General | You and your dental plan | Dental plan co-paymenents | My dental claim reimbursement was limited or declined

My dental claim reimbursement was limited or declined. Where do I turn for help?

The explanation of benefits from your dental plan administrator, usually an insurance company, will explain how your benefit was calculated and it will identify any limitations or exclusions that have been applied.

Look for language such as "Under the terms of your dental plan.", "Your plan limits coverage to." and "These services are covered only when.". These types of statements indicate that there are limitations within the contract and they have been applied to your claim. As a result, some or all of the costs associated with the treatment will remain an out-of-pocket expense not reimbursable under the plan. For more detailed information about the specific provisions of your dental plan you should refer to your employee handbook.

If you believe that your claim was declined incorrectly, the first place to turn to is the dental plan administrator. This will give you an opportunity to obtain clarification about its decision which will have been based on the contract that exists between the plan administrator and the plan sponsor, usually your employer. If you still have concerns then your next step is to discuss the matter with your employee benefits department. The Advisory Services Department of The Ontario Dental Association is also able to provide you with assistance and advice.

If after reviewing your information it appears that there is a problem related to the adjudication of your claim, we can contact the insurance company your behalf to request that your claim be reassessed. Please be sure to have the explanation of benefits from your plan administrator available as this document will contain the information that we need in order to provide assistance.

Dental plans are designed to assist patients pay for their dental treatment however not all dental treatments are eligible or fully reimbursable. If your dental treatment is only partially covered, you will have share in the cost of your dental care. Information courtesy of the ODA (www.oda.on.ca) top