What should you do when your dental insurance refuses to pay claims submitted by your provider? Denials can happen for one of two reasons.
First, dental plans contain a host of contractual exclusions, meaning they cover very little. In this case, you will need to find other ways to pay for services.
Second, the insurance company might deny claims because they think the proposed treatment is unnecessary. In this case, a letter of reconsideration has a better chance of success than a lawsuit.
Because of these two details, many people can’t afford expensive dental work, even with insurance. Therefore, prepare yourself with alternatives.
Dental Insurance Limits Benefits
When dental insurance doesn’t pay a specific claim, it can seem like it does not cover anything. Companies design plans to promote preventive oral care (exams, cleanings, etc.) rather than protect your finances from expensive restorative treatments such as implants, dentures, veneers, or gum surgery.
Dental loans and payment plans could provide the funding needed to fix your teeth when your insurance denies a claim due to any of these contractual limitations in many policies.
Annual Maximum
The annual maximum benefit is a valid reason why dental insurance stops paying claims it once did, especially for the most expensive treatment. This exclusion limits the amount paid annually to about $1,500 to $2,500 on average.
After maxing out your dental insurance, the obvious thing to do is delay treatment until the following year. Of course, this only works if you are close to the time the limit resets or when your oral care is not urgent.
After reaching the yearly maximum, people needing emergency care must find an alternative. For instance, a painful tooth abscess needs immediate antibiotics or a root canal treatment.
Missing Tooth Clause
The missing tooth clause is another valid reason why dental insurance won’t pay claims for dentures and implants. This exemption works similarly to pre-existing condition exclusions with other types of coverage.
Getting around the missing tooth clause will not be easy. You can buy another plan without this exclusion, provided your employer makes the option available. However, you will not find new coverage without this limitation in the individual marketplace.
You could also file an appeal but would have to show that you had creditable coverage in force before your current plan became effective.
Waiting Periods
Failure to meet waiting periods is another contractual reason dental insurance denies some claims. A waiting period defines when your plan will not pay benefits for treatments such as crowns, implants, bridges, dentures, or root canals.
Full coverage dental insurance with no waiting periods might offer immediate benefits for major services but may not be the direction you want to take. Instead, you might fare better if you continue with your current plan.
Dental insurance without waiting periods includes other provisions that limit payments, such as graded benefits in the early years. Initially, the policy will cost more premiums than it returns in claims.
Frequency Limitations
Frequency limitations are another reason dental insurance won’t pay for previously covered services. Your policy contract will state the number of times it will honor claims for a specific service in a given period.
Look under the coverage overview for your plan, and you might find various frequency limitations similar to these.
| Service | Frequency Limitation |
|---|---|
| Amalgam (Metal Filling) | 1 per tooth every 365 days |
| Bitewing X-rays | 1 per 1 Service Year |
| Comprehensive and Periodic Exams | 2 per 1 Service Year |
| Dental Crowns | 1 per tooth every 10 Years |
| Dentures and Partials | 1 per 10 Years |
| Full Mouth Debridement | 1 per 1 Lifetime |
| Full Mouth X-Ray | 1 per 60 Months |
| Gen Anesthesia | 3 per 1 Day |
| IV Sedation | 3 per 1 Day |
| Occlusal Guard | 1 per 5 Years |
| Prophylaxis Cleaning | 2 per 1 Service Year |
| Posterior Resin (White Filling) | 1 per tooth every 365 Days |
| Root Plane/Scale | 1 per quadrant every 2 Years |
| Periodontal Surgery | 1 per 3 Years |
Uncovered Services
Non-covered services are another contractual reason why dental insurance will not pay specific claims. Most plans do not cover everything your dentist might recommend and publish a written list of excluded treatments.
Once again, examine the coverage overview for your plan. You might find many of these services excluded.
- Cosmetic procedures
- Fluoride for adults
- Tooth implants and crowns
- Localized delivery of an antimicrobial agent
- Major oral surgery
- Orthodontic braces
- Preventive resin restoration
- Sealants
- TMJ treatment
Fighting Denied Dental Claims
Finally, when your dental insurance denies claims not otherwise excluded by a contractual limitation, it might make sense to fight back to prove the procedure is necessary.
You might want to file an appeal for a service that does not trip the annual maximum, missing tooth clause, waiting period, frequency limitation, or list of uncovered services. Filing a lawsuit would not be cost-effective.
Use your Health Savings Account (HSA) to pay for oral care deemed unnecessary by your dental insurance. The HSA rules are far more lenient – provided the treatment is not cosmetic (tooth whitening, labial veneers, etc.).
Letter of Reconsideration
Have your dentist compose a letter of appeal to get your dental insurance to reconsider coverage for a service deemed unnecessary in an earlier claim. Also, contact the company and request their specific underwriting guidelines for the proposed treatment.
The reconsideration letter should include additional evidence showing that the proposed procedure meets the company’s objective underwriting criteria. For example, precise measurements should be provided if the guidelines dictate that at least 4mm pocket depth is needed to deem periodontal root planing and scaling necessary.
Filing a Lawsuit
Suing your dental insurance company after a denied claim is probably an ineffective way to resolve your problem because the amounts at stake are too small. The cost of hiring a lawyer to take the case to court is probably more than you might get back in return – if you win.
Before suing the dental insurance company, refer to the annual maximum benefit stated in your contract. Most people have yearly limits in the $1,500 to $2,500 range, meaning this is the most you could win in a lawsuit.
