Peculiar Insurance Coverage Situation (Single Tooth Implant and Orthodontics)

[PPGJR]

In December 2013 I started the dental implant process on my front tooth and this also coincided with braces for my top front 6 teeth. I have been with my Dentist since 2001 and up to this point I have had zero complaints and we have a great relationship. So when I was told by my dentist that my Delta Dental PPO would not cover the implant and braces, I took his word for it at 100% trust that I was being given accurate information. Overall, I ended up paying close to $6K out of pocket for the implant and braces. Literally today, July 8, 2015, I called Delta Dental and found out that my Delta Dental PPO actually DOES cover a single tooth implant (up to $2500 cumulative lifetime) and orthodontics (up to $1000 cumulative lifetime). I also learned that this coverage was available to me in December 2013 when the procedure was started. Now, the problem with me getting reimbursed is that the procedure was started over 1 year ago and so Delta Dental says I would not be eligible for reimbursement, even if my dentist submits a claim retroactively.

Now, I have some questions for all of you:

1. is it my responsibility as a Patient to double check the information that my dentist gave me - that the implant and the braces were not covered? Or, was I within reason to take his word for it since I have a great relationship with him?
2. Any solutions to the problem of not being reimbursed because the claim is over 1 year old? We literally live paycheck to paycheck and are severely struggling financially so the $3500 that I could have saved if my dentist filed the claims through my insurance would REALLY help me. We wanted to take a small vacation to Disneyland for my children's birthdays in August but we can't afford it right now. The $3500 would allow us to give our children that experience and so much more.

Please help me with your expertise, opinion and advice.

Thank you very much!

 

[Zuri Barniv]

1. Yes, the relationship is between you and the insurance. The dentist is not responsible for your insurance unless they are a DMHO/DMO Delta provider. Assuming they are Delta Premier or Delta PPO, then it's all on you. Keep in mind that even a great dentist with a wonderful and experienced staff can make mistakes. When dealing with this much money, you should always double check everything.
2. Yes, try writing Delta an appeal letter. If you state the facts of the case, there is a better than zero chance they will consider making payment or partial payment. I would ask the dentist to write a letter you could attach stating it was no fault of yours and would support your appeal. If that doesn't work, escalate it and keep appealing as much as the law allows. It only costs you a stamp and you have nothing to lose.

One last thought. Even when I know for sure a procedure is not covered by Delta, I still submit the claim just in case. I have had many situations when Delta made payment even when the claims representative said it would not be covered. This is why most all dentists submit a claim for expensive treatment even when it seems pointless. One question to your dentist is: "don't you always submit a claim for everything you do and especially for very expensive treatment?". Had he done this, you would have gotten a pleasant surprise when the check came in.

Keep us updated on what happens.

 

[PPGJR]

Thank you very much for your reply Zuri. I really appreciate it and it makes a lot of sense.

1. This is good to know for future reference and I consider it a lesson learned. I'm sure my dentist will consider it a lesson learned for him and his staff as well.
2. I completely intend on writing as many appeal letters as necessary until they tell me to stop. Great advice to have my dentist write a letter to vouch for me as well. I have been loyal to his practice for 14 years so I am hopeful that he would do this for me.

Another great piece of advice for my dentist. He is currently working on my case to see what he can do but if it doesn't work out, I will ask him that question as part of the learning process for all of us.

I will keep the forum posted on the outcome and ongoings. Thank you very much once again!