Policy Limit

POLICY LIMITATIONS/RESTRICTIONS

The post below explains the restrictions/limitations that insurance companies cleverly integrate into their insurance plans to make the grade. Those, who are seeking dental insurance plans in the market, must be no stranger with the policy limitations/restrictions to make an informed decision when buying a dental insurance plan for them.

Are Pre-existing Conditions Covered in Dental Insurance?




It has always been evident in the dental insurance plans and coverage offering to have some sorts of restrictions or exclusions attached to it. These limitations or restrictions may spell a negative impression on the policy preventing it from serving your immediate dental needs. Some of the possible restrictions could be as stated in the following points:

  • Restrictions on the dental procedures that are covered in the dental insurance
  • Curtail the benefits associated with dental insurance, i.e., dental work that is promised in the insurance plan
  • Limitation on the monetary benefits (cash benefits) associated with dental insurance.

Why Are There Policy Restrictions?

A company that offers insurance to customers/patients to ensure them with good oral health is in the market for the sake of profit. Thus, they are not meant to offer patients with the insurance benefits more than they actually get. For the reason, an insurance company, it doesn't want to go out of business, will never pay our more in benefits than it actually receives in premiums.


The restrictions and limitations are incorporated into insurance plans as a way to regulate their overall expenses and make a balance between their losses and profits. The limitations in place help the insurance companies remain in business; without restrictions, the insurance companies will be out of the market with no gain.

Pre-existing Dental Conditions: Are They Covered Under Dental Insurance?

Dental disorders are not kind of ailments that develop out of blue. Oral infirmities take time to develop. If anything happens to mouth and its dental fixture, it happens out of a long course of small oral problems. Dental problems that have occurred before one takes dental insurance are referred to be pre-existing dental conditions. Some insurance plans may offer complete coverage for the pre-existing dental conditions while many others may not.

Waiting Period: Insurers’ Tool To Impose Restrictions

When insurance companies tend to impose restrictions on their insurance policy, they find no other tool better than the waiting period. By integrating a waiting period clause in its policy, an insurer aims to delay the time for a dental procedure, particularly of the pre-existing dental conditions.
Take a patient, for instance, who has been offered the insurance cover of pre-existing dental conditions. He is made aware of the fact that his pre-dental conditions are covered in the insurance plan, however; he is not informed about the waiting period that may commonly be of six months to a year.
A customer may find that during the first year of his new plan's term, he has been provided with the cover only for the diagnostic and preventive dental services such as exams, cleanings, x-rays. More extensive dental work such as root canal treatment, placement of crowns or other complex dental procedures isn’t included. Having the term of waiting period lapsed, the plan initiates the benefits for the previously excluded services and this is how the game goes on.

Waiting Period Variations

There might be too restrictive insurance plans to include the treatment cost of dental procedures. Having restrictions in place, such plans only covered the cost of preventive and diagnostic services during the waiting period such as medical examination, preliminary inspection, and preventive measures, etc.

How Waiting Period Turns Out to be a Significant Aid for an Insurer

When there exists the clause of the waiting period in the policy, it turns out to be a way for the insurance company to avoid insurance claims for pre-existing conditions. For example, a patient, who is already going through the pain of broken teeth at the time of insurance enrollment, will be placed cleverly in the spot where he will have to pay for the dental procedures.

Restrictions on Other Types of Pre-existing Conditions

There are insurance plans that come with clear restrictions for patients. Such insurance plans contain explicit norms and clauses with an explanation of particular pre-existing conditions that are not covered in the plan. Such insurance plans come with:

  • No benefits associated with dental procedures, i.e., a patient will not get insurance cover for the dental ailments that happened to him before being enrollee to the current insurance plan
  • No insurance cover for replacing dentures, crowns, or bridges i.e., dental ailments older than 5 or 7 years shall not be covered in the insurance plan
  • The exclusion of coverage for dental appliances, i.e., bridges, dentures, implants will be excluded from the cover benefits if the teeth were extracted before the person was covered with the current dental insurance plan.

How Insurance Cover is Designed for Pre-existing Conditions

The insurance cover for dental procedures is designed with the two key determinants in view, i.e., policy cost and governing regulations. Plans excluded from the previously existing condition are likely to be lower in cost or monthly premium, thus they are sold out in the market. In some cases, state and federal regulations apply to the insurance plans where the law of the land directs insurance companies to design insurance plans in favor of customers.
All in all, it is the policy cost and government regulations that remain in consideration while designing the insurance plans with cover for pre-existing dental conditions.

Where Waiting Period Restrictions aren’t Applicable

The integration of the clause of the waiting period in the insurance policy may make it unaccommodating for the purpose an insurance plan is meant to serve. However, there are ways to have it out from the policy only if:

You've had Previous Dental Coverage

There are norms in some dental insurance policies that if the insured had a dental cover in the past two months, there are chances for the waiting period to be waived from the dental policy.

One Holds Membership of a Group/Organization

Waiting-period restrictions are not applicable to those who hold a membership with a group or an organization, e.g., HMO, PPO or PPO. Those, who are the members of any of the group mentioned, the waiting period will be called off.
Patients are advised to take advantage of available services associated with the insurance plan without worrying about the waiting period. Go for regular clinical examinations and never hesitate to ask for preventive measures until your waiting period is over.

Cosmetic Procedures are Oftentimes Covered by Insurance

Cosmetic dentistry is a different sort of thing if put in a comparison chart with dental treatments. Nevertheless, there are plans where cosmetic dental procedures are included in the policy. As a matter of fact, most insurance policies don’t include dental procedures that are performed for the purpose of cosmetic reasons.
Cosmetic dentistry is not meant to treat a dental ailment, it is rather for the purpose of beautifying existing dental fixtures. It may include teeth whitening, composite veneers, porcelain veneers, and potentially even some bridges, white fillings, and dental crowns. This is also a kind of limitation that is integrated into a dental insurance plan that people and dentists must be aware of.

Limitations on Dental Procedures: How Frequently They can be Performed

There are certain dental procedures that a patient is denied in the curse of dental insurance as there is limited coverage available for the same. Here the matter is not of the cover that the insured one is denied of, the concern is of the frequency; i.e., how frequently the dental procedure can be performed.
The cost of some dental procedures is cheap at half the price and if an insurance company provides the customers with the facility of frequent dental procedures, it will lose its way in the market with no gain. Such costly dental procedures come with limited insurance cover where the insured can get them performed not more than once or twice a year.

Here are some examples of such restrictions/limitations:




  • Bite-wing x-rays may be covered as frequently as every 6 months, or just once a year.
  • Full-mouth x-rays may be limited to once every several years (3 to 5).
  • The frequency of coverage for some types of Major dental services may be limited.
  • Benefits for dental crown replacement are often restricted to once every 5 years.
  • Full and partial dentures may only qualify once every 7 years.

Maximum Annual Benefits

Maximum annual benefits are literally the maximum benefits that an insurance plan comes with or that is said to be the maximum monetary benefits associated with an insurance plan that can be utilized in a year. Those, who take the insurance policy, must calculate such benefits associated with the plan in a year or the time period, a plan’s benefits will be effective/applicable for.

General Insurance Limit

Maximum limits are oftentimes seen with traditional (indemnity) and Preferred Provider Organization (PPO) insurance plans. It may range somewhat between $750 and $2000 per year, however, the actual value will vary with each insurance policy. This is why the insured person or the one who takes the insurance policy is recommended to have a measure of insurance limit available to him for utilizing. Capitation programs (dental HMO's) typically don't come with high insurance limits as compared to the PPO plans.

Know-How Limit is Calculated

This is worth noting here that the term ‘limit’ represents the maximum benefits associated with an insurance plan offered by an insurance company, not the total value of the dental work received.

Clever Way to Plan Dental Procedures in Line With Dental Insurance

This is evident that the general maximum benefits associated with an insurance plan are relatively small as compared to the dental requirements. If this is the case with you, here are some clever recommendations for patients to look for when seeking new dental insurance in the market:

  • Look for an insurance plan where the policy permits all or at least some of the unused benefits of the previous year to be added up in the next year. If an insurance company gives this choice in its insurance plan, it will sort out most concerns for the insured one.
  • Pick the insurance plans that come with group coverage, i.e., your family members are also covered in the same insurance plan. The more members it covers, the more benefit a person gets as your premium that goes into buying the insurance plan is less as compared to the plan that is taken for a single person.
  • Knowing beforehand what the insurance policy covers are one of the wisest ways to find the right insurance plan for a person. What the insurance plan is actually covering is the first and foremost thing to be known by the insured.

Why Elite DentalRCM

We, at Elite DentalRCM, provide clients with insurance verification services aiming to standardize the admission process at a dental care facility. Our services are aimed to keep an eye on the misinformation that is oftentimes provided by insurance carriers. We serve our clients with the insurance verification process where we tend to obtain necessary insurance information that is brought in use for the payment of dental services.