You just received new insurance and you’ve got dental coverage! Along with your new card came a thick packet explaining your benefits, and it is packed full of the “fine print.” Most people have a hard time understanding dental insurance so we have decided to use an example that may help.

Let’s say your hot water tank starts leaking. The good news is your hot water tank is still under warranty and can be replaced. The bad news is, the carpet in your newly finished basement is soaked and needs to be replaced. Taking this situation into consideration, let’s look at what the fine print and common clauses that many dental insurance policies contain.

Dental Insurance Clauses

Least expensive alternative: You want the new carpet to be a better quality and installed correctly, however your insurance will only cover the basics. Your insurance is not telling you that you shouldn’t get the better “carpet”, they aren’t even disagreeing that it is better, they are simply telling you that they are not going to pay for it.

Bundling: The water soaked through the carpet and the padding and has ruined the floor beneath. This will be an extra cost to get the floor repaired. Your insurance will overlook this extra cost by bundling it with your carpet repair. Any further expenses must be paid by you.

Pre-existing condition: The leak from your hot water tank occurred before you got your insurance. Your claim will be denied.

Medical Necessity: You need to have the carpet replaced, but your insurance states that it will only pay for a carpet square, anything additional, you must pay for.

Frequency Limitation: You get the carpet replaced but a year later your basement floods and the carpet is ruined again. Your policy states that they will only pay for this every 5 years and you are denied.

Fees and Percentages: Under your policy, you have 50 percent coverage for your carpet repair. After receiving multiple estimates all around $2000, your insurance company gives you their fabricated estimate of $1000, which they will only pay half of. So they are giving you $500, which is not 50% of the actual cost.

Maximum: Your policy has a maximum amount of coverage of $1000 and will only pay out that much for your carpet repair, even if this is less than 50% of the fabricated estimate they provided you with.

Better Plans: Last year, your friend had the same problem with their hot water tank leaking and destroying their carpet, however, they have a better insurance policy than you do. Even though you both have the same carrier, he received more coverage for his repair than you.

Need Verses Contract Language: You basement is larger than the contractor was anticipating and the job costs a bit more than quoted. You send a letter of protest to your insurance asking for reimbursement for the added cost, however your request will get denied. The coverage you receive is solely based on what is in your contract, not what your condition requires.

Hopefully that was able to help clear up a few of the clauses you may find in your own insurance policy.

As you’re reading through your packet, you may come across a few terms that are unfamiliar to you. Below is a list of some of those terms and what they mean.

Deductible – This is the amount you must pay before your insurance company will begin to pay. This is generally around $50.

Maximum – This is the most money your insurance company will put out for you each year. Generally, this amount is around $1000-$5000.

UCR Fees – This pertains to a fabricated fee that your insurance company assigns to specific dental procedures. If your policy states it will pay 80% for a crown, then the insurance company will pay 80% of this fabricated fee, not what your dentist is charging.

Categories – Insurance companies generally present their percentage of coverage based on three different categories of services:

  • Diagnostic – These include simple cleanings, exams and x-rays and are usually covered 80-100% of the fabricated fee.
  • Basic – These include fillings and root canals and are typically covered 60-80%.
  • Major – Included in this category are crowns, bridges, dentures and gum treatments. On average, these types of services are covered 0-50% of the insurance companies fee.

Exclusions – This simply means procedures that are not covered. It is common that over 50% of dental procedure codes are not covered by insurance. The most common procedures not covered by insurance are cosmetic, but can also include dental implants and treatment for gum disease.

Alternative Benefits – Often times there are a few different options for treatment for your specific dental issue. If this is the case, you insurance provider will generally only pay for the least expensive option, even if it is not the option you choose.

Pr-existing condition – If you had any dental problems prior to receiving your current insurance plan, services may not be covered for treatment of those.