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  1. #11
    Join Date
    Jun 2006
    Location
    Massachusetts
    Posts
    24,521

    Default Re: Foreign Dental Claim Denied

    A legal source that says an insurance carrier doesn't have to pay a claim when all the requirements aren't met? That's Contract Law 101, son. You don't know much about insurance, do you?

  2. #12
    Join Date
    Mar 2005
    Location
    Michigan
    Posts
    28,906

    Default Re: Foreign Dental Claim Denied

    With the caveat that I can't interpret the terms of an insurance policy that I have not had the opportunity to see, cbg is correct. If the contract requires specific information before a claim can be approved, and that information is not provided in a manner consistent with the requirements of the contract, the insurance company has the right to deny the claim.

    I do understand why people engage in dental tourism, but if you work with a dentist who is not familiar with the documentation and billing expectations of U.S. insurers, problems are likely to arise if you later try to obtain coverage. It's a trade-off.

  3. #13

    Default Re: Foreign Dental Claim Denied

    Claim was discussed via 3way phone call with the claims manager and we were told all paperwork looked fine.

  4. #14
    Join Date
    Sep 2005
    Location
    Behind a Desk
    Posts
    98,846

    Default Re: Foreign Dental Claim Denied

    Quote Quoting donaldj
    View Post
    Claim was discussed via 3way phone call with the claims manager and we were told all paperwork looked fine.
    Even if so, it seems clear that such a preliminary impression was not correct, you were told what additional documentation you needed to provide, and you did not provide the required documentation. If you choose, you can now assemble the documentation and see if they'll reopen the claim based upon its submission.

  5. #15

    Default Re: Foreign Dental Claim Denied

    The information wanted was "dentist narrative". As I said above, we made 3way phone call and then they change their story yet again and say they do have the "dentist narrative" and I do not need to supply it. They stated everything looks good, and they should have a decision in 10 days. It took them 40 days. As I stated, no part of the delay was due to missing info on my part (zero).

    In the letter I received yesterday is a copy of the email reply sent to the HR person after she faxed them the "dentist narrative" (again). The email said "Oh, this is same info as we already have". Yet they twice had denied having that info, the "dental narrative".

    So I will rephrase my question. If the claim instructions do not mention "requiring" a claim code and the policy does not mention a claim code being "required", can they turn down the claim because the 3 bridges were combined into one claim amount, and not 3 separate claim codes with 3 prices? Also since there has been obvious and deliberate effort on their part to excessively delay this claim (no fault of mine), is there any time limit on me supplying additional claim details from the dentist? As I understand, I have 120 days to file a grievance appeal from time claim decision is made. But should I get the additional information before or after filing an appeal?

    Once again, they appear to have greatly exceeded the ERISA time limit of 90 days per claim, but you guys don't seem to mind their failing to meet legal guidelines.

  6. #16
    Join Date
    Jan 2006
    Posts
    38,867

    Default Re: Foreign Dental Claim Denied

    They stated everything looks good, and they should have a decision in 10 days. It took them 40 days
    Once again, they appear to have greatly exceeded the ERISA time limit of 90 days per claim
    stating something looks good is not an enforceable statement. It requires a proper review of the submission to determine if in fact it is complete and proper.



    Delta Dental denied the claim saying we needed a separate claim item from the dentist for each bridge, also identifying teeth involved on each bridge.
    have you provided the insurance company with this information? If not, check out this:

    (4)Calculating time periods. For purposes of paragraph (f) of this section, the period of time within which a benefit determination is required to be made shall begin at the time a claim is filed in accordance with the reasonable procedures of a plan, without regard to whether all the information necessary to make a benefit determination accompanies the filing. In the event that a period of time is extended as permitted pursuant to paragraph (f)(2)(iii) or (f)(3) of this section due to a claimant's failure to submit information necessary to decide a claim, the period for making the benefit determination shall be tolled from the date on which the notification of the extension is sent to the claimant until the date on which the claimant responds to the request for additional information.
    so, the 90 day limit is tolled due to your lack of providing the necessary information.


    so why do you think they cannot require the bridge work to be individual for each bridge? would you pay a bill that said:

    car repair $XXXX.xx without an itemized statement of what was repaired?

    one reason they need specific teeth noted is so your wife cannot make a claim in the future on the teeth replaced by the bridge. Not saying you or your wife would do that but many people would. The itemization removes the possibility the insurance company would ever have to pay for any more work done on the teeth replaced by the bridges.

  7. #17

    Default Re: Foreign Dental Claim Denied

    >>due to your lack of providing the necessary information

    once again, there was never lack of info on my part. Every time a call was made, they eventually said "no more information is needed". Not sure where you are getting that from ("my lack of info").

    >>.car repair $XXXX.xx without an itemized statement of what was repaired?

    I suppose they could ask for a receipt for each of 4 xrays, instead of one price for x-rays.
    It is obvious nit-picking to avoid paying a valid claim. The price distribution of the $1400
    amongst the 3 bridges is totally irrelevant to anything. The claim code is also obvious to
    any knowledgable person, and is just further nit-picking.

  8. #18
    Join Date
    Jan 2006
    Posts
    38,867

    Default Re: Foreign Dental Claim Denied

    Quote Quoting donaldj
    View Post
    >>due to your lack of providing the necessary information

    once again, there was never lack of info on my part. Every time a call was made, they eventually said "no more information is needed". Not sure where you are getting that from ("my lack of info").

    >>.car repair $XXXX.xx without an itemized statement of what was repaired?

    I suppose they could ask for a receipt for each of 4 xrays, instead of one price for x-rays.
    It is obvious nit-picking to avoid paying a valid claim. The price distribution of the $1400
    amongst the 3 bridges is totally irrelevant to anything. The claim code is also obvious to
    any knowledgable person, and is just further nit-picking.
    where am I getting it?

    from you:

    Delta Dental denied the claim saying we needed a separate claim item from the dentist for each bridge, also identifying teeth involved on each bridge.
    obviously somewhere along the way you were informed they required an itemization of the teeth involved and it must be prepared by the dentist.


    No, it's not nit picking, especially when they demand the dentist provide a list of the teeth involved. It is for, among other things, to protect the insurance company from fraudulent claims in the future.

  9. #19

    Default Re: Foreign Dental Claim Denied

    That decision was just received yesterday, after a 6 to 7 months of "processing?".
    And once again, they repeatedly said no additional info was needed on the phone calls.

  10. #20
    Join Date
    Sep 2005
    Location
    Behind a Desk
    Posts
    98,846

    Default Re: Foreign Dental Claim Denied

    Okay: Here's the deal: You can get together the information they require, and try to make a valid claim. You can pursue the administrative appeal process of the denial -- but if you failed to properly document your claim consistent with the requirements of your contract, you will lose. Once you have exhausted those appeals, if this is an ERISA plan you can hire a lawyer and file a federal lawsuit -- but if you failed to properly document your claim as required by the insurance contract, you will lose, and it will cost you $thousands. Also, you won't get your lawyer fees back even if the insurance company decides that the easiest thing to do at that point is to pay off the claim.

    You don't need to argue with me that it's not fair, or that it's difficult, or that if somebody gave you the wrong impression about what documentation you needed the insurance company should give you the benefit of the doubt. But the insurance company can nonetheless buckle down and insist that you follow the terms of your insurance contract.

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