Weight loss is a journey that starts with lifestyle changes and diet adjustments, but might require further steps to make a real difference. In cases where obesity impacts someone’s health severely, medical intervention – including weight loss surgery – can become the most viable option.
But how does private health insurance work for weight loss? Is surgery covered, and what about general consultations? Here, we’ll take a look at what level of insurance covers weight loss surgery in Australia, what’s required (from you) to qualify, as well as the types of procedures that might be included in your policy.
Does insurance cover weight loss surgery?
Yes, many private health insurance providers in Australia cover weight loss surgery or bariatric surgery, but you need to be on the right policy (or tier) to get access to the benefits. Coverage for weight loss surgery includes procedures like gastric bypass, sleeve gastrectomy and gastric banding, provided that the surgery is medically necessary – and that’s an important point.
Private health insurance can make these surgeries much more affordable than would be possible if you were only reliant on Medicare, but it’s still worth understanding what’s included and the eligibility criteria so you can make the most informed decision for yourself.
Qualifications for weight loss surgery
Bariatric or weight loss surgery is recommended when traditional weight loss methods have proven ineffective. For insurance cover, you need to meet several requirements, which will vary depending on your insurer:
- Body mass index (BMI): Most insurers require a minimum BMI of 40, or 35 if there are associated health conditions such as diabetes, hypertension, or sleep apnoea.
- Age restrictions: You’ll need to be over 18, although some insurers might consider surgery for younger people with exceptional cases and serious medical recommendations.
- Medical documentation: Insurers will require a doctor’s referral for surgery, along with documented evidence of previous, unsuccessful weight loss attempts.
- Comorbid conditions: Your insurer will also consider related health conditions, or comorbidities, when approving weight loss surgery. The most common of these are diabetes, high blood pressure, joint pain and other conditions impacted by weight.
Types of weight loss surgery covered by health insurance
Different types of bariatric surgeries are covered under private health insurance, but the specific types and levels of cover vary from health fund to health fund. The most common procedures include:
1. Gastric bypass (Roux-en-Y)
Gastric bypass surgery cuts down the stomach size and reroutes the digestive tract, limiting food intake and nutrient absorption. It’s one of the most effective surgeries for long-term weight loss, but it requires big lifestyle changes post-surgery.
2. Sleeve gastrectomy
This involves removing a large portion of the stomach, reducing its capacity and helping patients feel ‘full’ sooner. The stomach’s smaller size naturally limits food intake and therefore promotes weight loss.
3. Adjustable gastric banding (Lap-band)
A band is placed around the upper part of the stomach to create a smaller stomach pouch. It’s a procedure that’s adjustable, which means doctors can control food intake levels over time. However, it might not result in as rapid weight loss as gastric bypass or sleeve gastrectomy.
4. Biliopancreatic diversion with duodenal switch
More intensive surgery that involves both the stomach and small intestine. While highly effective, it’s usually reserved for severe cases and has much bigger risks.
Make sure you check with your insurer about what is – and isn’t – covered, as some policies will only cover specific procedures. Different hospital tiers (like Bronze, Silver and Gold) will have different amounts of cover.
Portability
Don’t re-serve waiting periods when you switch to a new health fund or policy
“John was immediately covered for a hip replacement in private hospital because he had already served his waiting periods for joint replacements on his old policy”
What can impact cover for weight loss surgery?
- Level of hospital cover: As you’re probably already aware, health insurance plans in Australia are divided into tiers – Basic, Bronze, Silver and Gold (with -plus options available with some health funds). While Basic and Bronze policies might not cover complex procedures, Silver and Gold hospital cover are more likely to include bariatric surgery.
- Policy inclusions and exclusions: Every insurance policy will have specific inclusions and exclusions. Make sure you read the fine print, as some policies could exclude weight loss surgery for people with particular pre-existing conditions.
- Waiting periods: Health insurance policies require a waiting period for elective procedures, including weight loss surgery. Most health funds have a waiting period of 12 months.
- Pre-surgery requirements: Your provider might ask that you show proof of an attempt at alternative weight loss methods before approving cover for bariatric surgery. Examples include participation in supervised weight loss programs or medically documented lifestyle changes.
- Network hospitals and providers: Choosing in-network hospitals and providers can minimise your out-of-pocket costs, but they might not be your preferred specialists. Speak to the experts at Fair Health Care Alliance to find private health insurance that meets your needs in terms of choosing a doctor or specialist.
What doesn’t health insurance cover for weight loss?
- Pre-surgical consultations: Initial consultations with specialists might not be fully covered by your insurance.
- Nutritional counselling: Post-surgery support, such as dietary advice and planning, might fall under extras cover.
- Follow-up surgeries: Some follow-up procedures, in case of complications, will require separate cover or additional approval.
- Weight-loss medications: Medications for weight management are usually excluded from private health cover, although they might be available through prescription benefits or as part of a specific extras package.
How much does weight loss surgery cost in Australia?
Without insurance, costs can range from $15,000 to $30,000 for procedures like gastric bypass or sleeve gastrectomy. With private health insurance, you can expect big reductions on those fees, although exact costs will depend on your insurer, the hospital and specialist you choose, surgeon’s fees and whether the surgery is in-network.
You’ll also need to think about hospital excess fees. As most policies require an upfront hospital excess payment, you’ll be taking care of that bill yourself. There’s also post-operative care, with nutrition counselling, follow-up appointments and physical therapy that you’ll need to cover if these separate costs aren’t covered under your current private health insurance policy.
4 steps to take if you’re considering weight loss surgery
- Contact your insurer: Reach out to your health fund to confirm whether or not you are covered for bariatric surgery or another procedure.
- Get a medical referral: Obtain a referral from your GP or another specialist. Your doctor can document your health history and recommend surgery based on your specific needs.
- Compile documentation: Get written proof of all your previous weight loss efforts, including medically supervised programs and treatments, as this information will support your claim.
- Request pre-approval: Pre-approval from your provider will make sure you avoid any unexpected out-of-pocket costs.
Conclusion
For many, weight loss surgery can lead to life-changing improvements, not only in weight management but in overall health and quality of lifestyle. Armed with the right health insurance, you can get the treatment you need without burning through your savings.
For more information on finding a policy that covers your weight loss needs, reach out to Fair Health Care Alliance to compare health funds today.
