Question re: Dental plan exclusion for "accident repair."

[Guest FAQ]

While reviewing a self-insured dental plan for compliance with ERISA et al, I came across an exclusion for "charges for accident repair while in the hospital." "Accident repair" is not defined.

I imagine it would exclude dental work if, for example, a participant had a few teeth knocked out by a steering wheel in a car wreck and was treated in a hospital. The plan sponsor was not sure why the exclusion was put into the plan, or what it excludes. The plan already excludes work not performed by a "Dentist," and I see no reason to exclude dental work just because it was caused by an accident and done in a hospital.

I haven't reviewed many dental plans and haven't seen this exclusion before. Does anyone have any thoughts on why such a provision would be in a dental plan, what it would be designed to exclude, and whether it would be enforceable?

[KIP KRAUS]

These types of exclusions are typically in dental plans because most health plans will cover accidental injury to sound natural teeth in the event of an accident.

[Guest FAQ]

Thanks, Kip.

Your reply was dead-on. Upon further review, their health plan covers injuries to teeth due to accidents.