Why do I ask? I'm a 49 year old married father of five. I have a good job with what most consider excellent benefits. Just over $100 out of my weekly paycheck goes towards my health insurance and a little over $28 goes towards my dental insurance. Up until recently I never really thought about just how different these two insurances work.
With my medical insurance, as a family we have a small deductible of $250 dollars after which I am responsible for a copay with every doctors visit or procedure. There is a maximum to the coverage but its a very high number, in fact I had gallbladder surgery two years ago where insurance laid out over $20k and I spent about $100 out of pocket.
Dental insurance? Not so simple. In fact, unless you're a dentist it's very difficult to figure out what you pay for every visit. There's this whole schedule of fees which tells you what they pay for any given procedure and what you are responsible for. The problem is they don't always use the same language as the dentist and the dentist doesn't always agree with their fee! So I usually ask the dentist to check with my insurance and give me a price. Once I get the price from the dentist, I decide whether I can afford to do this now or of I should wait. BIG MISTAKE.
With my medical insurance, as a family we have a small deductible of $250 dollars after which I am responsible for a copay with every doctors visit or procedure. There is a maximum to the coverage but its a very high number, in fact I had gallbladder surgery two years ago where insurance laid out over $20k and I spent about $100 out of pocket.
Dental insurance? Not so simple. In fact, unless you're a dentist it's very difficult to figure out what you pay for every visit. There's this whole schedule of fees which tells you what they pay for any given procedure and what you are responsible for. The problem is they don't always use the same language as the dentist and the dentist doesn't always agree with their fee! So I usually ask the dentist to check with my insurance and give me a price. Once I get the price from the dentist, I decide whether I can afford to do this now or of I should wait. BIG MISTAKE.
Around the first week of October this past year my daughter's orthodontist suggested that she have a procedure at an oral surgeon. In a nutshell, she needed a tooth extracted and a chain like device attached to the permanent tooth (she was 12 at the time) so the orthodontist could pull that tooth down. We were told it was in no way an urgent matter. So we went to the Center for Oral & Maxillofacial Surgery for a consultation. I asked them to please check with my insurance and give me a total price on this procedure. They quoted me a total of $494. I said fine, and scheduled the procedure for October 16th. I paid and forgot about it.
A few weeks later I get a call from the practice's billing department telling me I owe them $492. Figuring it was a mistake I explained to the woman that I had already paid and would be glad to show her a copy of the check. She said that no, my insurance would not cover it. I told her that I had asked them to check, she just said that I had reached my yearly maximum and that Dr. Elbaum did not work for free. I explained that it was not free since I had paid almost $500, but that even though I saw this as negligence on the part of their billing department I would gladly (sort of) pay more in order to take on some of the burden for this error. They wouldn't budge. That's not where this ends.
At the end of June I received a notice from the Ocean County Court that I was being sued by my dentist in small claims court. My wife called me frantic, "we're being sued. What do we do?". I was pretty calm, I told my wife that it was probably a blessing in disguise. I felt once I explained my side to a judge he or she would understand, then I would be willing to compromise. I would meet them half way I told my wife, it's just the principal of the matter. So I patiently waited for my court date of July 17th, going over all the details to my case, growing more confident by the day.
July 17th came, I was a little nervous because this was a first for me, but still feeling that once I got my story out to the judge and showed how I was willing to compromise from the get go, I would surely get my due in court. No such luck. Court was scheduled for 9 am, there were 75 cases on the docket. My first sense of worry came when I examined the docket to look for my name. I was smack in the middle of it all which told me it wasn't going to be a quick day for me. What really scared me though is that the Center for Oral & Maxillofacial Surgery was the plaintiff on over 20 cases! How could they have so many cases in one shot? Maybe they bunch them together but 20 plus cases? That's got to be a lifetime of disputes. How many legitimate businesses have 20 customers that are negligent enough for them to sue in a decade or even in a lifetime? I started to get the feeling that they probably did this because they knew they had an edge.
The judge walked into the courtroom at about 9:15. He proceeded to explain how the court strongly suggests that you settle matters through a court appointed mediator, since there is a limited number of mediators if you have to wait, he strongly suggests you try to work it out amongst yourselves. Then he laid down the process, first for the plaintiffs. To them he said that this is not the best solution and an amicable compromise with through a mediator was as good as a judgement on his part. He explained that as a civil court if he rules for the plaintiff, that does not mean the plaintiff will ever see a cent of the settlement. The plaintiff will have to take other measures and figure out how to get that money and that would take know how and resources. If they agreed to terms in mediation and the defendant reneged on the agreement then the full judgement would be ruled in favor of the plaintiff. So the plaintiff has nothing to lose through mediation. So far so good.
Now to the defendants. He said that we all heard the story on the plaintiffs, and most of that applied to the defendants. One difference. He asked " is there anyone here in the courtroom today that doesn't expect to ever have to buy a house, a car, apply for a credit card or need any kind of credit ever in the future? If so, please raise your hand". Of course, no one did. He then explained how if we decided not to go through mediation and brought the case in front of him, if we lost, this would put a negative civil judgement on our credit report. This would happen even if we paid in full on the spot! He then explained that not all cases are guaranteed to be heard today, there will be a one hour break for lunch and basically gave the impression that if we didn't settle we would face a angry judge. Lovely.
I was floored. No way I could risk a blemish like a civil judgement on my credit report. I'm looking to get a mortgage next year. So begrudgingly I go out of the courtroom to wait for a mediator. The attorney for the dental practice was right outside, young guy who looked like he's just out of law school. He says to me that we could sit down and try to work this out. I say sure. There was no working out here, he felt like and negotiated like someone with the upper hand. I was being sued for the original $492 plus attorney fees and court filing costs, a total just north of $600. I told him my story, he simply nodded and said that his client is willing to settle for $514.50 and if I would like I can pay that in installments. I refused and told him I would rather go through the mediator.
My next shock was with the mediator. He greeted my attorney like an old buddy. They practically walked down the hall arm in arm. We went into a room and I told my story uninterrupted in front of both of them. As soon as I finished (about three minutes) the mediator asked me to step out of the room. I waited outside for just over 10 minutes. I came into the room and the mediator said they were willing to settle for $514.50 and that I could break it down into installments. After me trying to reason with the mediator for another minute or two it was evident we weren't going anywhere. At this point I said fine, I'll pay it, I'll do it over ten months. I was immediately told by the mediator that they won't do this, they'll give me three, maybe four months. Then the lawyer jumps in like he is now the good guy and says they'll give me four months. I settled.
While waiting for my finalized paperwork I spoke to another of the defendants. His story was really sad. His son had some kind of Medicaid. He went to the same group, had to have a procedure and was told that his Medicaid would cover it in full. The day of his procedure the dental office called to reschedule due to some issue they had. They didn't check and his Medicaid coverage did not extend to the next appointment. They told him he was responsible for the entire fee. He was almost in tears.
I got the feeling we got gypped, me, the father and his son and another 20 or so defendants. But then as I was stewing over my situation I realized how stacked the deck was in the dentist and insurance company's favor. There has to be someone or some watchdog type group that is willing to look into this. 20 cases on one calendar court date? Do dental practices have no responsibility? If my car mechanic quotes me $500 on a repair there is not a court in the land that will force me to pay him $1,000. Why does a dentist get away with it? Twenty plus times on today's court docket. How many times this year? How many over the past five years? I bet there are many who have been taken advantage of. There has to be a better standard. A quote is a quote. If there was negligence with the insurance company then the dentist should go after them. Maybe they shouldn't take insurance. My guess is the dentists make a lot of money through the insurance company and unless they get pressured they will not rock the boat.
A few weeks later I get a call from the practice's billing department telling me I owe them $492. Figuring it was a mistake I explained to the woman that I had already paid and would be glad to show her a copy of the check. She said that no, my insurance would not cover it. I told her that I had asked them to check, she just said that I had reached my yearly maximum and that Dr. Elbaum did not work for free. I explained that it was not free since I had paid almost $500, but that even though I saw this as negligence on the part of their billing department I would gladly (sort of) pay more in order to take on some of the burden for this error. They wouldn't budge. That's not where this ends.
At the end of June I received a notice from the Ocean County Court that I was being sued by my dentist in small claims court. My wife called me frantic, "we're being sued. What do we do?". I was pretty calm, I told my wife that it was probably a blessing in disguise. I felt once I explained my side to a judge he or she would understand, then I would be willing to compromise. I would meet them half way I told my wife, it's just the principal of the matter. So I patiently waited for my court date of July 17th, going over all the details to my case, growing more confident by the day.
July 17th came, I was a little nervous because this was a first for me, but still feeling that once I got my story out to the judge and showed how I was willing to compromise from the get go, I would surely get my due in court. No such luck. Court was scheduled for 9 am, there were 75 cases on the docket. My first sense of worry came when I examined the docket to look for my name. I was smack in the middle of it all which told me it wasn't going to be a quick day for me. What really scared me though is that the Center for Oral & Maxillofacial Surgery was the plaintiff on over 20 cases! How could they have so many cases in one shot? Maybe they bunch them together but 20 plus cases? That's got to be a lifetime of disputes. How many legitimate businesses have 20 customers that are negligent enough for them to sue in a decade or even in a lifetime? I started to get the feeling that they probably did this because they knew they had an edge.
The judge walked into the courtroom at about 9:15. He proceeded to explain how the court strongly suggests that you settle matters through a court appointed mediator, since there is a limited number of mediators if you have to wait, he strongly suggests you try to work it out amongst yourselves. Then he laid down the process, first for the plaintiffs. To them he said that this is not the best solution and an amicable compromise with through a mediator was as good as a judgement on his part. He explained that as a civil court if he rules for the plaintiff, that does not mean the plaintiff will ever see a cent of the settlement. The plaintiff will have to take other measures and figure out how to get that money and that would take know how and resources. If they agreed to terms in mediation and the defendant reneged on the agreement then the full judgement would be ruled in favor of the plaintiff. So the plaintiff has nothing to lose through mediation. So far so good.
Now to the defendants. He said that we all heard the story on the plaintiffs, and most of that applied to the defendants. One difference. He asked " is there anyone here in the courtroom today that doesn't expect to ever have to buy a house, a car, apply for a credit card or need any kind of credit ever in the future? If so, please raise your hand". Of course, no one did. He then explained how if we decided not to go through mediation and brought the case in front of him, if we lost, this would put a negative civil judgement on our credit report. This would happen even if we paid in full on the spot! He then explained that not all cases are guaranteed to be heard today, there will be a one hour break for lunch and basically gave the impression that if we didn't settle we would face a angry judge. Lovely.
I was floored. No way I could risk a blemish like a civil judgement on my credit report. I'm looking to get a mortgage next year. So begrudgingly I go out of the courtroom to wait for a mediator. The attorney for the dental practice was right outside, young guy who looked like he's just out of law school. He says to me that we could sit down and try to work this out. I say sure. There was no working out here, he felt like and negotiated like someone with the upper hand. I was being sued for the original $492 plus attorney fees and court filing costs, a total just north of $600. I told him my story, he simply nodded and said that his client is willing to settle for $514.50 and if I would like I can pay that in installments. I refused and told him I would rather go through the mediator.
My next shock was with the mediator. He greeted my attorney like an old buddy. They practically walked down the hall arm in arm. We went into a room and I told my story uninterrupted in front of both of them. As soon as I finished (about three minutes) the mediator asked me to step out of the room. I waited outside for just over 10 minutes. I came into the room and the mediator said they were willing to settle for $514.50 and that I could break it down into installments. After me trying to reason with the mediator for another minute or two it was evident we weren't going anywhere. At this point I said fine, I'll pay it, I'll do it over ten months. I was immediately told by the mediator that they won't do this, they'll give me three, maybe four months. Then the lawyer jumps in like he is now the good guy and says they'll give me four months. I settled.
While waiting for my finalized paperwork I spoke to another of the defendants. His story was really sad. His son had some kind of Medicaid. He went to the same group, had to have a procedure and was told that his Medicaid would cover it in full. The day of his procedure the dental office called to reschedule due to some issue they had. They didn't check and his Medicaid coverage did not extend to the next appointment. They told him he was responsible for the entire fee. He was almost in tears.
I got the feeling we got gypped, me, the father and his son and another 20 or so defendants. But then as I was stewing over my situation I realized how stacked the deck was in the dentist and insurance company's favor. There has to be someone or some watchdog type group that is willing to look into this. 20 cases on one calendar court date? Do dental practices have no responsibility? If my car mechanic quotes me $500 on a repair there is not a court in the land that will force me to pay him $1,000. Why does a dentist get away with it? Twenty plus times on today's court docket. How many times this year? How many over the past five years? I bet there are many who have been taken advantage of. There has to be a better standard. A quote is a quote. If there was negligence with the insurance company then the dentist should go after them. Maybe they shouldn't take insurance. My guess is the dentists make a lot of money through the insurance company and unless they get pressured they will not rock the boat.
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