Although dental insurance is not the same as health insurance, oral health has a great deal to do with general health. Oral health refers to the day to day care of the mouth and teeth that is vital to overall health. It touches every aspect of life but is often taken for granted. The mouth, in a major way, reflects the overall health of an individual’s body. For example, it can show signs of nutritional deficiencies or general infection. Systemic diseases that affect the entire body may first appear as anomalies in the mouth, such as lesions or other oral problems. Unless oral health is maintained, many aspects of physical health can be affected. To say nothing of the cosmetic factors that attend poor oral health.
As I may have mentioned, my father was a dentist. When he was practicing, I didn’t need dental insurance. But when he went to that big waiting room in the sky, it seemed to be a good idea, especially because I aged and the old dental work was showing its own age.
I’m not telling you to buy dental insurance; that’s not my place to do. However, I am suggesting that you understand it before deciding. That is what I am here for. I’ve explained various kinds of dental insurance in previous articles and have discussed other ways to handle the cost of dental care.
For those of you who have already bought, or plan to buy dental insurance, you have to understand that, like health insurance, it does not cover everything, and there are some quirks of which you should be aware. Although I knew that, I experienced how it can all play out in the course of my own recent dental care. I risked becoming a victim of the “missing tooth clause.”
Dental Insurance Exclusions
Here are some exclusions and quirks of dental insurance. Some of them do not have a counterpart in health insurance, but some do:
- Many dental insurance plans have waiting periods for certain coverage. This a period of time that the person must be insured under the dental insurance plan before a procedure is covered. The length of the waiting period varies based on the plan and the procedure. For example, dental cleanings may be covered immediately, but extensive dental work like bridges and crowns may be subject to the waiting period.
- Especially when extensive work is needed, the dental insurance policy may require the dentist to submit a pre-treatment estimate. This will address not only the estimated cost but also the dentist’s evaluation of why the treatment is needed. The dental insurance company will evaluate it and approve, deny, or require modifications. One of the reasons that it may be denied is that the proposed care is simply not covered under the plan. An adjustment of the care plan may be needed if, for example, the dentist proposes to install a porcelain crown and the plan only covers a resin crown (which usually costs less). As you might have guessed, the pre-treatment estimate and its approval by the plan is also the rough equivalent of a health maintenance organization (HMO) requiring approval before a member may see a medical specialist.
- And now, for the one that I recently experienced: The missing tooth clause. Most dental insurance policies exclude from coverage the replacement of a tooth that was missing before the effective date of the policy. The insurer may try to rely upon this if you lost a tooth before coverage started and later decided to get a partial bridge or implant to replace the missing tooth. This is broadly analogous to a pre-existing condition exclusion as was once allowed in health insurance policies. Since the prohibition against pre-existing condition exclusions does not presently apply to dental insurance, you may still confront this exclusion.
At the risk of TMI (too much information), my dental insurer denied coverage for a bridge based on the missing tooth clause. However, when proof was shown that I had been insured by that insurer all along (and therefore, that the condition arose while the dental insurance policy was in force), coverage was ultimately extended. A moral of the story is to keep a record of all time that you had dental insurance and of the insurer(s) providing coverage. The greater the continuity of coverage with the same insurer, the less likely that the missing tooth clause will bite you. Another moral is that, by and large, people do the right thing. Even insurance companies.