Dental Insurance Articles

Reasons A Dental Insurance Claim May Be Denied

2010-09-24

Dental insurance is purchased to provide relief from sometimes enormous dental bills. Unfortunately, when a dental claim gets denied, there's not much relief to be had. On the contrary, policy holders are often confused as to the nature of the denial. However, if you understand a few of the reasons why a dental claim may be denied, you'll know which missteps to avoid and what to do if your claim is unfairly denied.

One of the most popular reasons for a denied dental claim occurs when the claim falls under one of the exclusions listed in the dental insurance policy contract. These exclusions can be extremely specific or very general, but they prevent the insurance company from paying out in certain circumstances. They're commonly used to regulate the value of a dental insurance policy and to deny coverage on unnecessary or high-cost claims such as elective dental surgery. If your claim was denied due to an exclusion, there may not be much you can do, so be sure to read this section of your dental insurance contract.

Dental insurance companies typically use codes to identify a policy holder's claims, and sometimes paperwork can contain incorrect coding information. Your dental claim may be denied if the wrong claim number is written down. This may occur when you submit the claim, or you might have had nothing to do with the mistake. In either case, you'll need to contact your insurance company to sort out the mistake and get payment on your dental claim as quickly as possible. Remember to keep a record of any conversations you have with your dental insurance agent, and ask for paperwork if you resolve your claim's problems. This ensures you'll be able to prove your case if there's any more confusion down the line.

If you can't get a clear reason as to why your dental insurance claim was denied, consider filing a complaint with the American Dental Association (ADA) or your state's insurance commission. All dental insurance companies are required to submit an accurate, legitimate reason when denying a claim. If your insurer refuses to do so, they'll have to pay heavy fines and you can appeal your claim at the state level. This will result in a payout, more often than not. You can also appeal a denied claim if you disagree with the reasoning behind the decision; although in this case, you should appeal to your dental insurance company first before you appeal to the state. You'll stand a much better chance of eventually receiving your payout if you approach the denial quickly and by using the correct procedures.