Foreign Dental Insurance Claim Denied

[donaldj]

My question involves insurance law for the state of: Texas. My wife went to Ukraine to have various work done including 3 bridges. The Ukraine dentist receipt included a $1400 item for the 3 bridges. 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. I had included a chart showing teeth involved with each bridge, but it was my chart and not the dentists. Is this a legal basis for denying the claim? Also they have procrastinated greatly in processing this claim (6 months). According to ERISA regulations, I thought 90 days was the max they could delay a claim without written notification? Also are the US procedure codes required to be given by a foreign dentist?
thanks for any info.

[cbg]

I have not read your dental policy. However, it is standard for each bridge to need to be identified separately, including the specific teeth. A chart from you does not fulfill the requirements. Ukrainian dentists are not subject to US laws so if they are responsible for any part of the delay, that's too bad so sad but you chose to go outside the country. There is nothing illegal about Delta requiring that US codes be used.

[adjusterjack]

I thought 90 days was the max they could delay a claim without written notification?

According to you they haven't "delayed" the claim, they "denied" it because you failed to comply with the request for appropriate documentation. That's you delaying the claim, not them.

As for "written" notification, it's hard to believe that you haven't gotten any correspondence at all from Delta Dental in the last 6 months.

[donaldj]

yes, I just got the denial yesterday on one remainging claim item. Claim was submitted 7 months ago. They sent a small payment for a couple of fillings (without any claim codes) one month ago. Those are the only 2 letters we have gotten from them. Of course we have called a dozen times, asking status and have repeatedly been given false information. We called after one month and they said there could be no blank fields on the one page form. Called after 2 months and they said attachments were not allowed (everything had to be on the tiny one page claim). Called after 3 months and they said dentist narrative was missing (it was supplied). Company HR rep faxed it to them again. Called again and were told once again that dentist narrative was missing. After each of these calls, I got a rep from HR or Health Advocates on a 3 way call and they totally changed their story, and said all was fine. Each time they say it will be processed in 10 or 14 or 30 days and it never was..... Filed complaint with State Insurance Board and they could do nothing due to being a self insured company. In regards to "appropriate doc", it was supplied, but they claimed it wasn't. When doing 3 way call they said all doc was fine. The delay was in NO PART due to missing info on my part.

[hr for me]

Honestly, I am very surprised that they would pay for the out of country dental work at all. And would expect the claim to not go smoothly especially if there is any kind of language barrier.

[donaldj]

Foreign medical/dental is very common these days. After a quote of $20000 from local dentist and $1400 from my wife's former dentist, decision was easy. There are no language barriers in 2017. Another family member had surgery in Moscow for 500k rubles. United Healthcare paid claim quickly even though claim was not itemized.

[cbg]

Which does not change the fact that most policies won't pay foreign claims at all.

[donaldj]

>>most policies won't pay foreign claims at all.
That is irrelevant. Policy is usually clear about whether or not it does. You seem to be very biased.
If you accept foreign claim, I would think there would be no way you could require a foreign dentist to use a USA claim code.
If so, the policy should clearly state that.

[cbg]

As I said, I have not read your policy. But I do work with insurance every day of my working life.

You are making the same mistake most people make. Your insurance policy has no legal obligation to pay anything at all unless all the requirements for paying a claim are fulfilled. If a foreign dentist does not want to use US codes, the insurance carrier cannot force him, that's true. But the part you are missing is that if he does not, the insurance carrier is not obligated to pay since all the requirements will not have been fulfilled. THAT IS LEGAL.

[donaldj]

>THAT IS LEGAL
can you quote a legal source that says that?
they paid all the "small" items without any claim codes.
how can they deny a "large" item because claim code is missing?