We all feel lucky to have dental insurance. And, truthfully, most patients and their dentists have relatively few issues filing claims and receiving payment for them. While this tends to give the perception of savings, it can also be misleading, because most covered claims are small and straight forward. But sometimes insurance can become more difficult to manage when we need something more expensive, like a crown or a root canal, maybe a new denture supported by dental implants.
As claims are filed for more complex and costly services, determining the value of having dental insurance can become more complicated.
For example, a crown for your tooth might cost $800. Your dental benefits might pay half, after a $50 deductible, making your portion $450. If dental benefits premiums cost $480 per year, your total estimated cost for that crown would be $930, $130 more than if you had no dental benefits at all. Of course, those figures will depend on the plan, and assume there have been no other dental services and the insurance company actually covered the crown you needed. Going through the process, many have expressed that it seems like insurers try every trick in the book to not pay more costly claims, including, telling you your dentist’s recommendation - a crown, a dental implant, or perhaps a root canal- is not needed, without ever having examined you.
It is important to clarify that some insurance companies are viewed as better than others, some companies perceived as difficult are not always difficult, and that some patients have had no dental benefits problems, at all. Your dentist, however, has so-called “insurance wars” on behalf of patients, almost daily.
As we noted in our OPT-In Dental Advantage website section, What You need to Know about Dental Insurance, an insurance company’s goal (not unlike the goal of other industries) is for income from sales (premiums) to exceed expenses (claims and operations). Based on my experience and discussions with colleagues, it seems that insurance companies can use many tactics to avoid paying claims. They might even continually delay paying in hopes you or your dentist will give up in exasperation if their statistics show these tactics work.
Below is a consumer story that was published on the internet. We have removed the name of the insurance company because we cannot verify the author’s complaints:
I had dental work done on February 18, 2009. The claims were mailed. Today is April 27, 2009 and I still have not been reimbursed. It’s as if this insurance company couldn’t care less about reimbursing their clients. When I called to check on the status of my claims, I’m always told, more paperwork is needed from the dentist. My dentist immediately mailed the paperwork they needed and X did nothing!
I have called several times asking what is the status of my claims? I get the same answer, “we need more paperwork from the dentist… Just last week, I called and I was told the usual, “they were waiting on paperwork from my dentist.”…I paid up front because this is what I had to do with X. Now it’s a hassle to get my money. I’m a single mother with 2 children in college, money is tight.
Please, if something can be done to let X and other insurance companies know they have to pay the claims in a timely manner. I have to pay my insurance premiums every month or will not have insurance. I would like be treated the same.
The Games They Play
As mentioned, some insurance companies seem to do anything they can to avoid paying “out” even a small portion of the money you have paid “in.”
The below, published in the Philadelphia Inquirer, July 13, 2014, is an illustration of how some of these companies seem to think. While we did not investigate the facts of the story and lawsuit, the below reflects a portion of the published article:
Article Title: “After crash, a long, bruising court battle”
Original article written by: Craig McCoy, Philadelphia Inquirer Staff Writer
The vehicle Sherri Berg was driving was hit hard, spun four times, and hit a pole. No one was hurt, even though her automobile was ultimately classified as “totaled.” But that conclusion consumed 20 years and a 16 year lawsuit after Nationwide Insurance refused to pay other than for repairs.
According to the presiding judge, Nationwide had covered up the extent of the vehicle’s damage by hiding photos and reports from the Berg family, actions alleged to be part of a “written litigation” strategy to reduce company losses. According to the article, Nationwide’s strategy was “to fight smaller claims tenaciously.” In response, Judge Sprecher, of Berks County, PA, noted, “Nationwide’s message to customers who sued – and to their lawyers:
- Don’t not mess with us, if you know what is good for you
- You cannot run with the big dogs
- There is no level playing field to be had in your case
- You cannot afford it and what client will pay thousands of dollars to fight this battle?
- So we can get away with anything we want to
- You cannot stop us”
Nationwide claimed it had not acted in bad faith, and that their litigation strategy, which applied only to accidents with injuries, had been discontinued prior to the Berg’s accident. Judge Sprecher believed the strategy was being applied to the Bergs, despite Nationwide’s claims. “Nationwide was willing to risk the Bergs’ lives to save itself money on a collision claim,” according to Judge Sprecher.
What was not known by the Bergs was that their vehicle was declared a total loss by the original inspecting garage manager, due to a bent frame. The Bergs were later contacted by an ex employee of the repair shop who testified “I knew the vehicle wasn’t repaired properly. And I knew if it was in a major accident, it would come apart.”
Prior to awarding an $18M judgment to the Bergs, Judge Sprecher concluded that Nationwide “…simply buried the evidence and hid the fact that it knew anything about this report and what it means to the safety of anyone in the jeep in a collision.”
Nationwide, according to the Inquirer, spent $3M defending itself against the 16 year lawsuit brought by the Bergs. Judge Sprecher accused Nationwide of trying to “…price plaintiffs out of their meritorious claim dispute.”
Unfortunately, Sherri Berg died of cancer seven weeks prior to the verdict, never knowing the joy of victory after 16 years of legal battles. Nationwide has filed an appeal.”
Sometimes, legitimate dental claims for crowns, fillings, root canals, and other services are needlessly denied by insurers, causing patients to choose a lesser and potentially problematic solution. By appeasing the demands of insurers that have no stake in optimal care, patients inadvertently support the notion revealed in the above examples that insurers know best and should be trusted above all others.