Thursday, October 17, 2013

Bitching out MetLife Dental...

Those fuckers at MetLife Dental, which provides insurance to TRICARE beneficiaries, decided that the crown I just got was "unnecessary".  I hate dealing with insurance people.  I think insurance is basically a racket with companies doing all they can to deny legitimate claims.  Yesterday, after coming home from the dentist with a very necessary new crown, I found a denial letter in my mailbox from MetLife.  I have just spent a month on this ordeal, which would have been more expensive and unpleasant had I waited until the tooth was worse.  Anyway, for your shits and giggles, this is the first letter I'm sending to MetLife Dental.  I suspect it will take more than this, but it's a start.

This is a very common situation when it comes to dental insurance companies and MetLife in particular.  It pisses me off that I have to spend time writing letters and on the phone in order to get this company to do what it is paid to do.  But as I am an overeducated housewife with plenty of time on my hands, I guess it's what I'll do.

To Whom It May Concern:

I just received an EOB for services I received September 18, 2013 at La Cantera Dental in San Antonio, Texas.  The claim for a crown porcelain-base metal and a core buildup was denied.  

The notes on the EOB explaining the denials were:

J-72: Based on the information submitted and reviewed by our consulting dentists, no benefits can be allowed for this procedure because there appears to be insufficient evidence of extensive loss of tooth structure due to decay or fracture.

M-8Q: Benefits for a core buildup are available only when the tooth qualifies for prosthetic crown benefits and there is insufficient anatomical crown remaining to provide retention for the crown.  The clinical information submitted and reviewed by our consulting dentists did not appear to meet these criteria.

I visited the dentist on September 11, 2013 because tooth #19, which is a large molar on the left bottom side of my mouth, was giving me significant pain and was sensitive to cold and sweet foods.  My dentist, Dr. Victoria L.G. Thompson, who is a graduate of both Northwestern University and the dental school at the University of Michigan, examined the tooth.  She then pulled out a mirror, which she used to show me the large crack on the outside of the tooth.  This dentist, whom I assume must be very competent since she is properly licensed in Texas and is a member of your preferred provider network, told me that to fix the crack and end the pain and sensitivity, I would need to get a crown.

I wasn’t thrilled to hear that I would need a crown.  I have another tooth that was crowned in 2006 and again in 2011, so I knew ahead of time what goes into getting a crown.  I assure you that had a less intensive option been available to me, I would have preferred it to getting injections that numbed my mouth, having my tooth ground into a nub, and wearing a temporary crown for weeks while the permanent crown was made for me.  However, both Dr. Thompson and a number of reputable dental Web sites advised me that in order to fix the tooth, I would need to have the crown done or the crack in the molar would get worse and I would eventually experience more pain.  Under the circumstances, it was an educated decision and indeed, since I have gotten the procedure, the pain and sensitivity have abated.  

I am not a dentist, so I had no way of knowing what kind of “cheaper treatment” I could have had done to save my tooth from further decay and damage.  I am, however, a prudent person and it seemed wisest to seek dental care when my tooth started bothering me.  Otherwise, I feared the tooth would eventually need root canal treatment, which would have been even more painful and costly.  Moreover, since Dr. Thompson is a competent and licensed dentist who has actually looked inside my mouth, I am inclined to trust her judgment over that of your “consulting dentists”.  It’s ridiculous that your “consulting dentists” apparently expect beneficiaries to wait until they are in severe pain to seek dental care, which will ultimately be more expensive and unpleasant for the patient.

My husband has spent about 30 years in the Army and will soon be retiring.  Every month, we faithfully pay $36 a month so I can have dental insurance through your company.  I have not needed any major procedures over the years.  Until now, your company has made money off of me.  In your brochure, it clearly states that the MetLife Dental Insurance policy covers 50% of a crown procedure.  I have paid for my part of this procedure and I expect your company to pay its share promptly and as promised.

If you continue to deny my legitimate claim, I am prepared to complain to the Texas Department of Insurance as well as to the appropriate department in the military that makes decisions about which dental insurance carriers should provide services to TRICARE beneficiaries.    

Please attend to this matter promptly.


Sincerely,

    

6 comments:

  1. Great letter. My dad absolutely hates the power that insurance companies have.

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    1. I'm sure your dad has to deal with these headaches all the time. It's criminal that people pay these insurance companies and they have the right to deny holding up their end of the deal. Wouldn't it be great if we could do away with insurance entirely and let people pay their providers directly?

      Of course, that will never happen... but it's nice to think about it. I know there are providers out there, regular doctors even, who don't take insurance. I'm sure they have fewer patients and corresponding fewer headaches.

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  2. I have just received an identical letter from my insurance for the same denial reason. I am researching how to react and came across your blog. Would you mind giving me an update on how it ended up for you?

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    1. Hi Kelly,

      MetLife eventually paid. Here's an update. http://theovereducatedhousewife.blogspot.com/2013/12/more-ambitious-today.html

      I found it very effective to on their Facebook page and leave comments. They prefer to handle it directly, but when you leave comments on their Facebook that are public, it tends to rile up others with the same problem. It seems to light a fire under them (or at least it does for Tricare). Also, you might want to look into whether or not you can file a complaint with your state's department of insurance. Dental insurers don't like it when regulators check up on them.

      Good luck!

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  3. I too just received a denial from MetLife Dental for an onlay on a tooth with an old, large existing composite filling that had major decay. They used the same excuse - "J-72" about insufficient evidence, etc. I've had them for 4 years and have only had a filling done and no issues. I'm so pissed that I have to now appeal this issue. I'm curious - did you ever get them to pay the claim?

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    1. MetLife eventually paid. Here's an update. http://theovereducatedhousewife.blogspot.com/2013/12/more-ambitious-today.html

      I had another crown done in March and they paid for that one with no issues. In a couple of weeks, they won't be my insurer anymore, since my husband is leaving the Army.

      I recommend sending them a stern letter.

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