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Table of Contents   
REVIEW ARTICLE  
Year : 2011  |  Volume : 22  |  Issue : 1  |  Page : 144-147
Dental insurance! Are we ready?


Department of Pedodontics & Preventive Dentistry, National Dental College & Hospital, DeraBassi, Mohali, Punjab, India

Click here for correspondence address and email

Date of Submission08-Jan-2010
Date of Decision01-Jun-2010
Date of Acceptance10-Nov-2010
Date of Web Publication25-Apr-2011
 

   Abstract 

Dental insurance is insurance designed to pay the costs associated with dental care. The Foreign Direct Investment (FDI) bill which was put forward in the winter session of the Lok Sabha (2008) focused on increasing the foreign investment share from the existing 26% to 49% in the insurance companies of India. This will allow the multibillion dollar international insurance companies to enter the Indian market and subsequently cover all aspects of insurance in India. Dental insurance will be an integral a part of this system. Dental insurance is a new concept in Southeast Asia as very few countries in Southeast Asia cover this aspect of insurance. It is important that the dentists in India should be acquainted with the different types of plans these companies are going to offer and about a new relationship which is going to emerge in the coming years between dentist, patient and the insurance company.

Keywords: Dental insurance, Foreign Direct Investment, International insurance companies

How to cite this article:
Toor RS, Jindal R. Dental insurance! Are we ready?. Indian J Dent Res 2011;22:144-7

How to cite this URL:
Toor RS, Jindal R. Dental insurance! Are we ready?. Indian J Dent Res [serial online] 2011 [cited 2019 Jul 20];22:144-7. Available from: http://www.ijdr.in/text.asp?2011/22/1/144/79981
With the advent of the 21 st century and the stability in the Indian economy, the dental insurance prospect of business remains unexplored. The Government of India and its policies are to be blamed for this sector to be left out. Due to the large population of the country, insurance sector needs foreign collaboration in order to cover all aspects of insurance. The Foreign Direct Investment (FDI) bill which was put forward in the winter session of the parliament (2008) focused on increasing the FDI investment share from 26% to 49%. [1] This will act as an impetus to the multibillion dollar international insurance companies to enter the Indian market and subsequently cover all aspects of insurance in India.


   The Present Indian Scenario Top


Unlike most western countries, specific dental insurance plans are not common in India.

Oral health is normally integrated with the general health insurance schemes. The efforts of the Indian Dental Association to bring out a comprehensive Indian dental insurance scheme have seen partial success so far.

Indian dental insurance plans are mainly of two types:

Stand alone dental insurance plan: This type of plan covers the expenses related to general dental problems such as periodontitis and extraction of permanent teeth due to ailments such as caries. The amount of expense to be reimbursed as well as the period of such cover is fixed. This type of plan is generally provided by the popular dental care product companies in association with one of the insurance companies. [2] The first of its kind dental insurance scheme in India was launched through oral care brand, Pepsodent (HLL) in 2002. This plan was in partnership with the New India Assurance; the plan offered a dental insurance of Rs. 1000 on purchase of any pack of Pepsodent. Insurance cover against expenses for the extraction of teeth due to caries and periodontitis was also provided. [3]

But this plan was time bound and also did not cover other aspects of dental rehabilitation.

Dental insurance cover as part of general health insurance plan: This type of dental insurance is provided by the general insurance companies as part of their own general health insurance schemes such as health advantage policy or student medical policy. [2] One can claim dental expenses along with the other kinds of reimbursements such as the cost of medicines or hospitalization. These plans also offered tax benefits up to a certain fixed amount under the income tax act.

Example: The insurance plan provided by ICICI Lombard Dental Insurance Cover is not a comprehensive plan and is clubbed with the general health insurance scheme. [3]

In order to have a detailed review of the upcoming insurance sector, we have discussed the different plans of dental insurance existing in the western countries and their approach to different strata of the society.


   Dental Insurance Plans Around the World Top


Indemnity plans

This type of dental plan pays the dental office (dentist) on a traditional fee-for-service basis. A monthly premium is paid by the client and/or the employer to the insurance company, which then reimburses the dental office (dentist) for the services rendered. An insurance company usually pays from 50 to 80% of the dental office (dentist) fees for a covered procedure; the remaining 20-50% is paid by the client. [4]

These plans often have a pre-determined or set deductible amount which varies from plan to plan. Indemnity plans also can limit the amount of services covered within a given year and pay the dentist based on a variety of fee schedules. Some typical features of these plans:

  • High deductibles before coverage begins (well-designed plans do not apply the deductible to preventive services)
  • Probationary periods on certain procedures that last up to a year
  • Annual dollar* limit on benefits
  • Choose your own dentist
  • Your average monthly cost: $15 to $25*
  • Companies selling these plans are regulated by state insurance departments


Dental health maintenance organization

These insurance plans, also known as "capitation plans," operate like their medical HMO cousins. They provide a comprehensive dental care to enrolled patients through designated provider office (dentist). A Dental Health Maintenance Organization (DHMO) is a common example of a capitation plan. The dentist is paid on a per capita (per person) basis rather than for actual treatment provided.

Participating dentists receive a fixed monthly fee based on the number of patients assigned to the office. [4] In addition to premiums, client co-payments may be required for each visit. Some typical features of these plans:

  • Monthly premiums (some require the patient to prepay a year's worth)
  • Free preventive or routine care
  • Patient must select from an approved network of dentists
  • May have an initial enrollment fee
  • Annual dollar* cap
  • Average monthly cost: $5-$15*
  • Companies selling these plans are regulated by state insurance departments.


Preferred provider organizations

Another true insurance plan is a Preferred Provider Organizations (PPO) plan, which falls somewhere between an indemnity plan and a dental HMO. This plan allows a particular group of patients to receive dental care from a defined panel of dentists. The participating dentist will charge less than usual fees to this specific patient base, providing savings for the plan purchaser. [4] If the patient chooses to see a dentist who is not designated as a "preferred provider," that patient may be required to pay a greater share of the fee-for-service. The group of dentists provides services at a deeply discounted rate, giving the patient substantial savings as long as he/she stays in their network.

Unlike the more restrictive DHMO, here the patient can go out of network and still receive some benefits.

Some typical features of these plans:

  • Monthly premiums
  • Annual dollar* cap
  • Patient must stay within the approved network of dentists or pay higher deductibles and co-payments
  • Your average monthly cost: $20-$25*
  • Companies selling these plans are regulated by state insurance departments


(*Dollar is being used in western countries, Rupee in Indian currency, $5-$15 will not mean their conversion rate but according to proportional pricing set up by DCI/appropriate body, for different dental treatments in India.)

Dental discount

This type of dental plan is not insurance. The managing organizations negotiate with local dental offices to establish a set price for a particular dental procedure and offer deep discounts (some up to 70%) off the regular pricing code.

This plan has several advantages over traditional dental insurance plans, namely, there are no exclusions for pre-existing conditions. This allows a patient to receive immediate coverage for work without meeting any waiting period requirements.

Direct reimbursement plans

A dental care plan now coming into vogue is the direct reimbursement plans (DRP). This is a self-funded benefit plan and not an insurance plan. In DRP, an employer pays for dental care with his/her own funds, rather than paying premiums to an insurance company or third party administrator. The patient (employee) pays the full amount directly to the dentist, then gets a receipt detailing the services rendered and their cost paid. The employer reimburses the patient for part or all of the dental costs, depending on your specific benefits.

Example: The company (employer) might reimburse 100% of the employee's first Rs. 500 of dental expenses and then 80% of the next Rs. 1000, and 50% of the next Rs. 2000, with a total annual maximum benefit of Rs. 2500. Or it might reimburse only 50% of your first Rs. 3000, resulting in a Rs. 300 yearly cap.

Some typical features of a direct reimbursement plan:

  • Neither the patient nor the employer pays the monthly premiums
  • Freedom to choose any dentist
  • Typical employer cost depends on the number of employees and benefit caps
  • Benefits will be usually capped at Rs. 300 to Rs. 1000 annually


Dental care is quite different than medical care. Major illness can strike at any time and the costs can be enormous. Most dental diseases are preventable and treatment is predictable.


   What is a good Dental Insurance Plan? Top


Does the plan give the patient the freedom to choose his own dentist or is he restricted to a panel of dentists selected by the insurance company? If the patient has a family dentist with whom he/she is satisfied, consider the effects changing dentists will have on the quality or quantity of care he/she receives. Because regular visits to the dentist reduce the likelihood of developing serious dental disease, it is best to have and maintain an established relationship with a dentist the patient trusts. [5]

What is important here is to observe who controls treatment decisions - patient and or his dentist or the dental plan? Many plans require dentists to follow treatment plans that rely on a Least Expensive Alternative Treatment (LEAT) approach. If there are multiple treatment options for a specific condition, the plan will pay for the less expensive treatment option. If the patient chooses a treatment option that may better suit his individual needs and his long-term oral health needs, he will be responsible for paying the difference in costs. It is important to know who makes the treatment decisions under his plan. These cost control measures may have an impact on the quality of care provided to a patient.

Does the plan cover diagnostic, preventive and emergency services? If so, to what extent?

Most dental plans provide coverage for selected diagnostic services, preventive care and emergency treatment that are basic for maintaining good oral health. But the extent or frequency of the services covered by some plans may be limited. Depending upon the individual oral health needs, the patient may be required to pay the dentist directly for a portion of this basic care. Find out how much treatment is allowed in any given year without cost to the patient, and how much will the patient have to pay.

In general, the treatment without cost includes:

  • Initial oral examination - once per year
  • Recall examinations - twice per year
  • Complete X-ray survey - once every 3 years
  • Cavity-detecting bite-wing X-rays - once per year
  • Prophylaxis or teeth cleaning - twice per year
  • Topical fluoride treatment - twice per year
  • Sealants - for those under age 18 years


The other important considerations to be looked into are the following:

What routine corrective treatment is covered by the dental plan? What share of the costs will be borne by the patients? While preventive care lessens the risk of serious dental disease, additional treatment may be required to ensure optimal health. A broad range of treatment can be defined as routine. Most plans cover 70-80% of such treatment.

Examples of routine care include:
  • Restorative care - Amalgam and composite resin fillings and stainless steel crowns on primary teeth
  • Endodontics - Treatment of root canals and removal of infected tooth nerves
  • Oral surgery - Tooth removal (not including bony impaction) and minor surgical procedures such as tissue biopsy and drainage of minor oral infections
  • Periodontics - Treatment of uncomplicated periodontal disease including scaling, root planning and management of acute infections or lesions
  • Prosthodontics - Repair and/or relining or reseating of existing dentures and bridges


What major dental care is covered by the plan? What percentage of these costs will the patient be required to pay? Since dental benefits encourage getting preventive care, which often eliminates the need for major dental work, most plans are not generous when it comes to paying for major dental work, most plans cover less than 50% of the cost of major treatment.

Most plans limit the benefits both in number of procedures and rupee amount that are covered in a given year.

Major dental care includes:

  • Restorative care - Gold restorations and individual crowns
  • Oral surgery - Removal of impacted teeth and complex oral surgery procedures
  • Periodontics - Treatment of complicated periodontal disease requiring surgery involving bones, underlying tissues or bone grafts
  • Orthodontics - Treatment including retainers, braces and/or diagnostic materials
  • Dental Implants - Either surgical placement or restoration
  • Prosthodontics - Fixed bridges, partial dentures and removable or fixed dentures


Will the plan allow referrals to specialists? Some plans limit referrals to specialists. The dentist may be required to refer a patient to a limited selection of specialists who have contracted with the plan's third party. If the patient has children, he may prefer a plan that allows a pediatric dentist to be his child's primary care dentist.

Since specialized treatment is generally more costly than routine care, some plans discourage the use of specialists. While many general practitioners are qualified to perform some specialized services, complex procedures often require the skills of a dentist with special training.

Insurance companies do their best to ensure that their policyholders understand their plans and benefits, but it is up to an individual to make sure that they are making informed choices. The differences in the various plans one can choose from are:

  • the type of third party funding the plan;
  • methods of selecting a dentist;
  • compensation of the dentist's services to the patient; and
  • the calculations of benefits and payments.


Understanding these differences will enable one to make an informed decision when selecting a dental plan that is best for him or his family and dentist concerned.


   Benefits of Dental Insurance in India Top


Indian Dental Association has also been striving to bring out a new all-inclusive oral and dental health care insurance scheme. However, it has been unable to achieve anything substantial on this front. We, as oral health care workers, will be able to reach every class and village across the country. Dental insurance can also bring about oral health care awareness percolating at the grass root levels. It would serve as a good motivation to the people to regularly visit the dentist and this in turn serves as an effective preventive measure. [6] If we have to create awareness and pass on the benefits of longevity of teeth across the society, dental profession should impress on to the policy makers to have beneficial dental insurance schemes for the masses.

 
   References Top

1.Available from: http://www.tribuneindia.com/2008/20081101/biz.htm [last accessed on 2010 May 5].  Back to cited text no. 1
    
2.Available from: http://www.economywatch.com [last accessed on 2010 May 5].  Back to cited text no. 2
    
3.Nagda SJ. Dental insurance. J Indian Prosthodont Soc 2008;8:1.  Back to cited text no. 3
  Medknow Journal  
4.Available from: http://www.123-dental-medical-insurance.com [last accessed on 2010 May 5].  Back to cited text no. 4
    
5.Available from: http://www.dentalinsurance.com [last accessed on 2010 May 5].  Back to cited text no. 5
    
6.Available from: http://www.ehealthinsurance.com/dental-insurance [last accessed on 2010 May 5].  Back to cited text no. 6
    

Top
Correspondence Address:
Ravi SS Toor
Department of Pedodontics & Preventive Dentistry, National Dental College & Hospital, DeraBassi, Mohali, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.79981

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    Abstract
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