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

Dental Plans Explained
Employers sponsor dental plans for a variety of reasons, including the promotion of good health, to keep their work force healthy and fit and to attract and retain top-notch employees.  Your employer will provide you with details of your plan that are written in plain language (Benefits Booklet).  It will provide a brief overview of the covered services, limitations and exclusions, co-insurances, maximums and the fee guide used to calculate benefits.

The employer enters into a dental plan contract with a third party that will act as the plan administrator.  Dental plan contracts are lengthy, complex documents that define what services are covered and under what circumstances they are eligible for reimbursement.  Some limitations such as frequency limitations (e.g., this service is covered once every three years) are easily understood while others are more complex (e.g., this service is covered only when there is evidence of recurrent decay or fracture).  Dental plan administrators are contractually obligated to reimburse patients based upon the terms of the dental plan contract.  This means that in some instances, necessary treatment may not be covered. 

The Patient's Responsibilities
There are more than 30,000 dental plan contracts in Ontario and each plan will be a little different from the next.  You are the person responsible for understanding the details of your dental plan, furnishing the dental plan administrator with necessary information such as pre-treatment forms, claim forms or supplementary information such as x-rays and you are responsible for making arrangements for payment to your dentist for the dental care received.

The Dentist's Responsibilities
The dentist, in accordance with the Regulated Health Professions Act and applicable regulations, will give you information on available treatment options appropriate to address your dental care needs, regardless of the nature and extent of your dental plan coverage.  In addition, the dentist will assist you by supplying information required to enable you to receive any benefits to which you may be entitled under your dental plan.

How Dentists Help Patients with Their Dental Plans
Upon your request, your dentist will assist you by furnishing you with information that you need to enable you to receive benefits through your dental plan.  This would include giving you claim and pre-treatment forms.

Sometimes additional information may be requested by your plan administrator in order to ensure that the treatment is eligible according to the terms of your dental plan.  In such cases the plan administrator will write to you and ask you to obtain the information from your dentist.  Your dentist will furnish you with any information you request but it is your responsibility to provide it to your dental plan administrator.  This ensures that your health record remains confidential and your privacy is protected.

What will my dental plan administrator do with the information I submit?
Once your plan administrator has the necessary forms and any supplementary information requested it will be able to determine your plan's liability based upon the provisions set out in the contract.  You will be sent an explanation of how the benefit was calculated.  All, some or none of your treatments may be covered or, for some services, coverage may be limited to an alternative, less expensive procedure.  It is important to understand that necessary treatment and covered expenses are not the same things. 

My reimbursement was limited or declined.  Where do I turn for clarification?
First, read the explanation from your plan administrator carefully.  In most cases, it will explain how the 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 your contract and they have been applied to your claim and as a result some or all of the costs associated with your treatment will remain an out-of-pocket expense not reimbursable under your plan.  For more detailed information about the specific provisions of your plan,  you should consult your employee handbook, discuss the matter with your benefits department or speak directly to your plan administrator.  The Advisory Services Department of The Ontario Dental Association is also able to provide you with assistance and advice 416.922.3900.

The Last Word
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.  Covered services and necessary treatment are not the same things.

Remember, you are a partner in your oral health and all treatment and care decisions should be made by you and your dentist based upon your actual needs, independent of your dental plan coverage.  Your dental plan is not a treatment plan. Information courtesy of the ODA (www.oda.on.ca) top