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Why doesn't my insurance plan cover the treatment the Doctor is recommending?"

The first thing to understand about dental insurance is that it isn't insurance at all. Insurance originated as, and is by definition, a pooling of funds to pay for a rare, but catastrophic event. Fire insurance is an excellent example of this. Originally, medical insurance was also designed this way. Payment for routine office visits, basic medications, and low deductibles are a relatively recent modification in medical policies intended to create additional employee benefits that are not true insurance but "tax-free" benefits. Unlike events such as cancer or your house burning down, dental disease is neither rare nor catastrophic. Therefore, dental insurance isn't insurance at all, but really a method for people to receive "tax-free benefits".
Rather than insurance, it is more accurate to refer to them as dental benefit plans. When they were originally introduced in the 1970's these plans were very simply designed. To keep the premiums reasonable, total benefits in any one year were limited to $1000.00. Forty years later, most benefit plans still have close to the same annual limit. Premiums have gone up, of course, because the costs for administering these plans (employee wages, cost of living, etc.) have increased. In an effort to keep the insurance premium costs down for employers and to continue to serve the insurance company's shareholders with profits, health care companies have made significant modifications to the original plans. As a result there are many different plans available.


The differences in these plans are usually found in the limitations that exist. The most common of these limitations is in the services that are excluded. Most plans will assist with basic services such as examinations, x-rays, dental hygiene visits, fillings and extractions. As more services are included, the costs for the plans increase. Some plans pay toward root canal treatment, or periodontal treatment. Some will include orthodontics, or major restorative treatments such as crowns, bridges and dentures. Some plans do not.
Another limitation is the "Alternate Benefit Clause". Essentially this clause allows the insurance company to choose to pay a lesser amount for the cheapest material or treatment that they deem adequate for you. This decision is often made by a clerical person who knows very little about dentistry and nothing about a person's unique situation and dental needs. Even when referred to a dental consultant (a dentist who works for the insurance company) for assessment, the judgement as to whether a treatment qualifies for payment is made by someone who has not personally seen the condition being treated. Decisions were once based on need, but now they are often based on the specific terms of the contract negotiated between the employer and a health-care insurance company.


If people take the attitude that they will "only do what is covered by the insurance plan", it can have serious impact on both the quality of care they receive, and the ability to achieve optimal oral health. I feel that oral health is too important to allow the insurance to dictate what can be done. Dental plans don't "cover" treatments, they assist with payment on certain procedures. In our office we feel that it is of utmost importance to take the time to get to know you, perform a thorough examination in order to make an accurate diagnosis, and then to help you understand your current level of dental health and explain the treatment options that exist. I feel our job is to help you understand your problem, your treatment options, and the consequences of each choice, so that you may choose what is best for you. Because our obligation is only to you, once you choose your care, there will be no compromises in rendering it. Even though our contract is with you only, we will do our best to help you understand your dental plan and its limitations. We will provide you with the necessary documentation, so that you can receive the reimbursement that you are entitled to. We are your dental health advocates, and are available to answer your questions and concerns regarding your dental benefits.


The implication when a payment is denied or reduced by the insurance company seems to be that the treatment is not necessary, or the fee is too high. We feel that you are the best judge of your needs and not someone at an insurance company who does not even know you. Our response to the insurance company regarding the issue of fees is that their benefits are too low. You are the best judge as to whether the fees you pay match the quality of care that you receive. I hope that this explanation of a complicated and continually changing subject is helpful. Please feel free to ask us any questions about your care and insurance benefits at any time.

Yours for better health,

Dr. Marty Frankel
Smiles by Design
3030-3080 Yonge Street, Toronto, Ontario M4N 3N1 416-770-8526