Can't get insurance company to pay

[ryoko]

What is the name of your state? NH

Hello,

I'm having an issue with my dental insurance company refusing to pay for 3 surface fillings. They stated there was no 'evidence of disease or accidental injury'. My dentist has sent in x-rays several times, 2 clinical narratives, and the Dr's notes (per the insurance's request). My insurance company keeps refusing the claim, however will not tell me why other than the quote mentioned above. My dentist has been very cooperative, sending all the info as requested every time the insurance asked.

It has been over 8 months, 1 written appeal, numerous letters, phone calls and resubmittions of documents. and things look to be at a stalemate. I believe my dentist and feel he has done nothing wrong, however there is a chance he made an error. Making 3 errors I feel is highly unlikely. I believe I will find another local dentist and have that dentist look at my copy of the x-rays and give His/Her opinion as to if the fillings were necessary. This may be the only way to determine which of the two is in the right.

Once that is complete I feel litigation may be the only way to get this completed. A lawyer will cost far more than I am looking to obtain, so does this mean small claims court? The amount is under $1000, and I'm not looking for punitative damages, just the out of pocket expenses I spent to have the fillings. Can I take an insurance carrier to small claims court? How likely is it for a little guy like me to win against a big insurance company? Am I missing another option?

Thank you all for your advice.

[ecmst12]

Your dentist may(should) be able to get a more detailed explanation of why the claims were denied. And there is probably an appeals process you can go through with 3rd party mediation of some kind. These are avenues you can persue before paying for 2nd opinions out of pocket and going to court.

Why on earth would he give you fillings if there was no disease? It's not like they're a cosmetic procedure!

Oh also you can ask him to show you on the x-rays where the cavities were. You may not be able to recognize them yourself but he's trained to do such things, and if he points it out you should be able to see it.

[sukharev]

Chances of you winning in small claims are high, if you have expert witness (the dentist) to show it was indeed the cavities.

That said, if it's a big insurance company, try the 3 way conference call with them, and if you hit a non-cooperative rep just ask immediately for his name, and then for his supervisor. Eventually, you will reach someone who knows what he is talking about, then the dentist can square it away with that person. It's probably a billing error of some kind (assuming your insurance does have coverage for fillings)