Plan of Healthcare with Plastic Surgery Coverage: Discover your options!

Every day, the number of people undergoing surgical procedures in Brazil grows, whether for aesthetic purposes or on medical advice. Regardless of the purpose, Brazil ranks second in the number of surgeries, reaching over 1.46 million cosmetic procedures.

But the main question is whether or not the health plan covers plastic surgery. After all, you probably know someone who has received this type of coverage through their plan.

Although this actually happens in some cases, in this post we will explain in more detail in which situations so that you can guarantee your rights.

Does health insurance cover plastic surgery?

According to the National Supplementary Health Agency (ANS), plastic surgeries that should be covered by health insurance are reconstructive surgeries, which are listed by the ANS. In other words, surgeries performed to correct a deformity or defect, whether congenital or acquired.

Thus, they differ from cosmetic surgery in that their objective is to reconstruct a body part for medical reasons (impact on health) rather than altering any aspect of the body. Furthermore, other plastic surgeries that may be covered are those covered by the contractual relationship.

In any case, reconstructive surgeries are:

Removal of excess skin

Patients who have undergone gastric bypass surgery (bariatric or gastroplasty), usually to treat morbid obesity, may need to have excess skin removed.

This surgery is necessary because it can compromise the patient's health, causing infections, and their routine, compromising their emotional state. Therefore, the health plan must cover this surgery.

Breast reconstruction

The law provides that women diagnosed with breast cancer, traumatic injuries and tumors in general have the right to undergo breast reconstruction free of charge.

Just like removing excess skin, a mastectomy can affect physical and emotional health, and for this reason, the patient is entitled to breast reconstruction.

Breast reduction

Breast reduction is also a procedure that must be covered by the health plan if it is affecting the patient's health, such as back and posture problems.

Keloids, hypertrophic scars and burns

Although this type of surgery is somewhat cosmetic, the goal is to repair the consequences of a health problem that can affect the patient's emotional well-being. Therefore, the insurance plan is required to offer the corrective procedure.

Blepharoplasty

Although most people undergo blepharoplasty solely for aesthetic reasons, blepharoplasty can also have a clinical indication. It turns out that a droopy eyelid can seriously affect vision and, consequently, be life-threatening.

In these cases, a request must be submitted to the insurance company, which will review the request. If denied, a third doctor, chosen by mutual agreement between two other professionals, must be consulted for the final decision. If the doctor still refuses, the beneficiary may take legal action.

Orthoses and prostheses

Plastic surgery coverage is also mandatory for orthoses, prostheses, and their associated appendages. It's worth noting that this requirement is valid as long as the purpose is not solely aesthetic.

Does the health plan cover bariatric surgery?

Although bariatric surgery is not a reconstructive surgery, the health plan must cover it as long as morbid obesity is proven. Therefore, the beneficiary must meet the following criteria:

• Be between 18 and 65 years old;
• Have undergone clinical treatment for at least two years, without satisfactory results;
• Presenting a picture of morbid obesity for more than five years;
• BMI between 35 kg/m² and 39.9 kg/m² with or without comorbidities;
• BMI between 40kg/m² and 50kg/m² with or without comorbidities.

Some operators may challenge the release of the service; however, the beneficiary may claim that the condition directly interferes with their health and quality of life.

What is the coverage for plastic surgery?

To qualify for partial or full coverage of reconstructive surgeries, the contract type must be an outpatient hospital plan. This means all exams, consultations, and hospitalizations will be covered by the insurer.

Regarding cosmetic surgeries, the plan will only cover pre-operative exams, and the beneficiary will be responsible for hospitalization and medical expenses. However, some plans offer surgery coverage on a reimbursed basis.

Therefore, plastic surgery will only be covered if you have a doctor's referral stating that the procedure is essential for your health. However, be aware that the insurance company may still refuse coverage and request another doctor to perform the evaluation.

Is there any health insurance that covers cosmetic surgery?

Because cosmetic plastic surgeries are classified as elective by the National Health Agency (ANS), health plans are not required to cover them. However, because the plans offer different benefits and advantages, the provider can include this type of coverage in the contract if desired, thus differentiating it from the competition. In these cases, the waiting period is the same as for other surgeries, a maximum of 180 days.

That's why it's so important to read the contract carefully and understand the terms and conditions being offered. When cosmetic surgery is included, you can be sure this will be clearly stated in the contract, as well as whether or not the procedure is for health purposes only.

However, the plans that offer this coverage only provide the option of free choice, that is, you will have to choose the professional, pay and only then request a refund.

How to request plastic surgery?

Just like other services offered by health plans, you must make a request before undergoing the procedure. However, if it's an emergency, simply request it later. reimbursement total or partial.

For reconstructive plastic surgery, you'll need a doctor's referral stating that the surgery is essential for your health. However, keep in mind that the provider may request an evaluation from another professional, which will be covered by the plan itself, before authorizing the procedure.

Furthermore, it's a highly bureaucratic process, so it will likely be slower than if you were to do it privately. In fact, in some cases, you may need to go to court to obtain release.

Now that you know which situations your health insurance plan covers plastic surgery, look for a provider that fits your profile and needs. So, do your research and don't make any impulsive decisions.