What Is A “Missing Tooth Clause”?

Dental insurance can be complicated and confusing. Just ask anyone who has been told their plan has a “missing tooth clause.”

What is a missing tooth clause exactly? When a company has a provision in their contract that states that if a tooth is lost before the contract begins, they don’t bear any responsibility to cover replacing the tooth. The cost of replacing the tooth, whether via bridge or crown, falls on the patient.

The worst case scenario is when the dentist has already done the work to fix the tooth, a claim is filed and is then denied. At this point, the patient in question has a hefty bill on their hands.

The best way to avoid this situation is to research your policy before undergoing any procedures. When you change your dental insurance plan, spend some time reading the fine print. While figuring this out can be annoying and will likely require some time on the phone with your insurance company, it is worth it in the end.

If you discover that your insurance company does have a missing tooth clause, but you still need the procedure, you can set up a predetermination.

A predetermination, as defined by the American Dental Association, is an estimate of who pays for what on a particular service. While you still might be paying more than you would like, at least you know what you are getting into and you can budget, save, or set up a payment plan.

Start by having your dentist set up a treatment proposal plan and ask the insurance company to review it. According to WebMD, other terms for a predetermination arrangement include preauthorization, precertification, pretreatment review, or prior authorization.

The American Dental Association‘s website has an extensive glossary available where you can get familiar with dental insurance terms. Knowledge is power when it comes to dealing with insurance companies.

Another option for resolving the matter is asking if your insurance company has a policy of waiving the clause if the tooth extraction and beginning of coverage fall within a certain time period. Some insurance companies will do this if the tooth was extracted within 3 years of the proposed replacement date.

Another way to handle the situation is to ask if the procedure can be covered after a specific waiting period.

Above all, remember that politeness and persistence are key to getting what you want from your insurance company!

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