Irish Life not paying benefit

aoife161

Hi

Can I get your feedback on this please? My husband had emergency dental work done a couple of weeks ago. Our receipt from our dentist specified the work done (basically it was a periodontal abscess that had to be worked on).
I submitted this to Irish Health as we have a personalized package that covers for dental and optical treatment.

As per their website it states:
Emergency Dental: €350 contribution
We will contribute to the cost of Emergency Dental Treatment in cases that have been determined as emergency by the treating clinician. Just keep your receipts and send them in to us to claim for this benefit.

It was rejected.

I rang up today and the girl said to be as per their handbook it didn't meet the criteria which is that the emergency must be as a result of an accident or injury.

HEre's what their hand book states:

This benefit allows you to claim back some of the costs of dental treatments or procedures which are required as a result of an accident or injury and are required to alleviate pain or to treat an acute dental trauma which represents
a serious threat to the member’s general health. The patient must present to the dental practitioner within 48 hours following the accident or injury and receive treatment within 7 days of presenting to dental practitioner


Now when I read the above, I interpret that it would fall into the 2nd half of the sentence " or to treat an acute dental trauma which represents
a serious threat to the member’s general health"

What do you think?

It's just so bloody annoying.

hanaimai

I think the part 2 you refer to must still be as a result of an accident or injury. If you look at the sentence, you need to meet two criteria:
1. 'which are required as a result of an accident or injury' AND
2. 'are required to alleviate pain' OR 'to treat an acute dental trauma which represents a serious threat to the member's general health'.
This reading is further supported by the next sentence which states you must present within 48 hours following the accident or injury.

If that AND was an OR then I think your interpretation would be correct.

Very annoying though, I totally agree. I'm sure many people would just read 'emergency dental' and assume a procedure like your husband's would be covered. Insurance companies are masters at the art of fine print!

aoife161

hanaimai wrote: »

I think the part 2 you refer to must still be as a result of an accident or injury. If you look at the sentence, you need to meet two criteria:
1. 'which are required as a result of an accident or injury' AND
2. 'are required to alleviate pain' OR 'to treat an acute dental trauma which represents a serious threat to the member's general health'.
This reading is further supported by the next sentence which states you must present within 48 hours following the accident or injury.

If that AND was an OR then I think your interpretation would be correct.

Very annoying though, I totally agree. I'm sure many people would just read 'emergency dental' and assume a procedure like your husband's would be covered. Insurance companies are masters at the art of fine print!

ye I would tend to agree with your interpretation now that I re-read the paragraph. ARRRGHH!!

thanks for your input

coylemj

hanaimai wrote: »

I think the part 2 you refer to must still be as a result of an accident or injury. If you look at the sentence, you need to meet two criteria:
1. 'which are required as a result of an accident or injury' AND
2. 'are required to alleviate pain' OR 'to treat an acute dental trauma which represents a serious threat to the member's general health'.
This reading is further supported by the next sentence which states you must present within 48 hours following the accident or injury.

If that AND was an OR then I think your interpretation would be correct.

It depends on how you treat the 'AND' and the 'OR', this is like a mathematical equation with missing brackets.

It could be interpreted this way ..........

This benefit allows you to claim back some of the costs of dental treatments or procedures

1. which are required as a result of an accident or injury and are required to alleviate pain

OR ...

2. to treat an acute dental trauma which represents a serious threat to the member’s general health.

In which case the treatment would be covered.