What is a missing tooth clause?
What is the legal definition of this provision?
How does your dental insurance coverage work?
In this article, we will break down the notion of “missing tooth clause” so you know all there is to know about it!
We will look at what is a missing tooth clause, what it means to have dental insurance with no missing tooth clause or one that includes one, what are the important points you must consider before going forward with a tooth replacement procedure and what options are available to you!
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Table of Contents
What is a missing tooth clause
A missing tooth clause or a replacement clause is a contractual provision in a dental insurance contract where the insurance company excludes liability in certain circumstances for the cost of replacing a tooth.
With a missing tooth clause dental insurance, the insurance provider can deny coverage for the cost of the tooth replacement procedure if the tooth was lost, extracted or removed before the policy coverage started taking effect.
In other words, if you start your dental insurance coverage with a missing tooth, you are considered to have a pre-existing condition that will be excluded from your policy coverage.
It’s important to note that insurance companies consider the replacement of a lost tooth as a major dental procedure as it can result in higher costs to them.
Missing tooth clause definition
A missing tooth clause is a contractual clause protecting insurance companies from paying for a missing tooth’s replacement cost if the tooth was missing when the dental policy coverage came into effect.
Over 90% of dental insurance policies include a “missing tooth clause”.
Based on this contractual protection, an insurance company can deny coverage or refuse to pay for what you may have already incurred as tooth replacement charges or for a treatment plan proposed by your dentist.
If you have a missing tooth and need to have it restored or replaced, you are advised to read the fine print of your dental insurance coverage.
Insurance policy considerations
Whether you are a human resources professional looking after your company’s dental benefits and insurance coverage or looking for dental insurance coverage for yourself, you must be aware of the missing tooth clause or missing tooth exclusion.
A missing tooth provision in an insurance policy is a contractual term allowing the insurance company to deny coverage for the cost of replacing a missing tooth.
Most dental insurance policies will have this type of clause, so it’s important to understand what it means and what it entails.
Two aspects must be considered in a dental insurance policy:
- The terms and conditions of the missing tooth clause
- Whether or not there is a waiting period before a member is eligible for coverage
When evaluating dental coverage, you should first look at the insurance policy’s fine print to see if the insurance carrier covers the costs for restoring or replacing a missing tooth.
Suppose you see that the policy has a missing tooth provision.
In that case, you’ll know that the policy beneficiary will not be covered for the replacement of a missing tooth if the tooth was already missing when the policy took effect.
The pre-existing missing tooth’s replacement cost will then need to be assumed by the individual (out-of-pocket expense).
The second thing to evaluate is if there is a “wait period” or “waiting period”.
In some cases, the insurance policy will cover tooth replacement costs but only after the waiting period is over.
For instance, if your dental policy takes effect today and it provides for a twelve-month wait period.
The insurance company will not cover any tooth replacement costs between the effective date of the policy and the completion of the waiting period.
Missing tooth exclusion
If you are not aware of your dental coverage terms, you may end up with the great surprise of having to pay for your tooth replacement.
Before you instruct your dentist to start your tooth restoration or replacement procedure, it’s best that:
- You read the terms of your dental insurance policy
- Get your dentist to give you a tooth replacement estimate
- Contact your insurance company and ask them whether the intended procedure is covered or not
- Get a predetermination (preauthorization or pretreatment review) as defined by the American Dental Association
Just because you have a dental policy does not mean that your insurance company will pay for any missing tooth replacement costs.
By getting your dentist to provide you with an estimate of what the tooth replacement procedure will look like and cost, you can use the treatment proposal plan to ask all the relevant questions to the insurance carrier.
With the missing tooth exclusion provision, your insurance company can consider a missing tooth as an existing condition prior to your policy resulting in non-coverage.
Generally, if you purchase dental insurance before you need a tooth replacement, you should be covered.
However, if you already have a missing tooth, then it’s important to shop around for the right dental coverage to ensure the insurance company did not sneak a missing tooth clause in there.
How to get around missing tooth clause
You have a missing tooth and you need to replace it.
Your insurance policy has a missing tooth clause!
What do you do?
You should do a few things to ensure you get around the missing tooth clause and avoid making a costly dental procedure!
The first thing is to see when did your policy come into effect and if, at that moment, you already had a missing tooth.
If so, your policy will not cover your missing tooth costs.
Let’s say you did not have a missing tooth when the policy came into effect, are you covered?
The next thing to verify is the wait period applicable to the missing tooth restoration procedure.
Since the replacement of a missing tooth is considered a major procedure by insurance companies, you’ll typically need to wait perhaps as long as twelve months before your coverage kicks in.
So if you lost your tooth after your policy came into effect but before your wait period was over, you are still not covered!
Now let’s say that your policy does not cover your missing tooth, how do you get around that?
If you are not covered under your dental insurance plan, you have three options left:
- Look for a new dental insurance plan or coverage with no missing tooth clause
- Find a dentist who can provide you with tooth replacement services at a reduced price that you will need to pay from your pocket
- Find a referral service where you are referred to a dentist that has already predetermined a set discount on the missing tooth replacement cost
Dental discount plan
In situations when your insurance policy does not cover the cost of replacing your missing tooth, you can still choose to go forward with your tooth replacement by negotiating an agreement directly with your dentist.
This is typically called a dental discount plan.
Some dental plans may also work with designated dentists who provide a set percentage off on the cost of the procedure if you are referred to them.
It’s important to look around to find a dentist or have one referred to who is amenable to a discount on the tooth replacement cost.
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