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Thoreau (T-USA)
Thoreau (T-USA), Attorney
Category: Legal
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Experience:  Attorney
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My dental claim was denied becasue theconsultant hired by the

Resolved Question:

My dental claim was denied becasue theconsultant hired by the insurance company believed my tooth could have been restored by filling while my dentist believed the damage was too extensive and a crown was placed.
Submitted: 2 years ago.
Category: Legal
Expert:  Thoreau (T-USA) replied 2 years ago.
Thank you for the opportunity to answer your question. I am sending this answer to you only a few minutes after you submitted your question.
I am sorry to hear about your situation.
In which state is the matter?
Thank you.
Customer: replied 2 years ago.
Iowa
Expert:  Thoreau (T-USA) replied 2 years ago.
Thank you. You may wish to file a complaint with the Iowa Insurance Division, as the Division can review the matter and that may compel the company to negotiate on the matter of the claim. You can reach the Division here: http://www.iid.state.ia.us/file_a_complaint
Ultimately, if the insurance company won't pay, you'll have to sue them to get your money. Such a lawsuit will require expert witnesses (you'll have them, as will the insurer), and you'll need to show that the claim falls within the policy and should be covered. If you win, the court may award your attorneys fees and court costs too.
Customer: replied 2 years ago.

I don't think that my plan allows me to file a suit or complaint without first going through the plan administrator at my place of employment which puts me between a rock and a hard spot. I was hoping that your acnswer said more about whether the dispute was legitimate or not. And how I might go about finding what the ordinary treatment would be for the problem that I had without going to a lot of expense.

 

 

Expert:  Thoreau (T-USA) replied 2 years ago.
Thank you for your message.
It's not possible to determine the strength or validity of your claim in this forum because that's highly fact-dependent. As mentioned above, if you do wind up in court, you're both going to have arguments. Your insurance company will field experts and so will you. Unfortunately, the law, particularly in relation to fact-dependent things like this, often isn't clear or cut and dried. That said, the fact that your doctor's professional opinion was that you needed the procedure should weigh in favor of your success.
Even if your contract requires additional steps prior to litigation, I would highly recommend retaining an attorney at this stage to help you with those steps. Your attorney will then attempt to help you develop your claim at every stage to maximize your success and to preserve the strongest case possible should the matter come to a lawsuit.
Thoreau (T-USA), Attorney
Category: Legal
Satisfied Customers: 9176
Experience: Attorney
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