Guardian Life Insurance Company Of America

Review: [redacted]: Patient : [redacted] SS: xxx-xx-xxxx0, DOB:09/25/1975, Group# 00390841 Claim#25262V02400, Date of Service :01/22/2014 Procedure: D2392#18 OB, D2392 #19OBInsurance company: The Guardian Life Insurance Company of America [redacted]Unpaid amount: $252To whom it may concerned, We recently got denied from The Guardian Life Insurance Company of America on part of the claim on the care provided by [redacted] DDS on 01/22/2014 procedure code D2392 tooth #18 OB and 19 OB, because of the patient's yearly maximum has been met. However, on 01/21/2014 during the procedure of insurance verification we has been told by one of Guardian representatives Mrs. Ariel that patient's yearly max of $1,500 and the rollover amount of $1,250 can be used during the 2014 calendar year for dental treatment. Finally, after our dentist did most of the procedures we received the denial for the procedures described earlier. After calling the Guardian Costumer Service representative regarding this issue we were told by [redacted] that patient cannot use her rollover money except of $278 dollars that were already applied to Claim Number: [redacted] and that patient is responsible for the balance of $252 dollars. At the same day we contacted the patient regarding this issue and her responsibility for the balance, however, she refused to pay stating that she has a full coverage and rollover benefits from the previous year, which should cover all the procedures performed on 01/22/2014. Thank you for your help in advance.Sincerely,Desired Settlement: We would like to receive money for performed service.

Business

Response:

Revdex.com file number [redacted]. A full and detailed response was sent to the complainant.

Review: I had dental work with Oakwell Dental Care in San Antonio, TX back in December 2012. My 12+ front crown was replaced. My dentist has submitted all the necessary paperwork to Guardian Dental (synopsis of dental work, x-ray) and have sent in a second request for the dental insurance to pay their share of $519.40. I've paid my co-pay back in December. Guardian denied this once, again. This was not cosmetic dental work. The insurance company wanted a different mode by replacing the tooth and using an implant. The dental insurance is not doing their job by doing "right" by the patient, but instead denying appropriate/legitimate claims. We our hardworking people that pay our dental premium to receive subpar handling in our claim.Thank you for assisting me with this claim.Desired Settlement: I would settle for Guardian Dental to send me a check for $519.40.

Business

Response:

This letter is in response to Ms. [redacted]’s complaint submitted to your office regarding the benefit determination issued on her claim for a crown and crown buildup performed on 12/18/12. The remainder of this letter will explain the contractual provisions used in our handling of this matter.

Under the terms of Ms. [redacted]’s dental plan, coverage is available for replacement crowns and cast restorations only if the existing crown is at least ten years old and warrants replacement; both provisions must be met. Crown buildups are eligible for coverage only when performed in conjunction with an eligible crown and only when necessary due to substantial loss of natural tooth structure. Proof of loss must be substantiated through reviews of diagnostic radiographs and other supporting materials. Reviews are performed by licensed dentists acting in a consultant capacity. Treatment for which there is a poor/guarded prognosis is excluded from coverage. Pre-treatment review is recommended for treatment exceeding $300 to ensure that all parties are aware in advance of treatment of the projected available plan benefits and associated patient liability. A treatment estimate was not received for these services.

Two separate claim reviews were performed on this claim involving two different consultants. The crown and crown buildup performed on tooth 8 were originally received on 12/22/12 and were reviewed by a licensed dental consultant. After review of the clinical information provided, a consultant advised that the crown was a replacement appliance and the reason for the replacement was not evident. The crown buildup was denied because the tooth had sufficient tooth structure remaining to provide adequate support and retention for the crown. An explanation of benefits statement was issued on 01/08/13 reflecting denial of the submitted treatment.

The initial denial was appealed with additional correspondence received on 02/15/13 from Dr. [redacted]’s office. Based on review of the additional information supplied by Dr. [redacted], a second licensed dental consultant advised that the tooth appeared to have endodontic problems which presented a guarded prognosis. It was again advised that the tooth had sufficient tooth structure remaining to provide adequate support and retention for the crown such that necessity for a crown buildup wasn’t evident. An explanation of benefits was issued on 03/01/13 again reflecting denial of the treatment.

We understand that the method of treatment for a patient’s condition is a decision made between a provider and their patient. We don’t direct or dictate the care provided; we determine available benefits for submitted claims in keeping with the dental plan provisions under which members are insured.

While I regret Ms. [redacted]’s dissatisfaction with our handling of her claim, proof of loss was not established such that a contractual basis for coverage of the crown and crown buildup could be established. Therefore, at this time the claim has been considered in accordance with all plan provisions and no further benefits are available.

Enclosed are copies of Guardian’s explanation of benefits, as well as pertinent pages of Ms. [redacted]’s policy booklet for your review.

Please contact me directly at the address or numbers provided if you have any further questions on this matter.

Consumer

Response:

I just viewed the response from Guardian response in why they are not reimbursing the cost of a new crown. I disagree with their reasoning and only see this as excusing themselves from paying their portion of dental coverage. They had their Guardian dentist review the file and deemed it not a my crown as not structurally fit for a new crown. My new crown couldn't have been better and my dentist assured me that the install of it was structurally sound.

Please send another inquiry to Guardian Insurance to let them know of my dissatisfaction.

Business

Response:

This letter is in response to Ms. [redacted]’s second appeal submitted to your office regarding the benefit determination issued on her claim for a crown and crown buildup performed on 12/18/12. The remainder of this letter will explain the contractual provisions used in our handling of this matter.

Under the terms of Ms. [redacted]'s dental plan, coverage is available for replacement crowns and cast restorations only if the existing crown is at least ten years old and warrants replacement; both provisions must be met. Crown buildups are eligible for coverage only when performed in conjunction with an eligible crown and only when necessary due to substantial loss of natural tooth structure. Proof of loss must be substantiated through reviews of diagnostic radiographs and other supporting materials. Reviews are performed by licensed dentists acting in a consultant capacity. Treatment for which there is a poor/guarded prognosis is excluded from coverage. Pre-treatment review is recommended for treatment exceeding $300 to ensure that all parties are aware in advance of treatment of the projected available plan benefits and associated patient liability. A treatment estimate was not received for these services.

Two separate claim reviews were performed on this claim involving two different consultants. The crown and crown buildup performed on tooth 8 were originally received on 12/22/12 and were reviewed by a licensed dental consultant. After review of the clinical information provided, a consultant advised that the crown was a replacement appliance and the reason for the replacement was not evident. The crown buildup was denied because the tooth had sufficient tooth structure remaining to provide adequate support and retention for the crown. An explanation of benefits statement was issued on 01/08/13 reflecting denial of the submitted treatment.

The initial denial was appealed with additional correspondence received on 02/15/13 from Dr. [redacted]’s office. Based on review of the additional information supplied by Dr. [redacted], a second licensed dental consultant advised that the tooth appeared to have endodontic problems which presented a guarded prognosis. It was again advised that the tooth had sufficient tooth structure remaining to provide adequate support and retention for the crown such that necessity for a crown buildup wasn’t evident. An explanation of benefits was issued on 03/01/13 again reflecting denial of the treatment.

I resubmitted all the clinical information received from Dr. [redacted]’s office to our managing dental consultant for another review. He determined that a narrative submitted by Dr. [redacted] in the first appeal was not reviewed previously. Based on this new information the consultant was able to allow both the crown and buildup on tooth 8.

The claim has now been reprocessed and an additional benefit of $483.62 has been sent to Dr. [redacted]’s office which includes $14.12 of interest due from the date we received the additional narrative information.

Please contact me directly at the address or numbers provided if you have any further questions on this matter.

Review: On February 7th, 2014, I went to my dentist in order to receive a Root Planning & Scaling, which is covered under my dental coverage. This procedure is listed under basic care, without any small print indicating that it is subject to review. Other work, which is listed as major work (crowns, implants etc…) is subject to review as mentioned under my benefits package. Coverage for my Root Planning & Scaling procedure is 100%. With this in mind, I went to my dental office, paid my required co-payment and received treatment. Months later I was sent a bill by my dental office notifying me that I must pay $358.00 as Guardian refused to cover this expense. My dental office sent an appeal twice, with x-rays, perio-charting and a narrative indicating that my treatment was medically necessary. The claim was denied stating that upon review with Guardian’s Dental Specialist, it was noted that there was no loss of bone despite having gingival migration pockets of 4mm, 5mm and 6mm. When I called Guardian they mentioned that in order for this claim to be approved I must have both gingival migration and loss of bone. Upon calling my dental office, it was noted that I indeed have both gingival migration and loss of bone. When I spoke to Guardian, it was mentioned that if I want to, I can submit new x-rays or send an appeal myself, although the appeal was sent twice by my dental office. Why do I need to pay for new x-rays in order to validate my need of treatment? I was also informed by Guardian that if I had received a pre-determination, then my claim would be honored. However, since this treatment is considered basic treatment, pre-determinations are not required and even though my benefits do not state that Root Planning & Scaling’s can be subjected to review, it will be. If this is true, then it is Guardian’s fault for misinformation when reading my benefits as the only thing noted to be subject to review is major work.

I have spent multiple days speaking to representatives, requesting an escalation procedure where I can speak to a supervisor and was denied. I sent an email to corporate executives in which they forwarded my email to a Customer Response Unit and only received an automated e-mail verifying that they have received my email. My dental office has to now send yet another narrative along with the required x-rays and perio-charting while I must send a letter of appeal to the appeals department and await 28 days for this to be approved or denied. I should not have to wait an additional 28 days for this issue to be resolved when it should not be an issue in the first place. Guardian needs to honor their policy and cover their portion which includes the $358.00 they are refusing to pay. It is not the fault of the patient (Which is me) nor the responsibility of the patient to deal with this issue when I have followed Guardian’s procedure as mentioned in my benefits package. I should not have to deal with appeals and added frustration when it comes to health care as such benefits are covered 100% under the basic care of Guardian Insurance. I am disturbed, traumatized and deeply hurt by this and it feels as if Guardian Life Insurance is scamming me on my medical treatment.Desired Settlement: I want Guardian to pay their required coverage which at this time is $358.00

Business

Response:

response to [redacted]

Consumer

Response:

Revdex.com,

I have reviewed the response made by the business in reference to complaint ID [redacted] and have determined that this does not resolve my complaint. For your reference, details of the offer I reviewed appear below.

The issue still has not been resolved. Guardian's letter did not provide any means of a settlement. Meaning, that they did not state that they will honor the coverage they are suppose to provide to me under Guardian's basic care. I am still waiting on a response from a Guardian representative that progress has been made since Monday. I am still upset that my medical need for treatment has been put under this much scrutiny for something that is considered basic care and have not yet received any customer satisfaction. At this point, I am hesitant to even use Guardian ever again.

Regards,

Review: I have Guardian Dental Insurance, and broke one of my teeth. It was an old crown that broke completely out. Went to the dentist, Dr. [redacted], my dentist: [redacted]. Dr. [redacted] put a new crown in place as was needed, since the old one was broken and gone. Guardian refused to reimburse me for the bill which I paid $1500.00 approximately. Their excuse was that I did not have coverage, which was completely false. I called repeatedly, got my HR dept. at Presbyterian Schoool, where I work to call and verify that I had insurance....even though Guardian had paid claims previously on this dental policy. They finally agreed that I did, in fact, have coverage.Now they claim that it was an emergency, even though I went to the Dr. during normal business hours. They simply do not wish to pay and are stalling. Today they said I will have to send them an X-Ray...this is nothing but refusing to pay a just reimbursement for a contractual agreement which Guardian has.I report them for harassment, for failure to pay a just debt, for breach of contract, for rudeness in customer service, for failing to understand the terms of a contract, and for general all around incompetence in delivery of their services.Desired Settlement: THey need to pay me for the dental procedure according to the terms of the policy. It has been since June 2013. They simply are stalling and drawing interest on money that is justly mine.THey owe me 100% of the $1500.00. I have paid this debt and deserve to be paid.The policy states, and their phone agent agrees that the policy pays 100% of customary charges. Therefore I feel that they should pay all of the bill.

Business

Response:

This letter is in response to Ms. [redacted]’s complaint submitted to your office regarding the crown on tooth 1 1 performed on 6/20/13. The remainder of this letter will explain our handling of this matter.

Upon reviewing the information we have on file for [redacted], I have found the reason for the confusion regarding the handling of this claim. It seems there was confusion within this member’s file regarding the name of the patient. [redacted] was entered into our system under two different names, [redacted] and [redacted]. This error was found and the file under the name [redacted] was termed and referenced to use the other file. Upon receiving the electronically submitted claim on 7/17/13 for the crown on tooth 11, our system inadvertently used the termed file. This error came to our attention due to [redacted]’s call in to our customer service department. The claim was reprocessed on the correct file and a corrected explanation of benefits statement was sent on 9/13/13 for the amount of $680.50 made payable to the dental office BRSH.

We believe that we have now properly resolved this matter and sincerely apologize for the inconvenience this has caused Ms. [redacted]. Please contact me directly at the address or numbers provided if you have any further questions on this matter.

Sincerely,

[redacted] Quality Analyst Dental Claims Services ###-###-#### ###-###-#### Fax

Review: On December 29th I have suffered a trauma accident and the veneer on one of my front tooth broke. I talked to Guardian and after numerous calls and representatives, I was advised, since it was a trauma accident to go through my medical insurance first. I went to my primary care physician (I had a cracked lip and bruises) and they wrote a referral to the dentist. But the medical insurance does not cover the repair of the tooth. As per my dental benefits, in the case of a trauma accident, the insurance covers 50% of the dental work, in this case considered Major work.Guardian refuses to pay the claim although I have provided all the information requested, and as per the contract with our company. I have already spent 5 hours on the phones with many representatives that are giving me contradicting information. I requested an escalation procedure or that I talk to a supervisor. They are refusing to allow me to talk to the next line in-charge. It is very frustrating, meanwhile I am faced with a $1200 bill and I am wondering if Guardian is a scam operation.Desired Settlement: Guardian needs to provide prompt payment to [redacted] (50% of the contractual proce for the veneer replacement).

Business

Response:

Please note that this response was faxed directly to [redacted] on 1-9-14 and we had received confirmation that it was received. My apologies for not having access to your database to respond.

Review: This has been extremely frustrating! My wife is on my Guardian Dental Plan and we have been waiting FIVE MONTHS for them to okay her crown replacements. After being denied three times because they said her "crowns were under ten years old," I finally called and emphatically told them her crowns were over ten years old. In fact, they are almost twenty years old! So, we figured they'd finally approve the benefit of replacing her crowns,The next letter I got from them stated that they couldn't get a full x-ray of one of the teeth, and needed a new one. Yet, they still didn't approve the one for which they had a good pictureFinally, the dentist took new x-rays of the entire tooth that they requested, and sent in the x-rays about a month ago.Lo and behold, there is no record of the x-rays coming into their system! It appears as if they're doing EVERYTHING they can to not pay the benefits to which my wife is entitled!Now, I have to have the dentist re-send the x-rays. Where did the x-rays go, into a black hole? Into the circular file? The people I talk to on the phone are very nice and I know they're just doing their jobs, but Guardian itself is just another insurance company doing their best to not pay their benefits.Desired Settlement: I would like them to approve the dental benefits of replacing my wife's crowns. They are not following through on these particular benefits.

Business

Response:

This letter is in response to Mr. [redacted]’s complaint submitted to your office regarding the predetermination of benefits issued on his wife’s claim for two replacement crowns.

Upon reviewing the information we have on file for [redacted]’s predeterminations, 1 have found multiple errors were made on our handling of the claims. With the first predetermination we received, we originally had dental consultants review the crowns which were determined to be warranted, but as replacements. Based on the consultant seeing the crowns were replacements, a letter was sent asking for the ages. The dental office returned the letter to us stating the crowns were estimated to be five years old. The member’s plan has a ten year replacement provision, so the crowns were denied for not meeting the replacement guidelines.

We then received a new predetermination that supplied us with the corrected ages of the crowns. This is where our error came into play. The processor overlooked the new ages of the crowns which resulted in our denial of the predetermination due to age once again. With that, we then received a letter indicating the corrected ages again. At that point the ages were fixed, however an error on our part was made again by overlooking the original review on the first predetermination received. Overlooking the original allowance caused us to request x-rays in error, further delaying this claim.

1 have corrected the patient’s claim file and issued the predetermination showing benefit allowance for both crowns. This claim file was handled poorly. 1 apologize for the frustration and inconvenience this lias caused our member and his wife.

Please contact me directly at the address or numbers provided if you have any further questions on this matter.

Review: I am writing to report the unscrupulous and unethical business practices of Guardian Insurance Company. On 3/13/13, Lakeview Dental, the office of my dentist Dr. [redacted], contacted Guardian Insurance to obtain a pre-determination for an occlusal guard. The reason for the request was quite obvious: to establish what percentage of the cost would be covered so that I could make a financial decision of whether or not to proceed. The form that was returned to Lakeview Dental in an email and stated very clearly that 60% would be covered. The form says Covered Charge 0.00, as at that point there was no actual charge. It being a pre-approval request, it was a reasonable interpretation that this column, as well as the Benefit Amount column, would be zero. The form was transmitted to the dentists office by itself, with no further explanation beforehand or afterward. Based on the information that Guardian Insurance provided, I instructed my dentist to proceed with the manufacture of the occlusal guard. My dentist completed the work and contacted Guardian to receive payment. However, on 3/27/13 Guardian Insurance denied coverage. Guardian was contacted for an explanation of the denial of coverage. Guardian responded by saying the procedure was not covered, and attached the single page pre-determination sheet they had previously sent to the dentist's office. Furthermore, in an illogical argument that stretched the bounds of reason, Guardian claimed the reference to the 60% coverage for the procedure was the amount they would cover had the procedure actually been covered. I then contacted Guardian Insurance. I made very clear to Guardian Insurance, that the only reasonable interpretation of their predetermination form was that 60% of the procedure would be covered. I explained to Guardian Insurance that it was foreseeable that I would rely on their statement that the procedure was covered. Furthermore, because I relied on Guardian's statement to my detriment, they were obligated to cover the procedure. After I contacted Guardian Insurance, the company provided a second document. Guardian claimed this second document had been attached to the original email to the dentists office. This second document denied coverage for the procedure unless done within six months after osseous surgery. However, the dentists office reassured me that this second sheet was never received by them. In addition, when Guardian denied coverage the first time, they did not attach this second sheet. In fact, the original predetermination received on 3/13/13 had a page reference of "4 of 7", the alleged page two had the same exact series number of 4 of 7. The denial of benefits received on 3/27/13 had a page reference of 2 of 8, the alleged page two that would accompany that document had a page reference of 1 of 1, a different series altogether. Guardian's actions in this matter have been outside the bounds of normal business conduct and have been flat out fraudulent and unethical. I want to make you aware of their unscrupulous business practices because other people may be having some of the same issues. Thank you for your time and consideration on this matter.Desired Settlement: I would like Guardian to refund the cost of the occlusal guard.

Business

Response:

Dear Mr. [redacted]

This letter is a follow-up response to Mr. [redacted]'s request for reconsideration of his occlusal guard performed on 03/19/13.

While Guardian can appreciate Mr. [redacted]'s situation, the occlusal guard provision (occlusal guards are only covered once per lifetime and only when performed within six months after osseous surgery) is a specific contract limitation under the terms of the dental plan. Adherence to specific contractual provisions in the benefit determination process allows us to provide consistent and fair processing service to all our members. Therefore, based on the specific plan provision, coverage is not available for Mr. [redacted]'s occlusal guard performed on 03/19/13.

I am sorry that Mr. [redacted] is upset with the outcome of his claim. However, the information regarding occlusal guards was provided to Mr. [redacted]'s in his Guardian plan booklet. Also, I do realize that a pre determination of benefits was performed prior to Mr. [redacted] receiving his occlusal guard. It's unfortunate that Mr. [redacted]'s and his provider misinterpreted our explanation of benefits, which does clearly state that his occlusal guard is not a covered service.

Review: Guardian Dental Insurance decided to create time frames in which patients are only covered for a dental visit after every 6 months. If you are a day too early of 6 months, there is no middle ground of any kind, Guardian will bill you the full amount. Nowhere in the information I received from them said anything about this until I was already billed. Being that my dentist told me I am due for a cleaning at the time, I had my cleaning, completely unaware of the 6 month rule at the time. I have the letter from the dentist office to prove all this. Since the 6 month period had not ended and I was too early for my covered appointment, I received mail from both the dentist and Guardian(dental coverage), telling me I need to pay the bill because of this new rule. After attempting to write, mail and call Guardian several times, I finally got a hold of someone on the phone. The Claims Representative simply stated the rule and told me they are not willing to talk to me regarding the issue and that Guardian will not revise or amend it. At this point, it is clear that Guardian provides very poor coverage (based on this 6 month tactic to escape paying bills), is unwilling to assist its insurance holders and is charging Loro Piana for coverage without providing the coverage to its holders. I am surprised the Revdex.com even covers this scam. Guardian needs to be reviewed by the Revdex.com again for poor business ethics.Desired Settlement: Since I was supposed to be covered at the time and was recently laid off with nothing to support me, the dental bill is financially draining. The recorded bill from Diamond Spring Dental (Denville, NJ) was $185 (that I do not have). I believe the least they could do, on ethical grounds, is reimburse me for their very poor business practice.

Business

Response:

Dear Mr. [redacted],

I've reviewed Mr. [redacted]'s concerns as well as the terms of the dental plan under which he was covered as of the 12/20/12 treatment date. The treatment in question was accurately denied based on the frequency provisions of the plan and no further benefits are payable. The remainder of this letter will explain the plan provisions used in the benefit determination process.

Please note that the plan under which Mr. [redacted] was covered was a self-insured plan through Warren Corporation and not an insured line of coverage. Guardian provides administrative services while Warren Corporation assumes all financial responsibility for the funding of claim benefits.

Guardian has administered Warren Corporation's dental coverage since 5/1/04 and since that time the plan has always limited the coverage of exams and prophylaxis (cleanings) to one each 6 consecutive month period. Our records reflect coverage of an exam and cleaning performed on 7/30/12 therefore Mr. [redacted]'s 12/20/12 exam and cleaning were denied coverage as the 6 consecutive month frequency limitation had not been met.

While I regret Mr. [redacted]'s dissatisfaction, benefits were administered in keeping with the plan provisions selected by Warren Corporation and no further coverage is available. Please see attached contract language in support of our handling of this matter.

Sincerely,

[redacted] Group Quality Analyst ###-###-#### [redacted]@glic.com

Review: My son had braces put on in February 2013. Guardian was supposed to cover up to $1000 of the cost of the braces. I paid the remaining balance. I thought Guardian would pay their portion as promised, but their policy is that they will only pay quarterly. I left my employer in July 2013, and unaware of this policy, opted out of [redacted], and therefore my policy "termed". Unbeknownst to me, Guardian had not paid the full amount, due to this strange "quarterly" payment schedule, and refuses to pay anything after July 2013 due to this "terming" of the policy. They will only pay quarterly as long as premiums are still being paid, regardless of when service was rendered and a claim was submitted. As of now, they have only paid $410. I have spoken with several agents regarding this policy, but they state that they, I am paraphrasing, are no longer liable for treatment rendered. It is clear to me that Guardian did not live up to their end of the agreement, because at the time of service, I was a current and paying member. Their quarterly policy does not make any sense. Payment should not be contingent on me staying a member, but should be contingent on whether or not I was a member at the time the service was rendered.Desired Settlement: Pay final portion to orthodontist.

Business

Response:

My apologies...this response had been mailed out on 1-20-14. Please do not hesitate to contact me if there are any problems with this attachment.

Thank you.

Business

Response:

Please see attached.

Consumer

Response:

[To assist us in bringing this matter to a close, you must give us a reason why you are rejecting the response. If no reason is received your complaint will be closed Administratively Resolved]

I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that this does not resolve my complaint. For your reference, details of the offer I reviewed appear below.

Guardian insists that it is their policy that they pay quarterly. This is a ridiculous policy and quite frankly, a very sorry excuse. I have been ripped off. The agreement was, Guardian would pay up to $1000 towards the orthodontics. They have only paid $410. There is a remaining balance of $590. I was a premium paying customer at the time the service was performed and at the time the claim was paid. I continued to pay premiums for several months after that. The payment should not be contingent on me staying a policy holder, but rather, it should be contingent on whether or not I was a policy holder at the time of service. Guardian is merely rejecting their responsibility towards me, the customer, by refusing to pay.

Regards,

Consumer

Response:

[To assist us in bringing this matter to a close, you must give us a reason why you are rejecting the response. If no reason is received your complaint will be closed Administratively Resolved]

I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that this does not resolve my complaint. For your reference, details of the offer I reviewed appear below.

[To assist us in bringing this matter to a close, we would like to know your view on the matter.]

Review: I WAS GOING IN FOR ROUTINE PREVENTIVE CARE AT DR [redacted]'S OFFICE IN TALLAHASSEE FLORIDA TO HAVE A CHECK UP AND TEETH CLEANED. MY BRIDGE WAS PARTIALLY COMING LOOSE AND I TALKED WITH HIM ABOUT FIXING IT... HE TRIED SEVERAL TIMES TO GET IT TO COME OUT AND IT WOULDNT. FINALLY ON MY CLEANING APPT ON 10/23/2013 I ASKED TO GET THE GUARDIAN INSURANCE ESTIMATE FOR THE COST TO FIX MY BRIDGE AND GLUE IT BACK IN. I WAS GIVEN AND ESTIMATE AND I PAID TWO THIRDS OF THE ESTIMATE THAT DAY. THE REST I PAID ON 11/07/2013. I WAS FINISHED WITH TEMPORARY GLUE AND TOLD TO COME BACK WHEN IT COME OUT AND IT WOULD BE PERMANENTLY GLUED AND OTHER TEETH HE SANDED TO MAKE IT FIT WOULD BE POLISHED. I WENT ON LIVING MY LIFE AND MADE PREVENTATIVE APPOINTMENTS FOR JANUARY TO COME BACK IN AND DO PREVENTATIVE CLEANINGS AGAIN IN JANUARY. WELL DAYS BEFORE I WAS TO GO IN I WAS TOLD I HAD A BILL ON MY ACCOUNT FOR $133 STILL DUE. I KNEW NOTHING OF THIS BALANCE. NO BILLING NO CALLS NOTHING.... I CALLED DR [redacted]S STAFF AND TRIED TO RESOLVE THIS ISSUE TO NO AVAIL BUT THREATENING ME WITH COLLECTION WHEN I DIDNT EVEN KNOW IT EXISTED. I CALLED HR FROM MY HUSBANDS EMPLOYER AND GOT ADVICE WHAT TO DO. I FILED AND INQUIRY jANUARY 28TH OF 2014 REGARDING THIS EXTRA BILL THAT CAME OUT OF NOWHERE. AFTER 6 MONTHS OF TRYING TO CONTACT THE PERSON NAMED [redacted] WITH GUARDIAN AND AFTER NOT ONCE BEING ALLOWED TO TALK TO HER OR FOR HER TO EVEN CALL ME BACK( AFTER I HAVE CALLED AND LEFT SEVERAL MESSAGES) I RECEIVED A LETTER DATED JUNE 23RD 2014 STATING THAT I OWED DR [redacted] ANOTHER $153.20 AND THAT THEY CONSIDER MY INQUIRY CLOSED.Desired Settlement: I FEEL I WAS UNFAIRLY TARGETED BY DR [redacted]S STAFF TO CHARGE ABOVE WHAT THEY CONTRACTUALLY AGREED WITH MY HUSBANDS EMPLOYER, I FEEL AN WRITTEN APOLOGY LETTER IS IN ORDER FOR THAT.

I FEEL I DONT OWE THE $153.20 MORE DUE TO THE FACT I ASKED FOR A "GUARDIAN ESTIMATE OF CHARGES" DOCUMENT BEFORE WORK WAS DONE ON 10/23/2013 TO BUDGET MY MONEY (SINCE I DONT HAVE A JOB MYSELF) WITH THE WORK TO BE DONE AND TO KNOW EXACTLY WHAT I WOULD HAVE TO PAY, WHICH I DID PAY BASED ON THE ESTIMATE THEY GAVE ME! $212.50

I FEEL I FOLLOWED THE RULES AND THEY RAN OVER ME. NOT ONLY DID THEY MISS CHARGE MY ACCOUNT THEY ADDED MY DAUGHTERS FREE PREVENTATIVE CARE IN THERE ALSO AND THAT IS NOT FAIR WHEN ALL OF OUR PREVENTATIVE TREATMENTS ARE FREE SINCE WE HAVE THE MORE EXPENSIVE PLAN THROUGH MY HUSBANDS EMPLOYER.

I WANT THIS BALANCE DUE CLEARED FROM MINE AND MY HUSBANDS ACCOUNT AND ADJUSTED AND WE WILL MOVE ON TO A DIFFERENT OFFICE THAT FOLLOWS GUARDIANS CONTRACTS CORRECTLY AND DOESNT THREATEN THEIR CUSTOMERS. I HAVE ALL MY DOCUMENTATION AS NEEDED FOR YOUR INVESTIGATION I AM WILLING TO SUPPLY

Business

Response:

file number [redacted]

Review: I have Guardian dental highplan insurance. I had to have crown work done a tooth with a large filling(25yrs old) had a crack from one side to the other side of the tooth. I had toothache thats why I went to the dentist.Guardian origanlly said they would cover their part as per plan, but when time came to pay they denied payment, my dentist sent xrays, photos ect. Still denied payment, dentist submitted it again and again with more info. I finally called P&R Dental in NY who does Guardians reviews. He told me the work was unnessecary and he would only approve a 2sided amalgam filling $28 of the $1200.(I didnt know they still did amalgam)So I asked him "so what you are saying is that I should not trust my dentist as he does work I do not need?" He said "oh no you should trust him" SO what am I to do now?I have talked to more insurance people than I can remember on this subject and I am told Guardian is responsable for this payment and should pay it but they are refusing too. So this is my only recorse. I would not use any company associated with Guardian-anything ever again, I would be better off with NO insurance.Desired Settlement: I would like Guardian to pay the amount they agreed to pay when they took my premiums. I doubt they will.

Business

Response:

This letter Is In response to your request for review of Ms. [redacted]'s concerns involving her claims for crowns and crown buildups performed on 9/5/12 and 10/8/12*

Under the terms of Ms. [redacted]'s dental plan, crowns are eligible for coverage only when necessary due to decay or injury not otherwise restorable with routine filling materials. Crown buildups are eligible for coverage only when performed in conjunction with an eligible crown and only when necessary due to substantial loss of natural tooth structure. Proof of loss to support a contractual basis for coverage must be established through review of submitted diagnostic materials (pre-operative x-rays along with any other diagnostic materials) so that benefits may be provided in keeping with the terms of the plan. The plan provides for the professional review of submitted claims by licensed dentists (consultants) to assist in our determination of accurate plan benefits. Pretreatment review is recommended for proposed treatment exceeding $300 to ensure that all parties are aware of the projected available plan benefit and associated patient liability prior to work being performed. Guardian has no record of receiving a treatment estimate or issuing a PreDetermination statement prior to receiving Ms. [redacted]'s claims for the completed treatment.

Two separate claim reviews were performed for the 9/5/12 crown and crown buildup on tooth 29 and three claim reviews were performed for the 10/8/12 crown and crown buildup on tooth 31. After review of submitted clinical diagnostic materials, consultants initially advised that teeth 29 and 31 did not appear to have decay or injury to establish a contractual basis for crown coverage. The consultants also advised that both teeth appeared to have sufficient tooth structure remaining for support and retention such that necessity of crown buildups wasn't evident. Guardian issued notices of denial in keeping with plan provisions on both claims.

In the most recent claim review involving additional information supplied by the dental office, a consultant advised that teeth 29 and 31 did not appear to have decay or injury to the extent that a crown was necessary and suggested alternate treatment of routine amalgam restorations; a three surface restoration was recommend for tooth 29 and a two surface restoration was recommended for tooth 31. The consultant also upheld the previous review recommendations for the crown buildups and advised that both teeth appeared to have sufficient tooth structure remaining for support and retention such that necessity of crown buildups wasn't evident. The claims were processed on 5/23/13 issuing alternate benefit allowances towards Ms. [redacted]'s claims.

We understand that the method of treatment for a patient's dental condition is a decision made between a provider and their patient. There are numerous reasons that crown placement may be appropriate treatment, however the contract limits coverage of crowns to only those instances in which the tooth requires crown placement due to decay or injury not otherwise restorable with routine filling materials. Guardian doesn't direct or dictate the care provided; we determine benefits for submitted claims in keeping with the dental contracts under which members are insured.

While I regret Ms. [redacted]'s dissatisfaction with our handling of her claims, proof of loss in support of a contractual basis for full crown coverage has not been established in the claim reviews performed to date and no further benefits were found to be available.

Pertinent contract language in support of our handling of this matter is enclosed for your review.