Dental Insurance. Can they say it's covered then change their mind?

[Mrjimbov]

What is the name of your state (only U.S. law)? Indiana

I had a bridge put in last month. I called the insurance company prior to scheduling the procedure to make sure it would be covered and the person I spoke to said YES it was covered and they would pay up to $1000 of the procedure. My dentist called the insurance company to confirm that it would be covered and the insurance company assured them it would be covered. I got a call from the dentist today saying that they submitted the bill to the insurance company and they received a letter from the insurance company today stating that the procedure was NOT covered because they will only pay for a bridge if they paid for the tooth to be removed.
So, basically, I owe the full $3000 for the bridge.

 

[ecmst12]

Did you have it precertified and did you ask for all the details of coverage? If you don't meet coverage criteria then it's not covered, but it's not clear if you asked the right questions ahead of time.

 

[Mrjimbov]

So, my dentist and I both called to confirm it would be covered but because I didn't think to ask (and my dentist didn't think to ask) "will you pay for me to get a bridge when you didn't pay to have the tooth removed" I shouldn't be surprised that they changed their mind after saying "yes you are covered for this procedure"? My dentist has been in business over 20 years and he said he has never heard of any company having this policy, I guess you really do need to think of EVERY possible question, and make sure you think WAYYY outside the box

 

[cbg]

There is a difference between a phone call saying, Is such and such a procedure covered, and a pre-certification. The former is a generic question that may have qualifiers. The latter is quite specific to you, your policy, your dentist, and the exact work that your dentist intends to do and why.

 

[OHRoadwarrior]

Such approvals are usually given by CPT code.

 

[ecmst12]

The code would not have helped in this situation.