Orthodontics Cover

How it works and why it's different from other dental benefits

If you or a family member are considering braces or clear aligners, it's worth knowing that orthodontic cover works a little differently to other dental benefits, not only with Doctors’ Health fund but with most Private Health Insurers in Australia.

While orthodontics falls under your extras cover, it has its own rules around waiting periods, benefit limits and how benefits become available over time. Here's what sets it apart.

1. Orthodontics has a ‘lifetime’ limit

Unlike most dental services, orthodontic benefits are paid from a lifetime limit rather than a limit that simply resets each year. Orthodontic benefits accumulate over time and can be claimed up to the maximum lifetime limit available under your cover.

For example:

• On Total Extras, orthodontic benefits accrue at $600 per year of membership up to a lifetime limit of $3,000. We pay 100% of the cost up to the accrued limit at the time of service.
• On Essential Extras, orthodontic benefits accrue at $320 per year of membership up to a lifetime limit of $1,600. Please note that the orthodontic limit is combined with an annual limit of $1,600 for general and major dental services. Because of this, using part of that limit for services such as check-ups or simple fillings, for example, may reduce the amount available for orthodontic treatment in that year.

For example, if you had accrued $1,600 over 5 years, and spent $600 on general dental in a calendar year, you would only be able to use $1,000 of your lifetime orthodontic limit in that same calendar year. The remaining $600 in orthodontic benefits would then be available to use in the following calendar year.

Importantly, any orthodontic benefits you've claimed with a previous health fund are taken into account when calculating your available lifetime limit. That means, if you accumulated and claimed the entirety of your orthodontic benefits at a previous fund (unless that limit was less than that available to you with Doctors’ Health Fund), your lifetime limit for orthodontics is therefore exhausted and you won’t be able to claim any more benefits with Doctors’ Health Fund or any other fund you may be with.

2. Benefits are accrued over time and are not available immediately

Most dental limits either reset annually or are available immediately once you've served the relevant waiting period. Orthodontics is different.

Your orthodontic benefit grows with your length of membership. This means the amount available to claim depends on how long you've held eligible cover. The longer you've been covered, the more benefit you've accumulated towards your lifetime limit.

This approach helps members plan for longer-term treatments such as:

• Braces
• Clear aligners
• Orthodontic appliances designed to guide jaw development
• Retainers used to maintain tooth positioning after treatment

3. Orthodontics is treated differently from general dental

Dental cover is separated into two main categories:

• General dental
• Major dental (orthodontics)

General dental typically includes services such as check-ups, fissure sealings, bitewing x-rays and simple fillings.

The major dental category not only includes orthodontics but also includes complex dental procedures, including major dental restorations, endodontics, periodontics, crowns and bridges. It is only available with Essential Extras and Total Extras.

There is also a 12‑month waiting period for orthodontic services if you've never previously held orthodontic cover. However, members transferring from another fund may not need to re-serve waiting periods that have already been completed, provided they transfer within 60 days of leaving their previous fund.

Before starting treatment

Before commencing orthodontic treatment, ask your orthodontist for the relevant item numbers from the Australian Schedule of Dental Services and contact us to confirm your available benefits.

Because orthodontic benefits are subject to accrued limits and lifetime caps, checking your entitlements before treatment begins can help you understand what benefits are available and avoid surprises later.