Conference 7.286::digital

    I have a mouth full of crowns.  In one case, the dentist decided to go
    directly from a large cavity to a crown.  Hancock would only approve an
    amalgum filling.  After that, my dentist started getting anything other
    than routine work pre approved.  In at least one case, he wrote to
    Hancock three or four times and they finally approved the work.  I
    guess that they can be worn down!

    I always get a pre estimate, since Denatl prioces and coverage from
    John Hancock varies from area to area, and I always have to pay
    half for the crown since JH only approves the cheapest kind of
    crown and I think it's worth it to get gold.
    
    Marilyn

RE: .0

Getting preapproval for any work that is going to cost in excess of $100.00
is standard procedure.
At least that is what I was informed of a couple(?) of years back.
The dental plan admin. requires that any work that is to cost more than the 
$100 be preapproved by them. Otherwise, the patient runs the risk of not 
having it covered and having to pay for it out of their pocket.

    Thanks for the replies.  My understanding of the dental plan, which was
    confirmed by benefits personnel is that the pre-treatment estimate is
    recommended, but no required.
    
    I actually went throught the pre-estimate process.  Since it was taking
    so long to get an answer (5 weeks) I called John Hancock, who said they
    routinely approved this type of work, so I shouldn't wait to get the
    pre-estimate.  I went ahead with the procedure and a week later got the
    pre-estimate denial, which specifically stated that no " objective
    evidence of the condition" had been submitted, i.e. the the pain in my
    mouth and the dentist's seeing the hairline fractures are not good
    enough.  
    
    I requested the correspondance between the ADE, who do the
    pre-estimates and John Hancock, and ADE had indeed denied the procedure 
    2 weeks before I phoned John Hancock, but that information wasn't available
    when I phoned.  
    
    My appeal is based on ADE's asking for evidence that is far beyond
    generally accepted dental practice when they denied the pre-estimate. 
    My dentist provided x-rays to show that the cracked teeth already had
    large central fillings,  along with his diagnosis, and ADE recommended
    fillings.  ADE spoke with my dentist and agreed that they would
    recommend crowns if they thought the cracks existed, but they found no
    reason to believe the cracks existed.
    
    Clearly, I will in the future wait for WRITTEN communication from John
    Hancock before proceeding.  But even if I had waited for the
    pre-estimate denial, I would still be faced with somehow showing a
    dental condition that typically can't be seen on x-rays or even by
    sight.  The consequences of ignoring cracked teeth are well documented:
    your tooth crumbles.  But now you are in luck, since this shows up on
    the x-ray, and the Dental Plan covers it.
    
    Regards,
    
    Terry

    You waited 5 weeks in pain?
    
    One would like to think that if you had a toothache the Insurance
    Company could expedite their administrative demands. If preapproval
    restriction is to work, it must not make the insured person suffer.
    
    Sounds like more lawsuits for JH to me. Can this possibly be
    saving anyone any money?
    
    

           I guess I just went on pure faith when I had my crown last
           spring (no pre-estimate).  I just asked at dentist office if
           JH would cover.  Most of the tooth was gone, and the filling
           had fallen off.  DEC/JH paid about 60%.  My wife's ins.
           (Delta) paid the balance (thank God).  I guess my case was
           more cut-n-dry, huh?
           
           Steve

    I just got off the phone with the American Dental Association's state
    office, who informed me that they have numerous complaints on file from
    dentists who have had problems with Digital's Dental Plan.  In their
    opinion, our plan is terrible, and the ADA has offerred to work with
    Digital to create a good plan.  The person I spoke with, the assistent
    executive director of the state office, wasn't aware of any efforts by
    Digital to improve the dental plan.  It is the state ADA's opinion that
    our dental plan is administered in a way that seeks to deny benefits,
    i.e. it is not a benefit.  Surprise.

    In February I cracked my front tooth in half in a hockey game. I belong
    to a mathew thornton where I went for emergency treatment to my face.
    After they were done the instructed me to see my family dentist the
    following day....I did, the cost was over 1000 dollars.  The Claim
    has still not been paid!  Hancock is claiming it was a medical accident
    so my medical plan should cover while at the Same time MT said it was
    a dental procedure and Hancock should cover!  Well it's currently on
    hold with Hancock with no end in sight!
    
    Very discouraging!
    

    Don't hold your breath. Once something gets lost in the Hancock
    "files", it can take forever to straighten out. I've had personal ex-
    periences with talking to the Hancock "wall"!
    
    Eric

    FWIW... 

    I needed a root canal the other month and when I first walked in to
    "Endodontics 'R' Us" in Worcester, they entered the information about
    the procedures and the fact that I had DEC's alleged dental insurance
    into a computer which bounced it up against some database that knew
    about the payment habits of the various companies.  It spat back that
    I'd have to pay about $200 out of pocket so they had me write them a
    check for that much on the spot before proceeding.

    Couple of weeks later, it turns out that I actually owe them another
    $225.  

    Oops.

    This is of course just the prep work and the temporary whatzit.  My
    real dentist sent directly to Hancock to see what they'd cover for the
    crown itself.  From what I can tell, they'll pay 100% of some number
    they made up, but if I want a dentist that works primarily on people to
    do it, I have to put out around $300 of my own money.  

    Since the reference dentists they use to determine the amount they'll
    pay (apparently, The Three Stooges) haven't practiced in Central Mass
    for several decades, I'll probably just have to wait until the temp
    breaks and get another one.  That'll only cost me about $75 every time
    it happens.

    -joe tomkowitz
    
    P.S.  Hancock covers Nitrous Oxide the same way they would cover you if
    you asked them to pay for a vial of "crack" and a pitcher of Bloody
    Mary's on a Friday night.

    Beware the temporary crown!  I thought I could get away with that too,
    at least for a while, and learned the hard way that margins --edges of
    the crown under the gum-- are not crafted as carefully, or of as good
    materials, and over time can do you some serious gum damage.  I ended
    up needing a bunch of perio surgery, some of which was due to 2 years
    with a temporary crown.
    
    If you are at all prone to gum irritation or inflammation, especially
    beware.
    
    (On the other hand, I suppose Hancock pays more towards the perio
    surgery than most other procedures ... )
    ;-)
    
    Holly
    

    I have been FAR LESS THAN PLEASED with JH dental coverage over the
    past few years!! It seems that what the dentist charges SELDOM falls
    into JH's guidelines. Having moved, we've seen this occur using several
    dentists in two states.
    
    My wife recently got a crown - JH paid only around 50%. This stinks!!
    
    Other than getting our own dental coverage, are there any other options
    available through Digital ?? I, for one, would be in favor of Digital
    exploring some other options.
    
    /jim

    Correction: JH pays 60% on a bridge. I asked the JH customer rep. why
    so little - They claim that Digital provides a dental "assistance"
    plan.
    
    /jim

    There is one possible alternative.  Have some money taken out for
    Health Reimbursment account.  At least the money you pay for the
    balance of your dental coverage will be tax free.  However, do not
    have too much taken out because if you do not use all of the money by
    the end of the year, you will lose it.  (Check with your PSA to find
    out the details of the plan.  You must sign up each year during
    enrollment.)

    re: .12
    
    Since Digital is self-insured it means that JH is simply providing an
    administrative function for the DEC medical and dental plans.
    
    You won't get a better deal if you shop around and sign on for
    independent coverage with other insurance companies under their
    indemnity plans.
    
    I have several friends who are self-employed and pay exorbitant rates
    for insurance policies that don't cover half of what DEC medical and
    dental plans cover.
    
    Laura
    

    
    
	I've been fighting with John Hancock since last September
    trying to get them to pay for a full bridge.  I was born without
    two secondary upper teeth (AdultPrimaryAdult). Finally after almost
    38 years the first primary tooth gave out.  It had been crowned
    18 years ago.  When I had the tooth pulled due to pain, I asked the 
    dentist if we should ask JH about coverage, he said that in his 
    24 years as a dentist, he had never seen a full bridge denied. Wrong.
    
    John Hancock tells us they will only pay for a partial bridge ($600
    vs. $1800).  I can't blame them but a partial is out of the question
    for me.  I have a lot of sensitivity around the base of my molars
    the action of metal retainers around the two anchor teeth would cause
    severe discomfort.
    
    The second of my primary teeth gave out last June.  I still owe $ on
    the first bridge so I have not been able to have a replacement bridge
    made for the new gap and I find talking and eating a bit of a hassle.
    Luckily both primary teeth were far enough back to not cause a great
    deal of cosmetic concern for me. But again I will fight JH to pay 
    for a full bridge because of the gumline sensitivity on the adjacent
    molars that would have to be used as anchors for a partial bridge. I
    have used Sensodyne and Denquel to relieve the hot/cold sensitivity
    but doubt it would do a lot for pressure discomfort. The only other
    solution would be root canal which would ultimately set JH back several
    hundred dollars. And still that would mean a partial bridge which the
    dentist feels is an inferior solution. 
    
    Anyone else been denied coverage for a full bridge?
    
    Jodi-
           
    
    

    RE .8
    
     Thanks to the efforts of my personnel dept and lots of phone calls to 
    
    John Hancock it seems my claim is about to be settled, it seems my 
    
    dentist not the plan was at fault as it seems that althought the work
    
    was done in february the claim wasn't filed until july.
    
    JH sent me a letter and told me that it was in the review board and
    
    That it should be paid within 10 days.
    
    
    Here's hoping for 50%
    
    
    -dave

    I was officially notified that my appeal to the U.S. Employee benefit
    claim appeal committee was denied last week, with the same reason given
    by the plan administration:  no objective evidence.  None of the
    specific points in my 3 page letter to the committee were answered, so
    I have no respect for this process.  
    
    On the bright side, my dentist submitted exactly the same claim to my
    wife's dental plan (she works for a giant pharmaceutical company) and
    her plan paid 80% instantly.  We have family coverage under her plan, 
    which provides coordinated coverage for my claims.  I got this
    approval 2 weeks after submitting it.  
    
    

re:                      <<< Note 1593.18 by VIDEO::FURMAN >>>

Hmmm. I don't understand that at all. I was in the process of getting a 
crown when this note was first started. I was very worried about whether
JH would pay. I called them before going in and they said they paid 
60% (of reasonable cost) for crowns. They made no mention that I would
need x-rays. The only reason my dentist knew I had a fracture is because
I told him about the pain. I didn't have x-rays taken or anything other
than his visual inspection. The end result is that JH did pay 60% for
the crown with no questions asked. I can't figure out why the rules were
different for you.

Jenna

    Congrats!  The best explanation I can think of is that you didn't submit a
    pre-estimate, which automatically involves the American Dental
    Examiners, the people whose job it is, in my experience, to deny
    claims.
    
    This is a perfect example of the twilight zone quality of our dental
    benefits.  
    
    Regards,
    
    Terry

    re: .20
    
    I doubt that the pre-treatment estimate resulted in denial of benefits. 
    My wife has had several crowns placed, and DEC Dental Plan has paid 60%
    each time.  Each time, a pre-treatment estimate was submitted.  The
    last instance was this past summertime.
    
    Must have been something else...