Understanding Dental Insurance

Serving Portland, Lake Oswego, & West Linn, Oregon

Most people are puzzled by how dental insurance works and why their necessary dental treatments are not covered, or not fully covered. At times we are just as puzzled here at Wendling Cosmetic and Reconstructive Dentistry, and we deal with it all the time.

Dental Insurance is no Longer Insurance
An insurance policy is an arrangement for taking care of emergencies or disasters. By paying a monthly premium we oblige the insurance company to pay for our expenses in the event of a future catastrophe, according to the "fine print" of your policy. A good example is Fire Insurance.

Originally dental insurance worked that way also. Now it is more appropriately called a Dental Benefit Plan. The change began in the 1970s. At first you could choose any dentist, pay small monthly premiums, and your yearly benefit amount was limited to $1,000.

Now, thirty years later your yearly benefit amount is often still $1,000 but your premiums are much higher and you cannot choose any dentist. You must choose from the insurance company's list.

Increased Complications
Premiums have gone up because the costs of administering these plans have gone up - wages, the cost of living and so on. To keep premiums as low as possible for employers, and profits as high as possible for shareholders, insurance companies have devised an array of plan structures:

More Restrictions
"Networks" -- although it is illegal in most states to restrict your choice of dentist, insurance companies get around that by having lists of dentists to choose from, and if you go outside that "network" your benefit will be reduced anywhere between 10 percent and 30 percent.
Exclusion of some dental services from coverage - usually this is the newest treatments or the superior services which use more advanced technology
LEAT clauses - standing for Least Expensive Alternative Treatment. This is a way for the insurance company to allow itself to pay less than your treatment costs. They will pay only for the cheapest alternative treatment or cheapest materials and leave you to pay the rest. Who makes this decision? A clerical worker at a computer who has not seen the condition being treated.

Besides the contract between your employer and the insurance company, there is also a contract between the dentist and the company. The dentist gets to have his or her name on the list and you are paid a higher benefit if you choose from that list. The dentist has "preferred provider" status, and must agree to whatever conditions which come with it. So benefits are now based on contracts instead of a patient's need.

In denying coverage, an insurance company will claim that the treatment is not necessary or that the fees are too high. We respond that the benefits are too low and that you can best judge what your needs are, rather than a clerk in an insurance office. We leave it to you to decide whether our services are worth what they cost.

Because most dental insurance plans continue to reduce covered services and have not increased their annual maximums, many employers are turning from this use of a "middleman" and offering direct reimbursement. If you would like some agent names and information about this to give to your employer, please let us know.

To get clear answers to your questions and learn more about dental insurance, please contact our dentistry office serving Portland for a personal consultation.