Where is the line: genuine medical need vs cosmetic treatment?

Most policyholders will already be aware that their private medical insurance won’t cover them for cosmetic procedures. However, problems arise when your insurers view of ‘cosmetic’ differs from your own. After all, sometimes people seek so called cosmetic procedures for genuine medical reasons, such as psychological distress or in the aftermath of a fire or car accident. So where does your insurer draw the line between genuine medical need and cosmetic treatment?

It’s a tricky one, and insurers will always assess claims on an individual basis. As the people who assess your claims aren’t medically trained they will ask your specialist or GP for further information and generally defer to their medical knowledge and judgement. While some procedures such as liposuction are blatantly cosmetic and will be denied by your insurer, they do operate a degree of discretion regarding certain cosmetic treatments. This means in limited circumstances some cover may be available.

What are cosmetic procedures?

  • Cosmetic procedures are those procedures that are carried out solely to improve a persons appearance without any medical benefit.
  • Insurers will also not cover for the removal of any undiseased body tissue.
  • Ultimately your insurer has the discretion to decide whether the treatment you are having is deemed cosmetic or not, and there decision is final.

Examples of cosmetic treatments that are commonly not covered

  • Breast enlargement – Both silicone and saline implants are not covered by your insurer. This includes situations where the patient is suffering from psychological distress from body image issues. Allowing one claim of this kind would open the floodgates for medical insurers, which would result in increased premiums for everyone.

  • Facial peel – No anti-ageing treatments are covered under your policy as these are primarily for cosmetic reasons.

  • Bariatric surgery (weight loss surgery) – Weight loss surgery such as gastric banding is considerably expensive. Although in some cases there is a genuine medical need, this treatment is available on the NHS.

  • Wart removal – Although warts aren’t very pleasant to look at, medically they don’t pose much of a risk – so your insurance won’t cover the removal of them. You can generally get them lanced or frozen off by your GP on the NHS.

Are there any exceptions?

  • Breast reduction surgery – Some women suffer from back pain due to the size of their breasts. In some cases your medical insurer will provide cover for a breast reduction after requesting letters from your specialist and GP that confirm the reasons for the surgery are medical, and not cosmetic.

  • Re-constructive breast surgery following cancer – Treatment for breast cancer may require the patient to undergo a mastectomy, whereby the breast is removed to prevent the spread of the cancer. In these circumstances most insurers will cover policyholders to have a breast reconstruction. If you ask your insurer prior to taking out your policy they will be able to advise you as to the level cancer cover that comes as standard and what this includes and excludes.

  • Nose job – A deviated septum is relatively common in patients with conditions such as sinusitis. In these cases your insurer will generally cover you for corrective nasal surgery, as the need for this is necessitated by a genuine medical illness. However, your insurer will scan the codes used by your specialist carefully. Some patients try to add cosmetic nose reshaping procedures like a rhinoplasty to the corrective surgery, but your insurer will deny these outright as cosmetic. So be careful if your specialist tells you he could reshape your nose at the same time as correcting your septum, as you would have to pay for this part of the procedure yourself.

  • Lipoma (fatty lump) – A lipoma is a fatty lump that generally grows between the muscle and skin. It’s completely benign and medically there’s rarely a need for it to be removed. Lipomas usually stay quite small and as such removal in most cases is regarded as cosmetic. However, in some instances the lump can grow to such an extent that it is uncomfortable or a hindrance to normal bodily movement, in these cases your insurer would be willing to cover a removal procedure once they’ve required medical evidence to verify this.

  • Blepharoplasty (eyelid surgery) – Droopy upper eyelids can occur as part of the natural ageing process or they can be caused by ptosis, a medical condition where the upper eyelid droops to such an extent that the patients field of vision is compromised. Understandably insurers will only cover treatment for droopy eyelids when it is the result of a medical condition and is hindering your ability to see clearly. In order to ascertain whether this is the case your insurer may commission a visual field study with an opthamologist to verify the extent of your loss of vision. Once this has been confirmed only then will they cover you for the necessary blepharoplasty procedure to rectify the condition.

For further information on the stance of your insurer with regards to specific procedures, contact them directly. They will be happy to help and will be able to clarify their position.

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