Private Health Insurance and Plastic Surgery: Insurance

In this blog, we cover how to be prepared for discussions with your private health fund about whether or not your plastic surgery is covered, and what you’ll qualify for in terms of Health Insurance or Medicare rebates.

Do you have private health insurance? Are you wanting to find out if your Tummy Tuck, Breast Reduction or Eyelid Surgery is covered by your Australian health fund?  Be sure you read part 1 of this 2 part blog (what does “fully covered really mean”) so that you understand the terminology of health insurance coverage documents.


This article is the 2nd of 2 parts. Read Part 1 – Private Health Insurance Hospital Coverage and Plastic Surgery.

Private Health Insurance and Plastic Surgery


Understanding your Health Fund Coverage


Dealing with private health funds in Australia can be frustrating for many patients.

Recent news stories about health insurance funds show that health insurance company complaints are up by 30% from last year alone. Articles suggest that some of the largest health insurance firms may have some of the highest complaint rates.

So it really DOES pay to investigate your Private Health Insurance Company’s reputation, and terms, BEFORE you buy. And if you, too, have a complaint about your private health insurance fund, you can contact the Australian Health Insurance Ombudsman’s office for information and assistance.

Excerpted from an SBS article, Record rise in private health complaints (May 2018, accessed online 18 June 2018 at

  • Complaints about private health insurance increased by 30 per cent in the last financial year, the worst rise in a decade.
  • The Private Health Insurance Ombudsman received 5750 complaints in 2016/17, up from 4416 in 2015/16.
  • “This is an increase of over 1300 complaints within one year, which is the largest rise we have experienced over the past 10 years,” the ombudsman’s latest State of the Health Funds report said.

To help our patients better understand common health insurance issues and health fund coverage terminology, we’ve published blogs with handy resources and links, to get you started as you connect with your health insurance company to discuss whether or not you’re eligible for any rebates for your Plastic Surgery procedure.

In today’s blog, we provide Australian Government resource links to help you better understand your private health insurance – including what your policy actually means.

health insurance cover plastic surgery - criteria, waiting periods, exclusions

What you’ll NEED to do BEFORE you can assess whether rebates for your surgery by your Specialist Plastic Surgeon will be applicable:

  • Read Part 1 – what the health fund term “fully covered” or “rebate” really mean in terms of plastic surgery costs to patients and then continue with the one you’re reading now.
  • Read and understand your Health Insurance Policy including exclusions, pre-existing conditions and waiting periods
  • GET your documents in order (your Policy, your notes about the surgery including the Medicare ITEM Number that your Surgeon has told you applies to your condition, your original referral from your GP, any accompanying documentation, scans, or images you have, along with your Surgeon’s notes and Estimates/Quote). Other paperwork may also be required so be patient, and be prepared.
  • Find a comfortable spot to be on the phone for some time (and allow adequate time – don’t try to squish in a call to your health fund during a 30 minute office break)!
  • Contact your health fund directly, by phone, with all of your documents in order.

Contacting your Health Insurance Company: Tips

  • Grab a coffee or snack and a fully charged phone
  • Allow at least an hour for the conversation (don’t try to squeeze it in on a short break from the office)
  • Put your feet up and plan to spend some time on hold (or maybe get out the nail polish while you wait)
  • Consider the possibility you may be given different or inaccurate information each time you call.
  • Ask for a reference number or name of person you speak to.

Some patients found it helpful to telephone their health insurance company on two separate occasions, to check what they’ve been told is covered, with different representatives, JUST to verify the information they’ve been given was correct.

Health Insurance Terms, Waiting Periods, and Exclusion Criteria – ‘it’s complicated’

Is it possible the coverage and exclusion terms are so complex, not even the health fund employees always fully understand them?  We can’t answer that question, but there is a push by the Government to insist on more plain-language health fund policy materials – especially in view of the increase in Ombudsman level complaints.

What to DO first, and what to HAVE in front of you, before you phone your private health fund to see what coverage you have in relation to your plastic surgery procedure.


Get a GP Referral for your concerns before you see a Plastic Surgeon (Specialist)

health insurance cover plastic surgery - criteria, waiting periods, exclusions

  1. Before you investigate any health fund coverage or medicare rebate eligibility for a plastic surgery procedure such as post-pregnancy Abdominoplasty and torn abdominal muscles repair, you need to see your GP to get a referral.
  2. Remember that Cosmetic Surgery is NEVER covered by Health Insurance or Medicare, but some Plastic Surgery procedures may qualify for a Medicare Code (functional or structural, not cosmetic).
  3. These procedures might include surgery for post-pregnancy damage, or chronic skin conditions from weight loss, or other functional plastic surgery procedures such as eyelid lift surgery or a breast reduction or breast lift. These Plastic or Reconstructive Surgery procedures may currently qualify for a Medicare Code/Medicare rebate. This does NOT, however, mean your operation is fully covered, and you WILL likely have out of pocket expenses for your procedure, even after a Medicare or Health Fund rebate.
  4. If you are seen by a Specialist and your concerns do NOT attract a Medicare Code (e.g, they do not meet the criteria), then you will be ineligible for either a Medicare OR a Health Fund rebate.


Visit our Downloadable Guides pages

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

cosmetic surgery for women and men Downloadable guides


Dig up the copy of your Health Fund coverage and read it thoroughly before you call your Health Insurance Company to ask about Plastic Surgery Coverage.

It’s also very important to read the MBS Online Medicare Criteria for rebates for the condition you have.

Read the Health Fund criteria, in detail, re eligibility for plastic surgery (e.g. a Tummy Tuck, Breast Reduction or Eyelid Surgery), including waiting times and other criteria – this can be very detailed reading and quite variable.

If you don’t understand anything in your health insurance policy about your coverage, make a note about it and be sure you have a list of questions you want to ask the Insurance Representative when you phone them.

In summary: if you have a GP referral to a Specialist for evaluation of a problem (such as torn abs, an abdominal hernia and excess skin bulges, heavy breasts causing you neck, back or shoulder pain, or droopy eyelid skin that impedes your vision), then you MAY be eligible for additional hospital cover or a rebate on your procedure This is only if your private health insurance company’s policy and your coverage plan – covers your particular scenario.

But the only way to find that out what you’re covered for, is to directly contact your Health Insurance Company with all your paperwork in order.

Phone us on (03) 8849 1444 if you need a copy of your original quote from your consultation with a Plastic Surgeon, or for our GUIDE on Medicare and Health Insurance and Plastic Surgery (or send an enquiry, below).



Do you know the difference between a Cosmetic Surgeon versus a Specialist Plastic Surgeon? Find out what they are.








This article is the 2nd of 2 parts. Read Part 1 below.

Private Health Insurance Hospital Coverage and Plastic Surgery


Phone (03) 8849 1444 or Email us at: or Book a FREE 15-minute Phone Chat with our Patient Liaison Manager.


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