Health & Wellness

Dental Crown Denied What Now?

  • Last Updated:
  • Dec 10th, 2019 12:46 am
[OP]
Deal Addict
Dec 16, 2012
2537 posts
471 upvotes
Vancouver

Dental Crown Denied What Now?

Hi

My wife needs a crown on her front tooth as it was root canaled and now it needs a crown on it. My Dentist has sent a few times now the estimate and each time it gets denied for the following reason.
However, under the terms of your dental plan, a major restoration is only an eligible expense when there is
extensive loss of tooth structure and the tooth cannot be adequately restored by a filling
My dentist has followed up saying it needs to be done and sent photos and images but they wont' budge.

Is there a complaint office I can file as I think this BS that they are basically saying that all we need to do is a filling and everything would be all right and won't do it.

I found this site: https://www.olhi.ca/ but not sure if it is the right thing.

Everything way probably next month we will have to get it done but I still would like to file some sort of complaint or something.
2 replies
Deal Addict
Oct 6, 2015
2463 posts
1367 upvotes
Talk to your employer -- presumably they've purchased this plan on your behalf, and if the insurance company is denying a benefit that is supposed to be legitimately covered per their contract, then they can escalate the matter. After all, its the employer that's being ripped off as well if the benefit is not being paid yet is supposed to be.
Deal Fanatic
Oct 26, 2008
6359 posts
2006 upvotes
BC
Blue Cross, Green Shield or whoever, they are in the business of minimizing what they pay out for covered procedures.

Not every root canal treatment requires a crown. Depends on how much the tooth has been weakened as a result of the decay that necessitated the root canal treatment, and that treatment itself.

And maybe the location of the tooth. I would think that front teeth (incisors and canine) are subjected to less strong biting pressures than pre-molars and molars.

Your wife's plan will have criteria regarding how much structure must have been lost before they will pay for a crown, and I don't think they document this even for dental offices.

While her dentist may feel a crown is in her best interests, a discussion could be had about a post and a filling now with a view to having a crown down the road when it may eventually meet the criteria.

Different dentists may have differing views because there are pros and cons of a crown even without the issue of whether it is covered by insurance.

Sounds like her dentist has exhausted all appeals so your lodging a complaint won't do much unfortunately.

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