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Insurance Wars Create Winners & Losers

By: Dean Mersky, DDS

        Founder, OPT-In Management, LLC


We all feel lucky to have dental insurance. However, when we think about all the sky scrapers insurers own and the horror stories we often read about, one needs to question just how lucky we actually are. In truth, most patients and their dentists have relatively few issues with dental insurance, and claims are filed and paid with few problems. While that always gives the perception of savings, it can also be misleading, because most claims are small and straight forward, like regular teeth cleaning visits. In these cases, annual premiums of about $480 pay for about $300 of services. Wow, could it be that having dental insurance is not all that lucky? What about if we need something more expensive, like a crown or a root canal, maybe a new denture supported by dental implants? As soon as claims become more expensive, value and actually obtaining insurance benefits becomes 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. But remember, your dental benefits cost is $480 per year. That means your total cost for that crown would be $930, $130 more than it would have cost if you had no dental benefits at all. Of course, that is assuming that your dental benefits company will actually pay for the crown you and your dentist know you need. The truth is, they will often try every trick in the book not to pay, including, refusing to pay and going so far as to tell you your dental care, a crown, a dental implant, or perhaps a root canal, is not needed, without ever having seen you. While the actual numbers can vary, depending on your plan design, there is definitely a reason insurance companies are amongst the wealthiest companies in the world. We’ve provided published accounts, below, of how consumers have been mismanaged by their insurance companies.


First, let’s be clear that some insurance companies are better than others, companies known to be difficult are not always difficult, and while some patients have had no dental benefits problems, others have been abused in the worst possible ways. While these problems don’t affect everyone, your dentist has insurance wars on behalf of patients, daily.


As we noted in our OPT-In Dental Advantage’s website section on insurance, an insurer’s goal is to take “in” as much of your money as possible, and to pay “out,” as little as possible. They do that by making your premiums as high as possible, and paying toward your dental claims as little as possible, or, not at all. Insurance companies use many tactics, some indirect, to avoid paying your claims. They might even continually delay paying them so they can keep your money, longer, hoping you’ll just give up in exasperation. They do these things because their statistics show their 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:



About My Dental Insurance

"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. They say this so much until they get caught up in their own excuses. Just last week, I called and I was told the usual, "they were waiting on paperwork from my dentist." Well, I had already spoken to my dentist and they got the notice from X and the paperwork was sent to X IMMEDIATELY. When the customer service rep told me they were waiting on the paperwork from X, I told her I knew my dentist had sent the paperwork and X should have it. I was put on hold and she comes back to tell me, "Oh, yes, we have it. I will post it so the claim can be processed and it will take 8 - 1o days to process the claim." I said ok. Today I logged onto X to check the status on my claim and once again, "PENDING, waiting on paperwork from my dentist." I called and spoke to a customer service rep and she stated to tell me X is waiting on paperwork. I told her NO, the paperwork was sent to them and they had received it. Once again I'm told it will take 8-10 for processing. Due to economical times, I need my money just as the doctors and dentists need theirs and as X needs theirs. 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 will do anything they can to avoid paying “out” even a small portion of the money you have paid “in.” That is why they delay, delay, and delay. They, of course, get away with it over, and over, and over, again, because it works. Well, the below story, published in the Philadelphia Inquirer, July 13, 2014, is the rare case of them not getting away with it, big time, but is also an illustration of how they 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, 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 not so fast, because 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 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 until much later was that their vehicle was declared a total loss by the original inspecting garage manager, due to a bent frame. Nationwide, according to the Inquirer report, demanded that the vehicle be repaired, costing $12,500, instead of totaled and replaced, at a cost to Nationwide of $25,000. The frame was welded back together and the engine, now misaligned, had to be reseated and modified.

Later, the Bergs were 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.


What it Means to You

Legitimate dental claims for crowns, fillings, root canals, and other services are needlessly denied by insurers on a daily basis, causing patients to choose a lesser and potentially problematic solution. Appeasing the demands of insurers that have no stake in care, patients inadvertently support the dangerous notion, revealed in the above examples, that insurers know best and should be trusted above all others.

We always want to believe we are getting what we paid for. Dental insurance is no exception. No matter how we perceive its value, the most important dental insurance relationship any patient has is with their dentist, their only real advocate. In fact, it is the only relationship a dental patient can reasonably count on. With insurance, we are just a number. When that number is preceded by a “$” in the insurer’s “loss” column, the bigger the number the more important your doctor-patient relationship.