).

It is not possible for fully qualified, experienced Private Practice Surgeons, who have spent years training and use best practice care, to provide their services for the small Medicare and Private Health rebate.  Some rebates are as low as $200.  The Public System will do a lot of surgery across many fields for these rebate amounts but the waiting time for some procedures is 5-10 years and the surgeons performing it can be a trainee surgeon or general surgeons, not Specialists.

Why are so many patients frustrated and disappointed with their Private Health Fund companies?


Private Health Insurance Policies and Cosmetic Procedures and Plastic Surgery

Many private health fund companies do not offer hospitalisation or procedure coverage even though they can charge hefty premiums.

Private Health Funds: Private or Publicly Traded (Shareholder focused)

So in thinking about which Health Fund patients like and which ones people complain about online, the key item seems to be whether they are client focused or shareholder focused (privately held or publicly traded on the stock market).

Many Australian Private Health Funds also appear to be focused more on returning shareholder profits, rather than on servicing the clients they charge so much to insure, and refund so little to, in terms of hospital coverage and surgery care rebates.

Read recent Research Articles about the benefits of Tummy Tuck Surgery (Abdominoplasty) as an effective treatment for reducing incontinence and back pain and the health impacts of abdominal hernias or torn abdominal muscles (diastasis recti) after pregnancy.

hospital coverage for cosmetic surgery - plastic-surgery-covered-by-insurance-private_preview

Health Insurance Hospital Coverage and what the term fully covered actually means.

What may not be covered by your Private Health Insurance Company (your Private Health Fund), even though it says you’re ‘fully covered’ for surgery?


Excerpted from the article source link above (Accessed online on 31 May 2018):

Health Insurance Policy limitations and hospital coverage

The health insurance policy you buy will have some limitations on hospital treatment. These limitations may impact coverage for corrective plastic surgery procedures.

These insurance policy limitations might include:

  • Exclusions – specific services that are not covered at all.
  • Restrictions – services that are covered to a limited extent, which means you will have greater out-of-pocket expense. Restricted benefits are not sufficient to cover the full hospital cost of a private hospital admission and you will need to pay for the difference in cost.  Sometimes this is called a co-payment.
  • Benefit limitation periods – which pay reduced benefits on one or more services for a set period of time after the waiting period, then pay full benefits after this period.
  • Surgery or hospital treatment that Medicare does not pay a benefit for – Medicare pays a benefit on all medical services necessary to maintain your health, but does not cover optional treatments such as elective cosmetic surgery.
  • Single vs shared rooms – some hospital policies cover the full cost of a shared room, but not a single room. Depending on your policy, this limitation can apply in a private hospital, or a public hospital, or both. If you are admitted to a single room and your policy does not fully cover the cost, the hospital should inform you that you will need to pay the difference between the fund’s benefit and the hospital’s charge. Your health fund can also provide more information about your cover.

Confused about what your private health insurance fund like BUPA actually covers?

frustrated dealing-with-private-health-fund-paperwork_preview

It’s best to contact your private health insurer directly to find out more, and be sure you read and understand the policy materials, inclusions, exclusions and waiting periods BEFORE you choose a private health fund.

For example,  here are links to Understanding Health Insurance Funds:

Understanding BUPA’s policies (corporate site)

Medibank Health Insurance – Hospitals Extras Explained

Understanding Medicare and Health Insurance Codes

If you are having a purely cosmetic procedure versus a Plastic Surgery procedure

More helpful terminology to understand your Private Health Fund policy before you phone them to find out if your plastic surgery procedure is covered.

Private Health Insurance – Glossary of Commonly Used Terms (from


Terms used in public health insurance.   Page last updated: 13 March 2018. Accessed and excerpted on 31 May 2018.


Health Funds and Private Insurance Companies – In The News

Last year, Choice Magazine aimed to shed some light on Private Health Funds in Australia.

Read the CHOICE article about Private Health Insurance here.

Now, ready to phone your Private Health Fund to ask about coverage for your surgery procedure?




Read Part 2 of this blog on Cosmetic Plastic Surgery and Private Health Insurance:

Private Health Insurance and Plastic Surgery: Insurance




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For more information about Cosmetic and Plastic Surgery options and research in Australia.

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