Is my insurer meeting their commitments?

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Joined: Wed Jul 19, 2017 3:40 pm

Is my insurer meeting their commitments?

Post by elucence » Sun Aug 13, 2017 3:12 pm

I have a disagreement with my dental insurer. I'm hoping to understand it better.

I recently had a cavity filled in a back tooth which required the removal of part of a resin filling.
The dentist who filled the cavity gave 2 reasons why amalgam could not be used:
1. There was not enough tooth structure left to use amalgam
2. He wasn't removing all of the old filling and needed to use resin to bond to it.
In my mind either of these reasons alone seems enough to rule out the use of amalgam.

My insurance policy claims to cover 100% of restorative work. In spite of that, my insurer only paid the amount it would pay for an amalgam filling. When I inquired why the insurer cited the following clause in its policy:
"When more than one covered Dental Service could provide suitable treatment based on common dental standards, Cigna HealthCare will determine the covered Dental Service on which payment will be based and the expenses that will be included as Covered Expenses."

In my opinion, the clause does not apply since only resin could be used in my particular case.
Two questions:
1. Is my insurer correct that the clause gives it the right to deny payment for the overage from using resin?
2. Do you have any advice on how I should handle this disagreement?

Thanks in advance

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Re: Is my insurer meeting their commitments?

Post by mbornfeld » Mon Aug 14, 2017 7:40 am

Please allow me to provide an answer that may be somewhat less than satisfying. To begin, your dentist's justification for choosing composite resin rather than amalgam because of the amount of remaining tooth structure is not necessarily based on established fact. In addition, even if part of the previous resin filling was allowed to remain, it does not mean that the new part of the filling needs to be bonded to it. In short, your dentist's explanation for insisting on resin is rather weak; I for one do not think it makes for a convincing argument, and his decision lies predominantly within the domain of treatment "style" rather than uniformly accepted standard practice.

Having said that, it's really beside the point whether the rationale for your dentist's operating protocol is truly valid; your insurer is not legally permitted to judge what is and is not appropriate treatment, because doing so is technically within the scope of a dentist's prerogative, and not within theirs. The only prerogative of the insurance carrier is to decide whether or not a particular service is covered under the provisions of the insurance policy. (This has not prevented some insurers from treading on the dangerous ground of judging whether a particular treatment is valid and appropriate. Insurance companies often hire licensed dentists to review claims and make decisions related to treatment. This raises all sorts of legalities which are still unsettled-- for example, whether a dentist-employee of an insurance company in one state can make treatment decisions for a patient located in a state in which he is not licensed. The advent of tele-medicine and tele-dentistry raises similar issues.)

Insurance policies usually divide dental services into three categories: preventive (examinations,x-rays, and cleanings), basic (surgical, restorative, periodontal, endodontic), and prosthetic (crowns, bridges, dentures, implants), and they may provide reimbursement of services in any of these categories at a stipulated rate. Let me translate what most insurance companies mean when they say they cover 100% of restorative work: it means that restorative services (fillings) are reimbursed at 100% of the pre-arranged fee schedule, subject to plan limitations (deductibles, exclusions, yearly benefit caps, and alternate benefit provisions). A plan's fee schedule (i.e., a list of fees attached to each dental service) may be explicitly stated in a distributed list, or it may be a more vague schedule based on some statistical rendering of a "UCR" (usual, customary, and reasonable) fee in a given locale. Note that the plan's fee schedule may not be the same as a dentist's fee if the dentist does not "participate" in the plan-- i.e., he hasn't made a contractual arrangement with the insurance carrier.

In your case, your question goes to the heart of the aforementioned "alternate benefit provision", which you previously quoted. The semantics of the statement are nuanced, but important: "...Cigna HealthCare will determine the covered Dental Service on which payment will be based". Translated, that means that Cigna will not determine the treatment that is appropriate, but they will determine the payment, even if it is not based on the appropriate treatment. I can assure you that this vague wording is not an accident, but has evolved as a result of much litigation between the dental and insurance industries.

You should know that most dental plans have alternate benefit provisions of some sort. They also provide a means for your dentist to appeal a negative decision with a clinical narrative, but this often times turns out to be a sham. Again, the alternate benefit provision is not explicitly intended to countermand your dentist's clinical judgment; it is intended to shield the carrier from what they perceive to be excessive claims exposure. Therefore, an appeal based on clinical considerations is not likely to change the insurance company's mind. Cigna has a history of ignoring appeals based on what is best for their policy holders. In a much-publicized case, Cigna refused to provide coverage for treatment of a dying California girl. Viewed in that context, it seems unlikely that Cigna will be moved by your dentist's entreaties to pay for resin rather than amalgam.
Mark Bornfeld DDS
Brooklyn, NY

Posts: 5
Joined: Wed Jul 19, 2017 3:40 pm

Re: Is my insurer meeting their commitments?

Post by elucence » Mon Aug 14, 2017 11:21 am

Thank you for your full and clear response. I now have a better understanding of my insurance policy, and see it is probably not worthwhile for me to pursue this issue with CIGNA.

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