Wisdom teeth - VHI reject claim as 'pre-existing condition'

po0k

My partner (late 20s) has had 2 wisdom teeth on one side removed under GA.
Last year one of her wisdom teeth had just broken through the skin so she went to the dentist.
The dentist couldn't take an xray or schedule surgery at the time as she was pregnant at the time.
After our son was born, she went back and had the x-ray to check the teeth and was referred for surgery to prevent complications due to prevention and decay of the neighbouring tooth due to impaction.

Everything was tickity-boo until VHI sent us back the invoices and a letter explaining that as the condition pre-existed her membership (3.5years, they have a waiting period of 5) they would not cover the claim.
We also have DeCare Dental cover through the VHI too which might cover the xrays but doesn't list wisdom teeth in the schedule of treatments.

I don't contest the waiting period, but I don't see how this condition (the impaction) can pre-exist. There was no condition until last year.
By the same logic someone developing Lukemia inside the 5 year period would also not be covered as they've always had their bones.

On the other side, by their own terms and conditions applicable to our current policy, the dentist/consultant must send a certificate and xrays to the VHI for approval before carrying out the surgery.
The hospital (Bons in Tralee) checked her VHI policy number and told her she was covered and charged her the excess at admission.

Do I need to get a letter or some form of proof from the dentist or consultant that the condition did not pre-exist the membership, or is it a closed case as wisdom usually come up in your late teens/early 20s and because it was unerupted, that is the pre-existing condition they refer to?
Is there any argument to be made that this was preventative, and we've saved the VHI the cost of repair to neighbouring teeth and bone due to infection and decay?

I know we can claim 20% on the MED1 but that's little comfort after shelling out for medical cover for the last 7 years (myself, she's 3.5)
Right now I'm resigned to having to pay for this, but I do feel like we're being squeezed.

Oral Surgeon

po0k wrote: »

My partner (late 20s) has had 2 wisdom teeth on one side removed under GA.
Last year one of her wisdom teeth had just broken through the skin so she went to the dentist.
The dentist couldn't take an xray or schedule surgery at the time as she was pregnant at the time.
After our son was born, she went back and had the x-ray to check the teeth and was referred for surgery to prevent complications due to prevention and decay of the neighbouring tooth due to impaction.

Everything was tickity-boo until VHI sent us back the invoices and a letter explaining that as the condition pre-existed her membership (3.5years, they have a waiting period of 5) they would not cover the claim.
We also have DeCare Dental cover through the VHI too which might cover the xrays but doesn't list wisdom teeth in the schedule of treatments.

I don't contest the waiting period, but I don't see how this condition (the impaction) can pre-exist. There was no condition until last year.
By the same logic someone developing Lukemia inside the 5 year period would also not be covered as they've always had their bones.

On the other side, by their own terms and conditions applicable to our current policy, the dentist/consultant must send a certificate and xrays to the VHI for approval before carrying out the surgery.
The hospital (Bons in Tralee) checked her VHI policy number and told her she was covered and charged her the excess at admission.

Do I need to get a letter or some form of proof from the dentist or consultant that the condition did not pre-exist the membership, or is it a closed case as wisdom usually come up in your late teens/early 20s and because it was unerupted, that is the pre-existing condition they refer to?
Is there any argument to be made that this was preventative, and we've saved the VHI the cost of repair to neighbouring teeth and bone due to infection and decay?

I know we can claim 20% on the MED1 but that's little comfort after shelling out for medical cover for the last 7 years (myself, she's 3.5)
Right now I'm resigned to having to pay for this, but I do feel like we're being squeezed.

The VHI have become very tight lately...

Who said that it was a pre-existing condition???

Just because she had some teeth out before being covered does not mean that you knew that the teeth in question would need removal 3.5 years later....

Could you clarify when she had her wisdom teeth out initially?? Did the surgeon tell her at that point that the other wisdom teeth definitly needed removal?? When did she first have symptoms with these teeth?? Have you or the surgeon told the VHI anything to make them beleive that this wisdom tooth problem has been ongoing for the past few years and not a new condition?? Is it the same surgeon or hospital or referring dentist??

VHI had to get this information regarding previous treatment from somewhere.

If you were told before taking the policy that these needed removal or you had symptoms before taking out the policy, then VHI are correct in their 5 year wait.

If you only developed symptoms or were only told of the need for removal after taking out the policy then the wait is 6 months...

VHI decare is no help here.

Your surgeon should be able to help clarify things here...

You haven't saved the VHI anything by having this treatment. They would prefer that you pay your premium and have no treatment... They wouldn't cover any of the decay or infection or bone loss anyway..... Medical insurance companies don't like paying out.... especially since James Reilly is killing them on public hospital bed fees...


OS

montzarella

"On the other side, by their own terms and conditions applicable to our current policy, the dentist/consultant must send a certificate and xrays to the VHI for approval before carrying out the surgery.
The hospital (Bons in Tralee) checked her VHI policy number and told her she was covered and charged her the excess at admission."

Did they send away the pre-cert form along with the xray to Vhi for pre-approval? That is what the Bons should have done; they would get a response from vhi to tell them it was covered or not.

Were the extractions done by an oral surgeon? Do you remember what the total cost of the treatment was for the two extractions?

Oral Surgeon

montzarella wrote: »

"On the other side, by their own terms and conditions applicable to our current policy, the dentist/consultant must send a certificate and xrays to the VHI for approval before carrying out the surgery.
The hospital (Bons in Tralee) checked her VHI policy number and told her she was covered and charged her the excess at admission."

Did they send away the pre-cert form along with the xray to Vhi for pre-approval? That is what the Bons should have done; they would get a response from vhi to tell them it was covered or not.

Were the extractions done by an oral surgeon? Do you remember what the total cost of the treatment was for the two extractions?

If it was done in the Bons, it was most likely an Oral Surgeon and he is most likely pre approved to do these procedures without having to send the forms and xrays in advance.... All he would check and satisify himself with is that you have insurance and have it for over 6 months and have a covered treatment....

po0k

Oral Surgeon wrote: »

The VHI have become very tight lately...

I suspect this may be the 'root' of the issue.

Oral Surgeon wrote: »

Who said that it was a pre-existing condition???

VHI

Oral Surgeon wrote: »

Just because she had some teeth out before being covered does not mean that you knew that the teeth in question would need removal 3.5 years later....

Could you clarify when she had her wisdom teeth out initially??

Sorry, to clarify, she has only had 2 wisdom teeth removed and this was performed in one surgery very recently.

Oral Surgeon wrote: »

Did the surgeon tell her at that point that the other wisdom teeth definitly needed removal?? When did she first have symptoms with these teeth??

She went to her dentist late 2012 as far as I understand which is where the suspicion arose as they had just broken through the gum (as far as I udnerstand).

Oral Surgeon wrote: »

Have you or the surgeon told the VHI anything to make them beleive that this wisdom tooth problem has been ongoing for the past few years and not a new condition?? Is it the same surgeon or hospital or referring dentist??

It's her family dentist so I would presume he'd have the full history. I'm not 100% she hasn't gone to somewhere up here, but after suggesting she have the removal done up here and her insistence on using her family dentist, I'm pretty sure she hasn't visited anyone else.

Oral Surgeon wrote: »

VHI had to get this information regarding previous treatment from somewhere.

If you were told before taking the policy that these needed removal or you had symptoms before taking out the policy, then VHI are correct in their 5 year wait.

If you only developed symptoms or were only told of the need for removal after taking out the policy then the wait is 6 months...

Then they should cover it. I'm not sure how/where I can get proof for VHI that the condition didn't pre-exist her joining VHI.

Oral Surgeon wrote: »

VHI decare is no help here.

Figured as much ironically

Oral Surgeon wrote: »

Your surgeon should be able to help clarify things here...

That's what I was thinking too, just wasn't sure about the pre-certifiaction.

Oral Surgeon wrote: »

You haven't saved the VHI anything by having this treatment. They would prefer that you pay your premium and have no treatment... They wouldn't cover any of the decay or infection or bone loss anyway..... Medical insurance companies don't like paying out.... especially since James Reilly is killing them on public hospital bed fees...

OS

montzarella wrote: »

"On the other side, by their own terms and conditions applicable to our current policy, the dentist/consultant must send a certificate and xrays to the VHI for approval before carrying out the surgery.
The hospital (Bons in Tralee) checked her VHI policy number and told her she was covered and charged her the excess at admission."

Did they send away the pre-cert form along with the xray to Vhi for pre-approval? That is what the Bons should have done; they would get a response from vhi to tell them it was covered or not.

Don't know if they sent off the pre-cert or X-ray.

montzarella wrote: »

Were the extractions done by an oral surgeon? Do you remember what the total cost of the treatment was for the two extractions?

Yes and ~750 including hospital charges, consultant fees and anaesthesiologist.

Oral Surgeon wrote: »

If it was done in the Bons, it was most likely an Oral Surgeon and he is most likely pre approved to do these procedures without having to send the forms and xrays in advance.... All he would check and satisify himself with is that you have insurance and have it for over 6 months and have a covered treatment....

Hopefully so, we're going to contact the Bons tomorrow to set this straight.

Thanks for the replies folks, has confirmed what I thought, though I'm still not optimistic that VHI will accept the claim.

Oral Surgeon

You need to write down the sequence of events here so that you are clear when discussing it....

Things to note;

She had wisdom teeth out before, when?? She had them out as they were causing trouble. The more recent teeth in question were never causing trouble until recently and she was not told of the need for removal until recently- this is important as the vhi claim form asks when did symptoms develop and when you became aware that this treatment may be necessary.
The form also asks when did the patient first consult with the surgeon. Maybe this is where the problem lies as she may have seen the surgeon for wisdom tooth removal but this is a seperate problem completely....
The form also asks if you have had a similar condition or claim before. She had a similar condition but no claim as she was not covered then....

When did she take out VHI cover??

When did she first have symptoms with the teeth, not when did they come up (everyones teeth hurt a little when they come up) but when they first caused pain and infection. If this is within the period of cover then you should be covered, end of...

Date of treatment etc....

What was the breakdown of extra fees??

OS

po0k

Oral Surgeon wrote: »

You need to write down the sequence of events here so that you are clear when discussing it....

Things to note;

She had wisdom teeth out before, when?? She had them out as they were causing trouble. The more recent teeth in question were never causing trouble until recently and she was not told of the need for removal until recently- this is important as the vhi claim form asks when did symptoms develop and when you became aware that this treatment may be necessary.
The form also asks when did the patient first consult with the surgeon. Maybe this is where the problem lies as she may have seen the surgeon for wisdom tooth removal but this is a seperate problem completely....
The form also asks if you have had a similar condition or claim before. She had a similar condition but no claim as she was not covered then....

When did she take out VHI cover??

When did she first have symptoms with the teeth, not when did they come up (everyones teeth hurt a little when they come up) but when they first caused pain and infection. If this is within the period of cover then you should be covered, end of...

Date of treatment etc....

What was the breakdown of extra fees??

OS

Cover started Q3 2010.
No previous wisdom teeth extracted, or any of her adult teeth.
The symptoms (noticing the tooth had only partially erupted, don't know if there was pain) first presented Q3 2012. I don't know if this constitutes diagnosis.
Diagnosis through X-ray Q3 2013.
First consultation with surgeon was Q3 2013.
No infection was present (to my knowledge), but she was advised to have them removed as food would get trapped under the loose gum tissue and could cause infection. Decay from the impaction on neighbouring tooth was present I believe.

Breakdown of fees:
Pending:
Q3 2013 730 Surgery
-- 330 Consultation Oral Surgeon
-- 180 Consultation Anaesthesiologist

Already paid:
Q3 2013 55 x-ray diagnosis
Q3 2013 140 Consultation Oral Surgeon for diagnosis
Q3 2013 75 Member Excess on Hospital fees

So is this sufficient to _prove_ that it wasn't pre-existing her joining VHI or do I need to get the Hospital, Dentist or Consultant involved so folks get paid and I'm not out of pocket?

Oral Surgeon

po0k wrote: »

Cover started Q3 2010.
No previous wisdom teeth extracted, or any of her adult teeth.
The symptoms (noticing the tooth had only partially erupted, don't know if there was pain) first presented Q3 2012. I don't know if this constitutes diagnosis.
Diagnosis through X-ray Q3 2013.
First consultation with surgeon was Q3 2013.
No infection was present (to my knowledge), but she was advised to have them removed as food would get trapped under the loose gum tissue and could cause infection. Decay from the impaction on neighbouring tooth was present I believe.

Breakdown of fees:
Pending:
Q3 2013 730 Surgery
-- 330 Consultation Oral Surgeon
-- 180 Consultation Anaesthesiologist

Already paid:
Q3 2013 55 x-ray diagnosis
Q3 2013 140 Consultation Oral Surgeon for diagnosis
Q3 2013 75 Member Excess on Hospital fees

So is this sufficient to _prove_ that it wasn't pre-existing her joining VHI or do I need to get the Hospital, Dentist or Consultant involved so folks get paid and I'm not out of pocket?

I'd ring VHI and ask what the problem is and why they believe it to be a pre-existing condition. They may tell you that the surgeon said it had been going on 10 years.... unlikely...

Explain the sequence as above...

Ask them what proof they need of your position. Your dental records or surgical records showing no previous mention of need for removal or a letter from dentist/ surgeon....

Good luck, let us know how you get on.

po0k

Just got off the phone with them there, since we received the initial letter from the VHI, there has been some further correspondence which may affect the outcome.
The consultant is fully participating in the VHI scheme and is exempt from the pre-certification.

For anyone else in a similar situation, these correspondence procedures can take up to 44 days to be processed so I might not hear back for another few weeks.

Thanks again for answering these niggly questions.
The lady I spoke to in the VHI was very straight forward and understanding.
Like my previous experiences with them up to this letter, it's been positive.
I might give them a bit of feedback about communicating the state of the claim through MyVHI though, this claim isn't even listed as declined, never mind still in progress and the letter we received seemed very final.

I'll update when I have a result either way.