Legal Question in Insurance Law in Texas

Dental work done for a medical injury, coverage denied

About a year ago, I broke my jaw playing soccer. At the time, I had medical coverage but no dental coverage with my insurance company. A broken jaw, however, classifies as a medical injury, so after a quick phone call, the insurance company assured my parents that all expenses related to treatment of the accident would be covered, EVEN if some of the expenses were technically dental work. They just had to put in the proper ''medical-dental crossover codes.''

I had two jaw surgeries, which are considered medical procedures. The oral surgeon gave me instructions to see a dentist for root canals, an orthodontist for braces, and a periodontist for a tooth implant. I have completed the first requirement and am almost done with the second. But the insurance company now denies my claims, stating I don't have dental coverage. The appeals have been denied as well.

So, I feel that because all this resulted directly from a medical injury, I should be covered and my claims should not be denied. But I have no idea what to do.


Asked on 3/11/04, 5:14 pm

2 Answers from Attorneys
Dan Street Street Law Firm

Re: Dental work done for a medical injury, coverage denied

Unfortunately, your situation is not unique. It seems insurance companies will deny any claim they think they can get away with. There is really no way to determine who is right without examining the insurance policy. After all, the policy is merely a contract (albeit unilateral), and the terms of the contract determine the rights and remedies of the parties. In the end, you will probably have to hire an attorney, and, of course, will have to pay your attorney either by the hour or on a contingency basis. Because it is a contract dispute, your attorney can sue for attorney's fees, but these will not be paid by the insurance company unless you go all the way through a trial and win.

Read more
Answered on 3/11/04, 6:06 pm
Alvin Lundgren Alvin R. Lundgren, L.C.

Re: Dental work done for a medical injury, coverage denied

IF you have exhausted all of your administrative remedies through the insurance company you will have to either sue or file for arbitration - depending on the terms of the policy. The policy sets out all of the administrative remedies you will have to follow, as well as the procedure if that is unsuccessful. You should consider getting legal assistance since you will be dealing with the insurance company lawyers, who tend to be aggressive and pretty competent. You may call for a free consultation if you like.

Read more
Answered on 3/11/04, 10:52 pm


Related Questions & Answers

More Insurance Law questions and answers in Texas