9.01.2015
Plastic surgery coverage for Medibank policyholders
Sometimes our policyholders require plastic surgery for medical reasons, perhaps for a deviated septum in their nose or
for a breast reconstruction after cancer treatment. This is very different to plastic surgery for cosmetic reasons, which
Medibank is not allowed to provide cover for.
To guarantee peace of mind, Medibank has developed a process which is simple and seamless, and ensures that
policyholders are covered for medical plastic surgery procedures.
How does the new process work?
From 1 January 2015, surgeons will complete a form confirming the process is for medical reasons, not cosmetic ones.
Policyholders will not need to go through a pre-approval process, nor be concerned that they will be out of pocket or asked
for payment up front by the hospital. This means they don’t need to worry about anything other than recovering from their
procedure.
Why is there a need for the new process?
Under the Private Health Insurance Act, insurers can only cover plastic surgery for medical reasons (such as breast
reconstructive surgery after treatment for breast cancer). Insurers are not allowed to cover cosmetic surgery (for example,
a rhinoplasty because a person is unhappy with the way their nose looks).
In 2014, Medibank conducted an audit on plastic and reconstructive procedures and found evidence that some claims were
actually for cosmetic surgery. It was obvious that we needed a more robust process for assessing plastic surgery claims.
Initially, we developed a process which was intended to determine whether a plastic surgery claim was for medical or
cosmetic reasons. Following feedback and review of the process, we have made some improvements to ensure
policyholders who need treatment are getting it, and are not being asked by hospitals for payment upfront. Hospitals also
told us they wanted to be sure that we would pay benefits for a plastic surgery procedure before the treatment
commenced.
Following this feedback, we have worked with the Australian Society of Plastic Surgeons to develop this new process.
When does the new process start from?
The new process took effect from 1 January 2015. It has replaced the current process for assessing plastic surgery claims
that Medibank introduced in mid-2014.
I have a plastic surgery procedure coming up, what does this mean for me?
If your policy covers plastic surgery and you meet the hospital eligibility check, then your procedure will be covered.
Once the surgeon has filled out the required form, all you will need to do is sign it.
Why is Medibank doing this?
Medibank wants to keep healthcare affordable.
We want to improve the process for policyholders and we want to ensure they get the treatment they need. We also want to
streamline the process for surgeons and hospitals, and ensure that we pay towards only medically necessary plastic
surgery.
Medibank Private Limited ABN 47 080 890 259