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Law Educator, Esq.
Law Educator, Esq., Lawyer
Category: Consumer Protection Law
Satisfied Customers: 118127
Experience:  Attorney experienced in commercial litigation.
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My son,, 38 years old was born with Dentinogenesis

Customer Question

My son, Jason, 38 years old was born with Dentinogenesis Imperfecta.
During his young years we spent a lot of time and money on crowns and dental visits.
At age 26 Dentists suggested implants. They did not do bone crafting and as a result his implants now are all loose. This disease is very rare, 1 in 8000 -10,000 people would be born with it. His teeth are hanging in his mouth for the last 3 months,
He has Kaiser health insurance HMO.
He is in a lot of pain, infections, migraine head aches, he can't sleep, can't eat, can't function at work ( administrative work at Reverside Ca Court House) He needs to be sharp at work and needs to talk to people all day. His family is affected because of his condition. Future serious health problems could be a result of neglecting this condition. He contacted his insurance and was denied implant removal surgery and care. This is a medical need not a cosmetic need. We as his parents don't have and other 100.000 dollars to pay for it again like first time. Our son does not have it either, he has 60.000 student loans to pay and a family to care for. Please advise with a solution.
Submitted: 1 year ago.
Category: Consumer Protection Law
Expert:  Law Educator, Esq. replied 1 year ago.
Thank you for your question. I look forward to working with you to provide you the information you are seeking for educational purposes only.
If he cannot qualify for medicaid, which many times someone with severe medical problems can be qualified for despite their income, then this is a huge issue. His medical doctor will have to work with his dentist to write a report to the insurer why this is a serious medical condition, which can lead to malnutrition from the inability to eat, and you have to file a written appeal to the insurance (second level appeal). If the insurer denies the second level appeal, then you need to write to the insurer and demand a third level appeal, which is sent to an independent party for review of the claim and his doctor's reports on the severity of his condition. Finally, if they deny that, then you can go to court and sue the insurer for breach of contract if his doctors are saying this is a medical necessity.
Also, I happen to know of one person who has the same condition and they got frustrated with the time the above appeals process took (it can take several months or more) and they actually went to Mexico (Not Tijuana, but they went across the border in Arizona, Nogales) and had the work done at about 1/4 of the price of the work done in the US and so far it has been 2 years and they have had no problems.
So those are your two options.