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Ortho Coordination of Benefits

Guest Nautical

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Guest Nautical

This posting is for further clairifaction on life time maximum rules between two insurance companies for Ortho.


Product: Invisalign

Cost: $4,500 (or whatever it costs)

Dentist requires individual to pay upfront for full cost of trays even though service has not been rendered.

Dentist submits claims monthly for each tray to insurance company. The 1st insurance company lifetime max of $2,000 is met & payments are sent to individual for reimbursement (no secondary insurance).

The individual leaves their dental plan during open enrollment and switches to their spouse's dental insurance plan. The individual is still receiving trays every month. The dentist submits claims to the new ortho/dental carrier with documentation showing the amount the other insurance paid to prevent duplication of benefits. The new insurance carrier states that thier plan has a life time maxium for ortho of $1,500. Since the first insurance company paid $2,000 previously the second (or new) insurance company does not pay for a single tray. The second insurance company states the member met the lifetime maximum under that plan because of the other insurance carrier payment.

Do you think this is some kind of preexisting rule or can a dental insurance company apply prior insurance payments towards meeting their own lifetime maxium for Ortho? I don't have a copy of that SPD, but I hope to get one to help the individual. The dental plans I have worked with will coordinate benefits for remaining treatments. Maybe I have been in the dark, I am not familiar with this situation. Please advise :)

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