The benefits you can receive from your insurance program are dependent on the amount your employer pays the insurance company. In order to make a profit, the insurance company must pay out less in benefits than they collect in premium. To limit their expenses, the insurance industry has created various restrictions which have nothing to do with your individual needs or health such as:
- An annual limit. Regardless of the treatment you need, they only pay so much per person per year.
- Excluded treatment. Regardless of the treatment you need, certain things are not covered like cosmetic work or in most cases, dental implants.
- Fee limitations. Regardless of the specifics of your case, only so much may be paid for any particular treatment.
- Frequency limitations. Regardless of what you might need, they will pay for a procedure only so often. An example is a dental cleaning which may be “payable only twice a year” regardless of your gum condition that may require cleanings three or four times a year.
- Procedural limitations. Regardless of what treatment might be best for you, they may only pay for the least expensive treatment possible. For example, they might only pay for a removable bridge when a fixed bridge would be better or they might only pay for a filling when a cap is clearly a better choice for your tooth.
- Time limitations. Regardless of when you want to do the treatment, they may request that you notify them in advance of your intended treatment. They cannot require you to get a pre-estimate prior to treatment as a condition to paying you your benefits. They will always pay you what you are entitled to. As a matter of fact, our experience has often shown that pre-estimates prior to treatment are actually more likely to stimulate a rejection of coverage.
Please remember that while it is nice to have the insurance program pay for as much of your treatment as possible, and finances are sometimes a consideration, your decisions on what treatment you choose are best based on your own best dental health interests.
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