Worst Claim Story- September 2017

In the world of insurance submittals it was simply unquestionable as far as whether it was a benefit of the policy.  The 85 year old sweet grandma had Delta premiere with $1500.00 a year calendar benefits and she had used just $250.00.  She had been a school teacher all her life and was covered by Delta for decades and now she was retired.  Her 20 year old fixed bridge on the lower right quadrant had fractured at the pontic.  It was a material failure, not the tooth.  The appointments went without incident with a perfect result of a porcelain fused to high noble three unit fixed bridge with perfect margins to restore her bite to function.

It was submitted with pre and post radiographs, and a narrative as to the history and reason for replacement.  It was DENIED!

A call to the representative revealed a very vague “Need more information” kind of response to which I challenged,  “What do you need?  I can provide it if I haven’t already!”

What I finally found out was that Delta did not want to pay for a bridge on an 85 year old patient because the “bone level looked questionable.”

I contacted her son and asked if he would take her to a periodontist that we recommended to get a report on the bone and tissue supporting the bridge.  He agreed.  I then sent the entire package again including the report from the periodontist stating that the bone and tissue were healthy and there was a very good long term prognosis for the bridge.

After almost a year, 3 denials, numerous calls and getting the patient and her son involved Delta paid this claim at 50% which was a total of $1,000.00.  The patient and her son were very pleased.

eAssist Helpful News and Billing Tips; Edition #115


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