Man denied dental coverage under national plan says insurer 'playing games' with Canadians

After months of probing, bruno walter hireré is relieve trying to acquire to the bottom of the inning of why he doesn’t qualify to get a crown covered under the Canadian Dental Care Plan (CDCP). 

The public insurance program subsidizes the cost of dental care for Canadian residents with a household income below $90,000, if they don't have access to a private insurance plan. 

Insurance provider Sun Life administers the CDCP and processes claims.

While most claims don’t need pre-authorization, it’s required for more expensive procedures, like crowns or partial dentures.

In the last year, Bossé said he’s had multiple pre-authorization requests for crowns denied, even after his dentist submitted the proper documentation, X-rays and a detailed explanation to show why they're medically necessary.

“I was quite surprised because the dentist was convinced it was straightforward,” said Bossé, who lives in Kirkland, Que., a suburb of Montreal.

Bossé had a broken filling. Although his dentist repaired the base, the tooth needed a crown. A subsequent pre-approval request a few months later for a different tooth, which was cracked, was also denied.

“I’m like, OK, what is Sun Life doing, they are playing games,” Bossé said.

Not one to take no for an answer, the retiree called Sun Life. 

“There was no explanation,” said Bossé. “It’s just denied as per the plan criteria.”

He then escalated the situation to a Sun Life supervisor, but they also wouldn’t specify the precise reason for the denial.

“I was flabbergasted,” said Bossé.

The Canadian Dental Care Plan was supposed to make dental care more affordable for millions of Canadians. To date, Health Canada says over $6 billion has been paid for claims under the plan.

But Bossé believes that’s being undermined by how Sun Life is processing claims for more complex, costly procedures. He’s worried the insurer is turning down claims to mitigate payouts. The estimate for his crown was a bit over $1,600.

“I’ve been a taxpayer for what seems like forever and continue to pay taxes,” said Bossé. “I’d like to get a little for my money.”

Across the country in B.C, the NDP MP for Vancouver East has heard similar complaints from several of her constituents. 

“They should not have to battle the insurance company to try and figure out what it is that they might be doing wrong,” said Jenny Kwan.

“For all we know, they might not be doing anything wrong.”

In one case, her office intervened after a resident’s pre-authorization request for dentures was rejected.

“He literally couldn’t eat,” said Kwan. “We had to fight tooth and nail to only get partial coverage.”

Other constituents in her riding were turned down for crowns. Kwan says neither her office nor the dentist clinics can “make heads or tails out of it.”

She’s concerned these denials may impact people’s health, as many residents can’t afford to pay out of pocket.

Earlier this spring, Kwan sent an open letter to Canada’s Health Minister Marjorie Michel, urging her to resolve the confusion around the CDCP’s eligibility requirements.

“It doesn’t make any sense when dentists submit an application following all the rules, following the eligibility criteria for their patients and they’re being rejected,” said Kwan. 

“They need to be transparent and tell people what the problem is.”

In Quebec, approximately 1.8 million people are enrolled in the CDCP and 1.5 million have received care, said Dr. Marie-Claude Desjardins, president of the Quebec Association of Dental Surgeons.

When it comes to basic care — general exams, cleaning, cavity filling and extractions — she said the program is running well. 

“There are people who sometimes haven’t seen a dentist in years or who have cavities that have been left untreated for years,” said Desjardins. 

But if it’s a more complicated treatment or procedure, she acknowledges it’s often unclear why coverage is being denied.

“So that’s something that we’re asking to be improved,” she said. “We’re asking for it to be simpler, clearer and more predictable for both patients and dental teams.”

The Canadian Dental Association echoed Desjardins’s call for more clarity, saying in an emailed statement that frequent denials were not only delaying timely care for patients, but creating an “administrative burden” for dentists.

Sun Life directed any questions about how the CDCP is being managed to Health Canada. The insurer would only say coverage is determined through a standardized assessment process that applies the CDCP’s policies. The clinical eligibility criteria was developed by Health Canada. 

This is not the first time the national insurance program has faced scrutiny for a high number of claim rejections. Last year, when the program was fully expanded to 18-64 year olds, half of the requests for complex dental work were turned down.

At the time, Health Canada said it was caused by several factors, including a high volume of submissions that were missing information. 

“Sun Life continues to process a high volume of claims for the CDCP in a very efficient manner, with faster turnaround times than many other plans,” said Karine LeBlanc, a spokesperson for Health Canada, in an email last week. 

The most common reasons for denials are incomplete submissions, such as missing X-rays, insufficient evidence that the clinical criteria has been met, duplicate requests and requests for services not covered under the program such as implants or bridges, said LeBlanc.

She went on to say that the CDCP does not have annual spending limits, but relies on clinical criteria that may be more stringent than other plans. As a result, not all pre-authorization requests are approved.

“The CDCP is not a free dental care plan,” wrote LeBlanc. 

Dentists sometimes charge more than the CDCP’s established fees, so only a portion of the cost may be reimbursed.

Household income determines what percentage the government pays. The remaining difference is paid by the patient.

LeBlanc said Health Canada has updated the explanation of benefit statements — a breakdown of what services are covered, how much the plan paid and the patient’s final share of the bill.

It’s also given dentists fact sheets to help better explain eligibility requirements with their patients.

LeBlanc said Canadians should ask their dentist about any additional costs not covered by the plan. They should also be aware of the total amount they’ll need to pay directly to their provider before accepting and starting treatment.

Since Bossé’s dental claims were rejected under the CDCP, his wife had a crown replaced.

Her pre-approval request for coverage was also denied without explanation.

She paid for it out of pocket.

“You can be sure that our dental costs will be claimed as medical expenses on our next tax return,” said Bossé.

Journalist

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