Medical benefits protect patients from catastrophic and unpredictable loss due to illness or accident. Medical insurers consider these potentially extremely high-priced scenarios when determining premiums and coverage. Medical policies usually require some cost-sharing through annual deductibles and co-payments, then provide coverage for the majority of costs incurred during the year after the deductible is met.
In contrast, the average dental care cost per-person per-year is well under $1,000, an amount that insurance companies do not consider “an insurable risk.” Therefore, dental benefit plans are designed to make available a finite amount of money (the “total maximum benefit”—which rarely exceeds $2,000 per year and is often significantly less) to help cover dental care. Once the benefit is used, the patient is responsible for all other dental costs.
Insurance companies reason that since most oral disease can be prevented by personal dental hygiene and regular cleanings, dental benefit plans are designed to encourage regular check-ups. This works well until further treatment is required and dental benefits can be exhausted very quickly.
Additionally, the average dental benefit amount has not increased significantly in 30 years!
Preauthorization or eligibility determination through dental plans does not guarantee payment by the plan; it is simply an estimate.
Dental benefit plans also may limit the frequency of coverage for certain services for a given year, including examinations, radiographs and root canal retreatments.