John C. Chao, DDS, MAGD

Research Associate Professor, Post Graduate Program in Periodontics, SUNY – Buffalo (University at Buffalo)
Anxiety Management, Faculty, USC School of Dentistry

(626) 308-9104

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John C. Chao, D.D.S., M.A.G.D
Anxiety Management,
Behavior Science,
Faculty, USC School of Dentistry

Why Doesn't My Insurance Cover This?

One of the most commonly asked questions is, "Why doesn't my insurance cover this?" There is no such thing as "Dental Insurance." The term "insurance" means "protection against loss."

Dental plans do not insure the patient against loss of any kind. That is why dental plans never include the word "insurance" after their name. Dental plans do not fully insure you for the expenses needed to keep you in good dental health for life.

Dental plans are merely a collection of benefits determined through negotiation between the dental plan representatives and employers. These benefits are based on what the employer can afford to pay. Therefore, the higher the premium paid by the employer, the better your benefits will be. These benefits will help defray the cost of treatment covered by the plan.

If a dental procedure is not covered, it means that the premium paid by your employer does not allow for this procedure to be covered. Again, your dental plan does not insure you against loss of dental health. If you allow your dental coverage to determine your dental treatment, you can place your teeth at risk of inadequate treatment, lack of treatment altogether or recurrence of a disease. Your dental plan cannot be held responsible for the loss of your teeth as a result of lack of treatment or under-treatment.

The good news is that most standard procedures needed are likely to be covered at least to a certain extent. The actual amount covered for a particular procedure depends on what your dental plan decides is the "usual, customary and reasonable" (UCR) fee for that procedure. The bad news is that UCR's vary greatly among dental plan carriers. Sometimes the same carrier has different UCR's for different policies. Some plans cover very little, while others cover more. Your dentist, however, can generally estimate the amount that would be covered based upon previous experience and can help you negotiate the complicities of dental plans.

Sometimes the amount of benefits covered is lower than what the patient expects; this is due to the fact that the annual maximum of most dental plans is $1000 to $1500. This annual maximum was adopted in the 1960's and has been the standard for approximately 50 years. Inflation over 50 years has eroded the value of the annual maximum. Nevertheless, this amount of benefits is still substantial and should be properly and intelligently utilized. For example, your dentist may offer you the option of postponing some non-urgent treatment until the next calendar or contract year so that you can take advantage of the next year maximum. No matter what kind of plan you have, your dentist is likely to recommend that you not leave that yearly benefit unused when treatment is necessary.

If you believe a procedure should be covered better than estimated, inform your employer of the problem. Your employer can most effectively correct the problem for you because the employer is paying the monthly premiums and has the option of not renewing the contract at the end of the contract period (generally November). Engaging the help of your employer or your personnel department would probably be the most effective way to address the issue. In the meantime, if you want to proceed with a procedure that is not covered but find it hard to afford it, discuss the problem with the dental office staff. Most offices offer extended payment plans, sponsored by financial institutions that offer no interest or relatively competitive interest rates.

There is nothing more important than a healthy smile. However, keeping your smile white and beautiful will sometimes require a financial commitment that might be temporarily uncomfortable, but remember that a smile is the universal language and "when you give someone a smile, the world smiles back."


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