A missing tooth clause is a fine print stipulation in your insurance contract that may exclude you from certain dental benefits. The affected benefits often involve the replacement of a missing tooth, hence the name.
Let us explain in further detail with examples of what that all means.
What is the missing tooth clause?
The missing tooth clause is similar to a “pre-existing condition” for medical insurance. The purpose of both of them is to deny you benefits which means you will be responsible for the entire bill out of pocket.
This is what the clause states: If you have a missing tooth prior to signing up with the dental insurance, you will not have benefits to replace that missing tooth.
Rephrasing the missing tooth clause for clarity:
- You will only have tooth replacement benefits if you get that tooth extracted while you’re actively eligible on the insurance plan.
- If you have the tooth extracted before getting the insurance, you will not have replacement tooth benefits.
What happens if you try to replace a tooth with the clause active?
If you have this particular clause in your contract and you try to replace a missing tooth, your insurance claim will be denied. Your dentist can submit it as many times as they want but the claim will return with a footnote stating denial of benefits due to missing tooth clause.
Basically you will receive zero benefits and zero help from your dental insurance when you try to replace the tooth. Ultimately you will have to foot the entire bill yourself.
Dental insurances with a missing tooth clause
Any dental insurance can potentially have a missing tooth clause but it all depends on your specific contract. This stipulation can be included in the contract often as a means of decreasing the insurance premium, thus lowering monthly payments.
Dental insurances that may have the clause:
- Aetna
- Ameritas
- Beam
- Cigna
- Delta dental
- Guardian
- Humana
- Metlife
- Principal
- United healthcare
- Unum
- Sun life
Whether or not these dental insurances have it, you will need to read the fine print of the contract carefully. If you are unsure, the best thing to do would be to call the insurance and ask one of the agents directly.
Which procedures does it apply to?
The missing tooth clause affects all dental procedures whose purpose is to replace said missing tooth.
Affected dental procedures:
- Implant – a fixed replacement option utilizing a medical grade titanium screw.
- Bridge – an alternative fixed replacement option that involves crowning the adjacent teeth. It is less conservative than an implant since at least two other teeth need to be shaved down.
- Dentures – a removable replacement option with either partial or complete dentures.
The image above is a dental panoramic x-ray of a combination of implants and bridges. Both of these procedures were used to replace several missing teeth on this patient.
Examples of how it may affect you
Various scenarios used to exemplify how having this clause may affect your insurance coverage.
Missing tooth before getting insurance
Scenario: You had a tooth removed before you signed up for the insurance plan. After getting the insurance you try to replace the gap with an implant.
Result: Your insurance will deny the claim. You are responsible for the full cost of treatment.
Missing tooth after getting insurance
Scenario: You signed up for insurance first and then had a tooth extracted using the insurance. Now you’re trying to replace the space with a bridge or implant.
Result: Your insurance must take your claim into consideration since the tooth was missing after you had insurance.
Changing insurance during the process
Scenario: Your insurance has a missing tooth clause so you wait to extract the tooth after you sign up for it. However, you changed your job after the extraction and received a new insurance that also has the clause. Now you’re trying to replace the tooth with a bridge.
Result: The bridge will be denied since the new dental insurance has the clause. You should be wary of switching insurances in the middle of the process or at least take it into consideration.
How to appeal the insurance denial
Unfortunately, all appeals for insurance denials due to a missing tooth clause will fall on deaf ears. The appeals never get overturned because the clause was in the contract when you signed it. It was there all along, you just never read it or never asked about it.
You cannot overturn wording that is set in stone since the beginning from a legal contract. That is why it is important to know of this stipulation and ask about it prior to purchasing the insurance.
Takeaway
A missing tooth clause will deny you benefits for replacing the tooth if you did not get it extracted while under the insurance. However it won’t affect you if you do your extraction while you’re active and eligible with the plan.
If you’re trying to get insurance to replace a pre-existing extracted tooth in your mouth, you should look for this clause. If you have one, it may rain on all of your hopes and dreams.