Dental insurance and claim

[janmarhen]

What is the name of your state? Maryland

My husband had some periodontal work done recently. The dental office gave me an estimate of what I would have to pay. They called my insurance company and did the estimate based on the call.

Now that the work has been completed, the Insurance is denying the claim.

Their explanation is that they would cover 3 teeth, but since he had periodontal issues in more than 3 teeth they won't cover any.

I am appealing this decision. It seems crazy that they would cover 3 teeth, but nothing if there are more than 3. Also, although the dentist office didn't get a formal quote from the insurance they did get a verbal of what would be covered.

I'm curious if I have any legal recourse against the dental office. I know that the estimate states that ultimately I am responsible for anything not paid by insurance, but it seems unfair. I would have explored other options had I known it was going to cost 50% more than expected. If the insurance company refuses the appeal, it seems the dental office should be on the hook for some of their mistake. Any advise ?

Thanks, Janet.What is the name of your state?

 

[moburkes]

What is the name of your state? Maryland

My husband had some periodontal work done recently. The dental office gave me an estimate of what I would have to pay. They called my insurance company and did the estimate based on the call.

Now that the work has been completed, the Insurance is denying the claim.

Their explanation is that they would cover 3 teeth, but since he had periodontal issues in more than 3 teeth they won't cover any.

I am appealing this decision. It seems crazy that they would cover 3 teeth, but nothing if there are more than 3. Also, although the dentist office didn't get a formal quote from the insurance they did get a verbal of what would be covered.

I'm curious if I have any legal recourse against the dental office. I know that the estimate states that ultimately I am responsible for anything not paid by insurance, but it seems unfair. I would have explored other options had I known it was going to cost 50% more than expected. If the insurance company refuses the appeal, it seems the dental office should be on the hook for some of their mistake. Any advise ?

Thanks, Janet.What is the name of your state?

What was the insurance company's mistake?

They fix teeth. They did that, right? It is YOUR responsibility since you are the insured, and it is YOUR money that is being spent, to make sure there is coverage.

 

[averad]

What was the insurance company's mistake?

They fix teeth. They did that, right? It is YOUR responsibility since you are the insured, and it is YOUR money that is being spent, to make sure there is coverage.

1) Insurance companies pay claims for any combination of medical, dental, prescription or life claims.
2) Dentists fix teeth

Most providers’ in medical or dental services will, as a courtesy, call your insurance and check your benefits. This is a courtesy and protections to make sure you are eligible. However this is commonly done weeks before the services are performed and prior to sending any dental records.

You are responsible to research your own coverage and eligibility before having services performed. This is explained to you in the benefit booklet and is part of the agreement you signed at the dentist’s office (most if not all providers have you sign an agreement for services placing the financial responsibility on you).

Estimates are based solely on benefits estimated, eligibility and benefits avaible at the time the estimate was created. Therefore, the estimates provided are not a guarantee of eligibility or benefits available.

 

[moburkes]

1) Insurance companies pay claims for any combination of medical, dental, prescription or life claims.
2) Dentists fix teeth

Most providers’ in medical or dental services will, as a courtesy, call your insurance and check your benefits. This is a courtesy and protections to make sure you are eligible. However this is commonly done weeks before the services are performed and prior to sending any dental records.

You are responsible to research your own coverage and eligibility before having services performed. This is explained to you in the benefit booklet and is part of the agreement you signed at the dentist’s office (most if not all providers have you sign an agreement for services placing the financial responsibility on you).

Estimates are based solely on benefits estimated, eligibility and benefits avaible at the time the estimate was created. Therefore, the estimates provided are not a guarantee of eligibility or benefits available.

You weren't, really, preaching to ME, were you? You were just referencing my remarks, right?!?!?