Limitations in Dental Insurance
A Insurance Article Contributed by Shobha Cutting
Limitations in Dental Insurance
To control the premium payable by the policyholder and keep it at a reasonable limit, most dental insurance plans will limit the amount of care you can claim on your insurance in any given year. This is done either by limiting the amount or by limiting the number and/or type of services that can be reimbursed. Some services may be totally excluded. It is important to know these limitations and exclusions, as applicable to the dental insurance policy that you hold.
Limitations and exclusions could be the processes that are obviously in the realm of experimentation and therefore not acceptable dental care, such as the services not performed under the care of a qualified dentist. Or/and there may be some less obvious exclusions. Sometimes the dental insurance and health coverage may overlap. It is important that the policyholder understands the limitations applicable to his/her dental insurance policy.
Exclusions in your dental insurance may be permitted by your health insurance policy. Sometimes the dental insurance policy that limits the cash that you may claim is better than the policy that may limit certain types of dental services since the latter restricts the range of services available to your dental care.
Most dental insurance policies have designated administrators responsible for administration of the policy and settlement of claims arising therefrom. Your administrator will be able to advise if your insurance plan provides for the following mechanisms:
Predetermination of Costs in Dental Insurance
Some dental insurance plans encourage submission of treatment proposals by the policyholder or his dentist. The administrators will then consider the eligibility, the required co-payment and the other limitations in respect of the proposed treatment. This process is also called the pre-authorization or pre-treatment review. Even though the cost of treatment may not be bound to strictly adhere to the pre-authorized plan, the treating dentist can thereby plan the dental treatment process.
Annual Benefits Limitation in Dental Insurance
Your plan may limit the amount that can be claimed by placing a ceiling on either the total number and/or type of the treatment and/ or by the amount expended in all treatments, or both, for any particular year. By knowing these limitations, your dentist can plan your treatment so as to reduce your out-of-pocket expenses, if so required. All good dental insurance policies provide adequate limits to ensure that the policyholders can access good dental care.
Peer Review for Dental Insurance Dispute Resolution
Disputes between the administrator, the policyholder and the service provider can also be resolved by peer review, thereby eliminating the need to seek resolution through costly court cases, in many insurance policies. Peer review is designed to maintain fairness, consideration of the individual case and examination of all relevant records, and aims to resolve disputes to the satisfaction of all concerned.
Adjustment of Premium
Policyholders must insist on regular revaluation of premiums payable, to ensure that the UCR and the Table of Allowances limits prescribed in the policy are realistic. The UCR limit refers to what is Usual, Customary and Regular payment in respect of services utilized and claims made by the policyholder. The Table of Allowances refers to what the insurance company considers reasonable payment for that particular service obtained in the particular locality. These limitations effect the claims in respect of service obtained.
