Authored by: Dr. Ilan Price
Dental treatments are an essential yet very costly aspect of healthcare expenses.
To address this need, private dental insurance exists.
Given that dental treatments involve financial complexities as much as medical ones, it is crucial to understand how to navigate wisely with insurance companies.
The complete guide to receiving the best dental treatments with maximum coverage.
How much does dental insurance cost, and what does it cover?
Dental insurance is provided by private insurance companies, with various coverage clauses that vary in scope and precise definitions depending on the policy terms.
Restorative dental treatments are typically included in insurance policies, but they are often subject to specific limitations.
For example, implants, which are one of the most common treatments required by patients, are usually covered by insurance mainly when the implant is placed between two teeth that are considered healthy.
Sometimes, the coverage is limited in terms of the number of implants covered—usually capped at four in most cases.
In terms of crowns, insurance coverage generally applies to older porcelain types and does not include the advanced zirconia crowns.
Gum surgeries are also covered in most policies, but the co-payment for such treatments can be high, sometimes reaching up to 50% of the total treatment cost.
Most insurance companies and policies do not cover the use of laughing gas, repeated treatments within five years of the previous one, emergency treatments abroad, or anesthesia for infants and toddlers.
The cost of dental insurance ranges between 30-200 NIS or more per month for individual coverage with private insurance companies.
Another option is to purchase family insurance.
The prices for family dental policies covering a couple with two children range from 100-500 NIS per month.
Private dental insurance versus group policies
Private dental insurance is contracted personally with insurance companies, whereas group dental insurance is collectively offered to employees in various organizations and companies, or those organized in unions and other groups.
In such cases, the terms of the offered policy are standardized, fixed, and binding on both parties for a specific period, typically lasting 5-6 years.
Participation in such insurance is not always voluntary for employees and may sometimes be a mandatory part of their employment terms.
In most group insurance policies, the employee’s family members can join based on individual consent.
Once an employee and their family members are included in a group insurance policy, they are entitled to receive dental treatments from any licensed dentist in the country.
Contracted dentists who have agreements with the insurance company do not charge policyholders directly for covered treatments but only collect a co-payment, as stipulated in the policy.
The insured need only sign a designated form, and the insurance company pays the full remaining amount directly to the dentist.
In contrast, if an insured individual chooses to receive dental treatment from a non-contracted dentist, they must pay the full amount and submit an original invoice for reimbursement, according to the policy’s terms.
If the amount paid exceeds the maximum coverage amount specified in the policy’s reimbursement table, the insured must cover the difference themselves.
Group dental insurance plans offer varying coverage types depending on the policy, including:
- Restorative treatment insurance
- Periodontal and surgical treatment policies
- Orthodontic coverage
- Dental implant coverage
Does the policy cover the best treatment?
Each policy has different terms, so it’s important to carefully review the offered plan before signing.
In most cases, policies only partially cover the required treatments and may only include the cheapest materials, which could result in lower health and aesthetic outcomes.
For instance, if you need a crown, your insurance may only cover a metal and porcelain crown, which could rust over time, leading to inflammation and gum recession later on, as well as the appearance of a dark ring around the site.
Additionally, sinus lifts and bone grafts are generally not covered in most policies, similar to simple implant procedures after an extraction, more than four implants, temporary crowns, and teeth whitening, which may not be covered or may only be eligible for partial and limited reimbursement.
Therefore, relying solely on the insurance company’s responses and terms may lead you to receive treatment that is not optimal for your actual medical needs.
Is it mandatory to receive treatment at a contracted clinic?
As a rule, every insured person has the basic right, as enshrined in the Patient Rights Law, to receive high-quality medical treatments from any doctor they choose.
Thus, you can undergo treatments at any private clinic of your choice and receive reimbursement according to the coverage listed in your policy.
Remember, your top priority should always be ensuring that the doctor uses the highest quality materials, and you should not hesitate to demand this explicitly.
Insurance companies are not allowed to require you to choose only their contracted doctors and must reimburse you for treatment costs according to the coverage approved in your policy.
How is the reimbursement or coverage for treatment handled?
Usually, treatments at contracted clinics are paid based only on the actual co-payment, with a signed form allowing the dentist to collect the remaining balance from the insurance company.
However, treatments with private dentists who are not contracted with the insurance company must be paid in full by the patient, and an original invoice must be submitted for reimbursement, in line with the policy’s terms.
The difference between these two cases lies in the required process, and the reimbursement when submitting an invoice will not be less in monetary value than what you would receive at contracted clinics.
For instance, if your insurance coverage for a treatment amounts to X NIS, plus the co-payment and upgrade cost for better-quality materials, the insurance company will pay you X NIS after the payment, submission of the invoice, and completion of the claim form.
This amount will be identical to the co-payment you would need to make at a contracted clinic for the exact same treatment.
Be aware that treatments not defined in the policy will not be covered, and the cost of any upgrades will not be reimbursed either.
Is it mandatory to use only the treatments and materials listed in the policy?
The simple answer is: Absolutely not! The insurance company is only obligated to cover the treatments defined by the policy and the materials specified in it or those commonly accepted as standard in the field, but you are entitled to upgrade treatment materials and follow your doctor’s full professional recommendations.
Even if they do not align with the insurance company’s guidelines.
These upgrades will not be reimbursed by the insurance company, but they also won’t reduce your entitlement to the coverage you are eligible for or diminish its value.
Never compromise on the quality of materials or the professionalism of the doctors treating you! It is always better to undergo the treatment that best meets your health needs from the outset.
No insurance company can prevent this from you.
In the case of an unjustified rejection by the insurance company, it is possible and advisable to appeal with a form provided by your personal doctor.
Final tip: Always keep a well-organized folder with all your correspondence related to your insurance claim with the insurance company to ensure you receive all the rights you are entitled to.
In summary, always prioritize your health and act wisely, responsibly, and assertively with insurance companies!
Private dental insurance and reimbursement from insurance companies are the perfect solution to get maximum coverage for dental treatments. Reimbursement for dental insurance and claims in dental insurance are among the services we offer to ensure you receive the benefits you are entitled to. Responsibility, quality, and innovation are our core values. Contact us for consultation and appointment scheduling.
