Delta Dental/Delta Care P M I Of Cerritos, CA Denies Coverage That Are CLEARLY Outlined in Their Description of Benefits Booklet Cerritos California

In August, 2007, I took my 17 yr. old daughter to have a wisdom tooth extracted. The Delta Care insurance refused to cover general anesthesia for the extraction saying they only cover "special needs" patients. After filing grievances and then a formal complaint to the Department of Managed Health Care, Delta Care finally agreed to pay for their part of the general anesthesia three months later.

Fast forward to August 8, 2008, our dentist informed us that our 15 year old daughter needed all 4 of her wisdom teeth removed because they were coming in before her mouth was ready for them which was causing the pain she was experiencing. We scheduled the surgery for September 24 and I warned the dental office of the problem that we had getting authorization for anesthesia with our older daughter.

To shorten the report, Delta Care refused to acknowledge on 3 separate occasions having received the x-rays and requests for authorization from the dental office. The office tried mailing, emailing, and faxing the requests - still with no acknowledgment. When 9/24 came around, we still had NO authorization. Delta Care told told them to submit it again and the dental office said if that didn't work, they would go through "emergency procedure" for approval. We rescheduled for 10/8.

When 10/8 arrived, we were told Delta Care would only authorize TWO (2) of the teeth, not all 4 as needed. The Oral Surgeon took us aside and said, "All four of the teeth must be removed." He showed us the X-ray and explained the path of teeth 1 and 16 were pushing on neighboring teeth and one was on a nerve (it looked clear to us that the X-ray proved the existence of teeth 1 and 16 impeding on other teeth and a nerve). We permitted the extraction of all 4 and paid out of pocket the total for teeth 1 and 16 that Delta Care would not authorize. We were told general anesthesia was approved and paid only the co-payment.

We filed a grievance with Delta Care and were denied. We filed with the Department of Managed Health Care and told we could not submit a claim since Delta Care had not denied the grievance through proper procedure and we had to start over. We are currently on our second round and Delta Care is continuing to deny the claim for the two wisdom teeth saying "Based on the information available, the denial for the extraction of teeth numbers 1 and 16 remains unchanged. The initial denial was based on the teeth's path of eruption in the mouth does not appear to be impeded based on submitted documentation and/or x-rays. There was no apparent pathology. Therefore, the extractions are considered to be elective/prophylactic and are not covered at this time. The Plan does consider these teeth to be impacted." To top it off, they are also denying general anesthesia coverage even though they DID authorize the bottom wisdom teeth to be extracted (which would make general anesthesia necessary).

In the coverage of benefits, page 6, it says, "The services are performed as deemed appropriate by your attending Contract Dentist." Well, not only did I send them a letter from her Contract Dentist saying teeth 1 and 16 needed extraction, but I also sent them a letter from the Oral Surgeon saying the path of teeth 1 and 16 were pushing on neighboring teeth, thus causing pain and requiring immediate extraction. So how can Delta Care, who has never met with or examined my daughter, come to their decision?

We are at our wit's end here. In October, we switched benefits from Delta Care to Safeguard which won't take effect until January 1, 2009, because we are so fed up dealing with this dental plan. We don't know if Safeguard will be any better, but really we can't imagine any plan being as stubborn and denial-happy as Delta Dental/Delta Care PMI of California.

Trish
Riverside County, California
U.S.A.