Grievance Or Appeal: Insurance Coverage And Limitations (Responding To Readers)

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Dear Pastor D.M.,

I went to the dentist last year to have a deep cleaning. I was told by the dentistry to expect 3D x-rays regarding my teeth when I came in for the deep cleaning. I called my insurance company the same week I went to the dentist (before I went to the dentist) to make sure I was covered for the service. The agent who took my call said, “You’re covered for your deep cleaning and 3D x-rays.” Right after my call with the agent, I went ahead and booked my dentist appointment for the end of the week.

I went to have my deep cleaning and 3D X-rays. Once my insurance card was run, I was told by the dentistry that “you don’t have a deep cleaning or 3D X-ray benefit available.” It wasn’t too long after this that the dental insurance provider wrote me and said, “your benefit has been exhausted.” I didn’t recall having used my benefit and I was told by the agent that I was covered, so I called back to the insurance company to find out the problem.

The agent who took my call this time (a different one), heard my case and issue and then went to look at my benefits. The agent said, “you qualify for a deep cleaning and 3D X-rays once every three years. Have you had a deep cleaning and 3D X-rays done within the past three years?” I told the agent I couldn’t recall because I honestly didn’t remember. The agent said, “No problem, I’ll call over to the dental provider and see what I can find out.”

The agent got back with me in no time at all and said, “It appears that, according to the records, you did have a deep cleaning and 3D x-rays done on such and such date, which is within the 3 years. This means that this benefit will not be redeemable again until such and such date.” The agent told me that, all things being what they are, the benefit is exhausted for now and that I am left to pay the dental bill because I’ve already used my benefit. The agent also told me that I have a non-covered services discount I received, so I saved a good percentage on that deep cleaning and 3D X-rays though I didn’t escape the full price of the dental work.

But the problem is that the first agent who told me “you’re covered” didn’t tell me that I’d already used the benefit. Had I known I’d already used it and didn’t qualify, I wouldn’t have gone and gotten those dental services done. Had I known, I wouldn’t have gone and created a dental bill for myself that I cannot afford to pay. I already have super affordable dental insurance and I keep it that way because I live on a fixed income. I can’t create bills when I know I cannot pay them. The first agent should’ve done a better job making me aware that I wouldn’t be covered for those services. Had he or she done their job, I wouldn’t have a new dental bill I can’t afford to pay.

I think the insurance company should foot this dental bill and I should owe nothing because the failure is not in me but in an insurance agent I trusted to give me all the details. The second agent filed a grievance, but I want to appeal my dental bill with the insurance company.

What should I do? Any help or advice you offer will be greatly appreciated.

Thanks, A Concerned Reader

what exactly did the agent say about your deep cleaning and 3D x-ray benefit?

Dear Concerned Reader,

Thank you so much for writing us here at The Essential Church! I’m sorry to hear about the dental bill you have and that you have been left to pay it because your benefit has been exhausted. I understand just how frustrating it can be when you feel you have been deceived or lied to. What I want to do in this response is be gracious but truthful. I want to walk that grace and truth line because I feel that it is necessary when giving people rich advice.

So with that said, let me first say that I’m sorry for the dental bill and expense. I can imagine it’s unnerving when you’re having to pay a bill that you can’t afford to pay.

But first, let me ask a question: what exactly did the insurance agent say? I’m talking about the first insurance agent. When you called in last year about your deep cleaning and 3D x-ray benefit, what did the agent tell you? Do you have a direct quote the agent said? Do you recall the details of what the agent said?

Why am I asking these questions? I ask them because I’ve found that sometimes, what we say and what others hear are two different things. Have you ever heard of the game called “Telephone”? It’s a game where someone starts off saying something and then they pass it on to others. By the time you get to the last person, what they say and what the first person said are entirely different. Why is this the case? Because people don’t listen accurately. They hear bits and pieces of info and then pass it on without context.

And even in the case of Adam and Eve, despite hearing what God said and being able to at least tell it to the serpent (though Eve went too far in what God said to do; He didn’t tell her not to touch the fruit, but rather, not to eat the forbidden fruit), in the end, Adam and Eve disobeyed God because the serpent made them think there was no loss in disobeying God. The serpent told them they would become Gods, and that’s all they heard. Oh, they could quote back the consequences, but they didn’t care. In other words, in the moment, they heard what they wanted to hear.

You said the agent told you that “you are covered,” but what did the agent say exactly? Is that all the agent said? Did the agent say “you’re covered” or did they say “you’re covered once every three years”? Perhaps you cannot remember. Did you ask the agent to read the benefit to you, word for word (verbatim)? Did you ask the agent, “what does once every three years mean?”

“Covered once every three years” is still “covered”; the difference, however, is that one phrase (“you’re covered”) doesn’t have limitations, while the other phrase does (“covered once every three years”). Even if you only get to use the benefit once every three years, you still have insurance coverage — it’s just that you’re not covered every year for the benefit, nor does the benefit allow you to get unlimited deep cleanings or x-rays done.

You can’t get deep cleanings twice a year, for example, or x-rays done every year. Simply because the benefit is only allowed once every three years doesn’t mean you don’t have coverage. It simply means that your coverage for that particular benefit has a timeframe limitation (only once within three years).

did the agent intend to deceive?

Did the agent intend to deceive? That’s another question to ask when determining whether or not there is a case to be made for an appeal. Not only is there a matter of what the agent said exactly (a quote would be ideal), but also, whether or not the agent intended to deceive. Intent cannot be proven without documentation or conversation.

In the absence of info, the agent can’t be faulted for providing you with the information available to them at that time. Do we know if the agent failed to read the benefit? Did the agent read only part of the benefit statement? Did the agent just say “you’re covered” and leave it at that? or did the agent read, “You’re covered, once every 3 years”?

Intent to deceive says that the agent meant to falsify the info provided in order to harm the member. There’s no proof of that. That makes the case difficult to merit an appeal.

member responsibility

Aside from the agent, what did you do on the call? Did you mandate the agent to read the benefit to you, word for word? Did you ask the agent for more details? Did you inquire about the agent sending you a paper copy of your benefits summary? As I said above, it could be the case that the agent said “covered once every three years” but you simply heard “covered” and ran to get the dental work done, not stopping to think about what you’d heard. Perhaps you forgot what was said in full because you heard “covered” and tuned out everything after that.

There’s also the possibility that the agent said “you’re covered” and left it at that. And in the event the agent did that, the agent bears some responsibility for the cost. With the phrase “you’re covered,” it’s easy to assume that one is covered every calendar year. And so, when the timeframe limitation “once every three years” isn’t mentioned, it’s easy to think that a member would be deceived by such information.

The fact that you went the same week to get your dental work done shows that you believed your benefit worked every year. Whether you assumed this and forgot what the agent told you, or the agent forgot to specify the timeframe limitation, is a matter of a coin toss. There’s simply no way to know what happened in that conversation.

But, even when an agent forgets to specify that timeframe limitation, members are still not off the hook with regard to what they’re paying for. It simply astounds me to think that members are paying for insurance plans but have no idea what they’re paying for. You said in your letter that you live on a fixed income and that you try to keep your insurance premium at an affordable price. It takes conscious effort to ensure your insurance premium doesn’t get over your head, doesn’t it?

And it takes that same meticulous attention when it comes to your benefits, the whole point of paying the premium in the first place. And the same responsibility you have to budget your bills and choose your insurance plan wisely is the same responsibility you have to investigate your benefits to ensure you’re getting the most for your money. It’s not enough to just ensure your premium is affordable; you must also check your benefits to see if your money is going far enough. That’s what you do when you want the most benefit for the most affordable cost.

And in that regard, it appears as though you took the word of the agent and ran with it instead of requesting your own benefits summary and viewing it yourself. Additionally, you could have also requested that the dentistry run your benefits card before you had the dental work done. That would have also alerted you that something was wrong bc you would’ve discovered that you don’t have a deep cleaning and 3D X-ray benefit available. That would have prompted you to call the insurance company before amassing a sizable bill.

It just doesn’t appear that you did enough to show your commitment to your own peace of mind. And your neglect of your individual responsibility over a plan you pay for consciously each month is another reason why you don’t have a case for an appeal. You cannot appeal wrongdoing when you failed to protect or educate yourself.

A homeowner cannot request financial payment for a robbery when they 1) failed to replace the locks on their doors and left the locks broken, 2) didn’t install a security system, 3) didn’t install a home surveillance system, 4) didn’t add floodlights that would help reveal a potential thief or burglar, and so on. Insurance companies do not pay out in robberies where the homeowner failed to protect himself or herself; the same goes for a situation such as yours.

You can’t file an appeal for financial compensation in a situation where you failed to request your own benefits summary and look out for your own money. If you had the know-how to ensure your insurance premium remains affordable, then you have a responsibility to educate yourself regarding your benefits.

No agent, no matter how incompetent, is responsible for your own neglect. No agent is responsible for what you fail to do for yourself.

Grievance vs. Appeal: why an appeal is invalid in this case

And this brings me to one final point regarding your case: that is, your desire to write an appeal for your case.

Appeals and grievances are two different types of complaints and deserve some discussion.

What are grievances? Grievances are a complaint made against a doctor or provider based on how one was treated in an appointment, whether or not the work was done in a manner that pleased the member, whether or not the member was covered for services their benefit entitles them to, whether the facility or provider billed them for something that should’ve been covered under their plan, and so on.

In this case, you weren’t treated wrong financially by the dentistry. You were billed correctly. You had to pay full price for your deep cleaning and 3D X-rays. The dental provider wasn’t wrong when it wrote you and said that “your benefit has been exhausted.” It is true: you had already used your benefit. The second agent was able to obtain the information regarding that, so the information is accurate. You weren’t assumed to have gone in for dental work that you never received. No one assumed your identity to have the dental work done in your name to escape payment.

There’s no financial wrongdoing in this case. You’ve exhausted your deep cleaning/3D X-ray benefit, so you owe the full price for the work done last year.

You’re simply upset because you believe the insurance agent didn’t go far enough in the details to inform you. You believe the agent should’ve done more to emphasize that you’d already used your benefit. While that may or may not be a valid belief, it isn’t a financial issue. That is an issue of neglect, or an issue of human error. That human error could be on your part, not necessarily the agent.

And so, in the absence of a financial issue, you don’t have a case for an appeal. Your issue rises to the level of a grievance, since you want to file a complaint against an agent. The agent, however is neither the dentistry nor the dental provider. The dentistry and dental provider didn’t wrong you. And, as far as we can know, the agent didn’t either.

In the end, you’re stuck with a bill because you failed to protect yourself. And while that is very unfortunate, it is a case of neglect, not financial wrongdoing. Appeals pertain to financial wrongdoing or error, not neglect or a lack of being thorough.

The good news in all of this is that you received a discount on those dental services, despite the fact you’ve exhausted your benefit for now. It’s not full coverage, but it is nice that you still got a discount for those services. The second agent filed a grievance, which is in step with your case. Unfortunately, there is no just cause for an appeal. You can still file an appeal, however, but there’s little hope that your bill will be overturned or eliminated.

advice for the future: make your insurance plan work for you, not against you

I don’t want to end this response without providing some advice for the future.

First, request a paper copy of your benefit summary. Once it arrives at your residence, keep it in your important files in the event you ever need to access it. Go over your benefits each year, as a new year could bring the addition of more benefits. You should request your benefits summary each year.

Next, read the benefits summary. Don’t just get it and throw it in your important paper stack. Look at it, review your benefits. If there’s something in your benefits that you can’t understand, contact your insurance company.

Last but never least, before you get any dental work done (and I mean, before you go for an initial consultation or evaluation), have the provider run your insurance card to verify 1) that you have benefits and 2) that your benefit(s) isn’t exhausted. Providers can run your insurance card like a store can run your credit — before you get any medical treatment at all.

If you’re going to a dentist, the dentistry can run your insurance card and then provide a list of charges and services, stating what you owe for non-covered services and what services are covered under your benefits. Had you done this in the beginning, you would’ve discovered that your benefit has been exhausted and you would’ve saved yourself the unwanted dental bill.

Once that insurance card is run and you receive a list of charges, inquire about any services or terms you aren’t sure about. For example, if a dentist wants to do some type of procedure that you’ve never heard of, ask the dentist, “What’s this mean? Explain to me what this is,” and so on. If you do enough interrogation, you’ll be able to tell the dentist what you’re willing and unwilling to pay for.

If a provider says “you can’t get a covered service done without paying for non-covered services,” call your insurance company, report the incident, and then ask the insurance company to give you another provider in-network that won’t force non-covered services on you. You can also request a provider directory from your insurance company whether you have an HMO or PPO plan.

As a final reminder, please remember that ignorance (that is, not knowing something) isn’t bliss and that what you don’t know can (and will) hurt you.

Thank you so much for contacting us. We wish you the best of blessings in your future endeavors and in getting the bill paid.

Do you believe you’ve been the victim of wrongdoing? Would you like for Pastor D.M. to give you some advice? If so, please feel free to contact The Essential Church at the Contact page here at the site. We’d love to hear from you.