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Background: I did a dental procedure during the waiting period of a new dental plan. My dentist contest that contracted prices do not apply during this period despite the fact that the insurance company gave a letter explicitly saying otherwise.

The dentist interpret following definition of covered services in Illinois SB 3242 to say that procedures during waiting period are considered as uncovered services:

"Covered services" means dental care services for which a reimbursement is available under an enrollee's plan contract, or for which a reimbursement would be available but for the application of contractual limitations such as deductibles, copayments, coinsurance, waiting periods,annual or lifetime maximums, frequency limitations, alternative benefit payments, or any other limitation.

Is this interpretation correct? If I understand correctly, above means the opposite and the dentist is still bound by the prices contracted with the insurance company. (Pardon if this is more of a English language question than a Law question.)

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  • Reporting back: This law grandfathers in any dentist has a contract signed with the insurance company before the law was enacted. The dentist claimed that this is the case in small claims court w/o providing evidence. The insurance company paid me the difference unprompted, probably because they gave me an incorrect letter. I didn't pursue the matter any further in the interest of time.
    – Aelian
    Commented Dec 4, 2022 at 7:05

2 Answers 2

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The language is pretty clear but what you have is the dentist, for whatever reason, not wishing to honor the contract.

But I'm not sure how anyone's opinion here is going to sway your dentist. Perhaps you should contact the insurer and seek their assistance. Failing that, there is always the courts.

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  • Thanks. I needed a sanity check before going to small claims court.
    – Aelian
    Commented Dec 10, 2021 at 20:22
  • "the dentist, for whatever reason, not wishing to honor the contract." What contract? Could you elaborate? From what I gather, the OP and the insurer are parties to a contract (namely, the insurance policy). Unless the dentist also is a party to that contract, there must be a separate contract involving that dentist and the OP. Just from what the OP describes, it is unclear who exactly is liable to the OP.
    – Iñaki Viggers
    Commented Dec 10, 2021 at 22:08
  • The OP said "...contracted prices". When I read that I get the impression that there is a contract between the dentist and the insurance network. This is a common arrangement.
    – jwh20
    Commented Dec 11, 2021 at 11:23
  • Yes, I meant the contract prices between the dentist and the insurance company.
    – Aelian
    Commented Dec 12, 2021 at 5:16
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Is this interpretation correct?

Unless I am missing an implication from "the waiting period of [the] new dental plan", it seems that the dentist's interpretation is accurate.

The given definition of "covered services" lists some limitations (see the "but for" particle). One of those limitations pertains to services performed during "waiting periods".

Your description is unclear on the terms & scope of your insurance policy as well as its relation to IL SB 3242. That information is necessary for putting in context the insurer's confirmation that the service is covered. For instance, maybe your insurance policy provides greater coverage than the statutory minimum, in which case the reimbursement might not involve the dentist at all. Hence the need for details on your insurance policy.

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  • Thanks for looking into this. My thinking is that would be available but for is what makes this a covered service for the purpose of contracted prices. E.g. After removing irrelevant parts, the sentence would read as: ... or for which a reimbursement would be available but for the application waiting periods. Will report back once I find out for sure.
    – Aelian
    Commented Dec 12, 2021 at 5:28
  • @Aelian The meaning of "but for" is "except for something". Adapting your example, it would make no sense for the insurer to reimburse the deductible, since by definition a deductible is something the insurer will not pay.
    – Iñaki Viggers
    Commented Dec 12, 2021 at 10:55

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