pomco medical denial of dental implants

[typhoon]

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

My son had a bicycle accident requiring several dental implants as the proper standard of care to repair the damage .
Pomco contract language states "you are covered for dental services necessary for the correction of damage caused by an accident"
Exclusions of implants set forth in that paragraph refers to "correction of damage caused by an illness, cogential disease or annomaly. There is no reference to damage caused by accident.
The interpretation of this apparent contradiction of policy is at issue. I have exhausted internal appeals to no avail.

 

[Mass_Shyster]

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

My son had a bicycle accident requiring several dental implants as the proper standard of care to repair the damage .
Pomco contract language states "you are covered for dental services necessary for the correction of damage caused by an accident"
Exclusions of implants set forth in that paragraph refers to "correction of damage caused by an illness, cogential disease or annomaly. There is no reference to damage caused by accident.
The interpretation of this apparent contradiction of policy is at issue. I have exhausted internal appeals to no avail.

If what you've written is correct, you have a breach of contract claim. You should check your policy for an arbitration clause that may preclude you from winning a lawsuit.

 

[ecmst12]

What is the specific reason for the denial?

 

[typhoon]

There is no arbitration clause although a lawsuit is cost prohihitive which Pomco also knows.
The specific reason is they are sticking to their interpretation of the master plan document that states implants are not covered as stated below....

Plan Exclusions section: "Dental services or provided by a dentist. However, you are covered for dental services and appliances necessary for the correction of damage caused by an accident provided the services are received within 12 months of the accident. You are also covered for dental care or treatment necessary due to congenital disease or anomaly.In addition, you are covered for oral surgery necessary for the correction of damage caused by an illness for which you are eligible for benefits under this plan, and which occurs while you are covered under this plan. Extractions, dental carries, periodontics (including but not limited to gingivitis, periodontics and periodontosis), implants or the corrections of impactions will not be covered."

 

[cbg]

Seems pretty clear to me that implants are excluded.