Dental and Other Health Insurance; Consumer Protection and Claims
Dental insurance
Dental plans group services into preventive, basic/restorative, major, and orthodontic categories, each with its own coinsurance. Scheduled plans pay a fixed fee per procedure; nonscheduled plans pay a percentage of UCR charges. Watch for annual maximums, deductibles, waiting periods, and the missing tooth clause (no coverage for replacing a tooth lost before coverage began). Predetermination submits a treatment plan for a pre-treatment benefit estimate, and coordination of benefits determines primary versus secondary payment.
Long-term care
LTC pays for custodial care when the insured cannot perform at least 2 of 6 activities of daily living (bathing, dressing, eating, toileting, transferring, continence) or has a cognitive impairment. Know elimination periods (calendar-day versus service-day), reimbursement versus indemnity benefits, benefit periods, and inflation protection. Tax-qualified policies receive favorable tax treatment and may be part of state partnership programs.
Other coverages
Vision, critical illness, cancer, accident, and hospital indemnity policies pay fixed benefits and are not substitutes for major medical.
Consumer protection and claims
Know HIPAA privacy, ERISA claims and appeal procedures, state unfair claim settlement practices acts, prompt-pay rules, and the insurer's duty to investigate and settle fairly. Insurance fraud includes false claims, application misrepresentation, and STOLI (stranger-originated life insurance). Producers must not misrepresent coverage when soliciting, must forward claims promptly, and must protect confidentiality; state immunity statutes encourage fraud reporting.
Worked example
An insured's crown is estimated at $1,200. With a $50 deductible, 20% coinsurance on basic services, and a $1,000 annual maximum, the plan pays the lesser of 80% of $1,150 ($920) or the remaining maximum - $920 here, leaving $280 to the insured.