Many hospital procedures include the use of prosthetic items (surgically implanted medical devices, such as hip and knee joints and heart pacemakers).

All surgical procedures that require a prosthetic item have at least one available that is fully covered by your hospital cover (a ‘no gap’ item). However in very limited circumstances you and your surgeon may feel that it is more appropriate to use a different prosthetic item where the cost is above the standard ‘no gap’ prosthetic fee. This additional amount will have to be paid by you.

What should you do?

  • Before you have any surgery, check your level of cover with the fund.
  • If your surgery requires a prosthesis, ask your surgeon which will be best for you and which ‘no gap’ prostheses are available.
  • If the surgeon recommends a prosthesis for which a gap is payable, ask why this is being recommended.
  • Ask the surgeon to explain the cost of the surgery including the prosthesis. If there are any gaps for you to pay ask for a written cost estimate.
  • Contact the fund again to confirm if your surgery will contain any gap payments.