Private Health Insurance - Cover for Prostheses

Information for consumers on the prostheses list arrangements.

Page last updated: 18 December 2015

If you are going into hospital and having surgery to implant or apply a prosthesis, your private health insurer is required to pay a benefit for it if you have appropriate cover the for treatment, and the product is listed on the Prostheses List.

The Prostheses List lists over 10,000 surgically implanted prostheses, human tissue items and other medical devices and the minimum benefits that private health insurers must pay.

What is listed on the Prostheses List?

The types of prostheses in the Prostheses List include (but are not limited to):
• hip, knee and other joint replacement devices
• cardiac implantable electronic devices such as pacemakers and defibrillators
• cardiac stents
• vascular stents and grafts
• heart valves; and
• human tissue items such as whole bones and bone fragments, corneas, heart valves.Top of Page

What is not listed on the Prostheses List?

Devices such as external limb prostheses, external breast prostheses and implants used solely for cosmetic purposes are not listed on the Prostheses List.Top of Page

How much will the private health insurer pay?

The private health insurer is required, by law, to pay the minimum benefit listed on the Prostheses List for a prosthesis.Top of Page

Will I need to pay any out-of-pocket expense for a prosthesis?

If the minimum benefit covers the cost of the prosthesis to the hospital, then you will not need to pay any money out-of-pocket.

If the minimum benefit does not cover the cost of the prosthesis to the hospital, then you might need to pay all or part of gap between the minimum benefit and the cost of the prosthesis. This will be up to the hospital.Top of Page

What should I do to find out more about private health insurance cover for a prosthesis?

Talk to your private health insurer

When you know you will need to have surgery involving a prosthesis, check your private health insurance product to ensure that you are covered for the surgery.

Some private health insurance products have exclusions or restricted benefits for some types of treatment, such as joint replacement surgery (hips, knees and other joints) and treatment for cardiac ailments.

If the product excludes benefits for your treatment, you will not be paid a private health insurance benefit for the prosthesis.

If you have restricted cover for your treatment, a private health insurance benefit will be payable for the prosthesis, but benefits for other aspects of your treatment and stay in hospital will likely be limited.Top of Page

Talk to your treating doctor

When your doctor tells you that you have to go to hospital and have a prosthesis implanted, talk with your doctor about the prosthesis that will be implanted.

Ask the doctor whether the prosthesis is listed on the Prostheses List. If the prosthesis is not listed on the Prostheses List, ask the doctor if there is a prosthesis that can be used that is listed.

The doctor might know whether the minimum benefit on the Prostheses List will cover the cost of the prosthesis, but in most cases the doctor will not have information about the cost of the prosthesis.Top of Page

Talk to the hospital

Before you are admitted to hospital for any procedure, you should always check with the hospital on the costs of your procedure and your stay, and if there will be any out-of-pocket costs that you will have to pay. This goes for prostheses as well.Top of Page

Check again with your private health insurer

Check with your private health insurer about the benefits that will be paid for your surgery and your admission to hospital and if there is anything that your private health insurance won’t cover.Top of Page

What can I do if the private health insurer won’t pay for the prosthesis or medical device?

If a private health insurer does not pay a claim, you are entitled to ask the reason why.

If the private health insurer has refused to pay a claim because the prosthesis or medical device is not listed on the Prostheses List, the private health insurer is not required by law to pay the claim.

You can ask the private health insurer to pay the claim on an ex gratia basis, but this will be entirely up to the insurer.Top of Page

Where can I get more information on the Prostheses List?

More information about the Prostheses List and the prostheses arrangements is available at this page.