Delta Dental Of Virginia

This letter is in response to the complaint submitted to Delta Dental of Virginia (DDVA) via email onDecember 28, 2015 for ID#[redacted].Please be advised that the subscriber has an Administrative Services Only (ASO) contract through hisemployer, [redacted]According to our records,...

the subscriber has not yet submitted an appeal per the Summary Plan Description.Below is the information found in the subscriber's Summary Plan Description regarding Delta Dental's internalclaims review and appeal process. The subscriber should request an appeal of this matter, at which time theclaim will be reopened and fully reviewed.How to Appeal an Adverse Benefit DeterminationIf you receive an adverse benefit determination, you have the right to file an appeal. An appeal must be sent tothe Claims Administrator no more than 180 days after receipt of such a determination. To initiate an appeal,send the Claims Administrator a letter stating why you disagree and including the following information:* Your member ID number* The claim number of the claim in question* A list of all the specific issues to be considered on appeal* Any additional dental informationClaims Administrator Corporate Address:Delta Dental of Virginia[redacted]
[redacted]
[redacted]Please contact me if you have any additional questions at [redacted].Respectfully,[redacted]Product Filing Analyst

I have reviewed the response offer made by the business in reference to complaint ID [redacted], and have determined that this proposed action would not resolve my complaint.  For your reference, details of the offer I reviewed appear below.
I don't really see how this situation is being resolved or providing any possible resolutions because the information provided is something I am already aware of. It just shows that the company did not try to provide other options when I explained that I was unemployed, didn't have the payment, and didn't have a credit card to make the payment. Despite this honest information, Delta still refused to help and continued to send the request to my bank causing my account to become overdrawn more and more causing more strain on me financially. I really feel like this is unacceptable, especially when I have been with the company for so long and stated that I didn't want the insurance to terminate but no assistance was even attempted to keep a loyal customer. I am stuck with a lot of overdraft fees that I have to struggle to pay when I made every attempt to prevent drafts.
Regards,
[redacted]

This letter is in response to the complaint submitted to Delta Dental of Virginia. Please be advised thatthe policyholder has Individual Clear coverage administered by Delta Dental of Wisconsin. Thefollowing is their response to the complaint.The member enrolled over the telephone so the member does...

not attest to having read the policydocuments. Those enrolling via telephone receive ID cards and a welcome letter that includesinstructions on how to access their policy via deltadentalcoversme.com or they may elect to return theenclosed post card for a paper policy.Attached is a copy of the Clear Plan summary of benefits, Welcome Letter, and Schedule of DentalBenefits, Limitations and Fixed Patient Copayments. Please note under Restorative Dental Proceduresthe policy indicates the fixed copayment for a crown is $500 and "Only one crown for each coveredperson every 12 months."Please contact me if you have any additional questions at ###-###-####Respectfully,[redacted]Corporate Compliance Analyst

It's like pulling teeth to get a person on the phone to even get an ID card issued, and their site will give you error messages on a good day.

Review: Delta Dental has refused a claim based on a dentist that has never seen the patient. I have the coverage and yes parts are excluded by policy. However many parts are covered by policy and have dollar caps. My Dentist is well respected in his field and would not do anything that would have poor results. It comes down to I pay for insurance to pay for procedures. I have followed Delta Dental path for filing and so has the dentist office. So far out of $5,300 they have only paid $42.00 for a tooth extraction. I find this to be a case of very poor insurance practice on the part of Delta Dental. In my view this is insurance fraud!Desired Settlement: Pay for services that I am truly insured for and not pay someone to keep what is due from services rendered!

Business

Response:

Delta Dental of Virginia is in receipt of a recent complaint for the above individual identified under ID number [redacted]The coverage for this individual is through an Administrative Services Only policy with the employer. Delta Dental of Virginia suggests that the individual work with the group administrator concerning this complaint.Sincerely,[redacted]Product Filing Analyst

Consumer

Response:

I have reviewed the response made by the business in reference to complaint ID [redacted], and find that this resolution would be satisfactory to me. I will wait for the business to perform this action and, if it does, will consider this complaint resolved.Regards,[redacted]

Review: When calling to receive quote of cost of services I was told that 50 percent would be matched out of their network and 80 percent if I used someone within their network . That is all the information they gave me for this quote . Come to find out there are several other charges and restrictions not mentioned that cost me around 400 . They were very deceptive in only giving the information they wanted you to have . They claim that the amount of 50% is not for the total amount of services rendered ( what my dentist actually submitted ) but rather 50% of what the cheapest dentist in my region would charge . How could I possibly know this ? How could I know what the cheapest dentist would charge without them telling me . I don't have access to this Information , only they do . Had they taken the time to properly explain their process instead of purposely not divulging necessary information, I may have chose another form of care . Instead they just say well you should have asked more questions .... I say we'll maybe you should just be honest and forthcoming with information instead of what your doing .Desired Settlement: I don't need the money ... it's not about money it's about them acknowledging that they have scrupulous practices and take advantage of ppl. All the time with bad information , or lack thereof .

Business

Response:

This letter is in response to the complaint submitted to Delta Dental of Virginia (DDVA). Please be advised that the policyholder has coverage through his employer, [redacted], a fully-insured Delta Dental PPO+ contract effective January 1, 2014.Attached is a copy of the subscriber's Evidence of Coverage booklet that explains How to Estimate Your Costs (Delta Dental PPO (Plus Premier) Plans, Predetermination of Benefits, Schedule of Benefits that explains the dental procedures and coverage levels for participating and non-participating providers.The subscriber's claim history reflects dental treatment performed by three (3) different dentists. For the service dated March 9, 2015 and January 8, 2015, the subscriber saw a non-participating provider. The services dated April 9, 2014 were performed by a participating provider.On April 24, 2015, the subscriber spoke to one of our Benefits Services supervisors after his previous phone calls regarding his benefits were reviewed. The supervisor determined that no one gave the subscriber the wrong benefits and DDVA will not pay any additional monies for his claims.Please contact me if you have any additional questions at ###-###-####.Respectfully,[redacted]Corporate Compliance Analyst

Review: I have had Delta Dental Basic Individual of VA insurance for some years before they switched to a different department. I never experienced any issues and when I had hard times making a payment, I always received assistance and was given options of paying by check or money order after my due date has passed. Not now. Since the switch of individual plans to a different department, I have noticed the change of helpful assistance. Recently, I have become unemployed and all of my unemployment benefits has ended leaving me with a huge lack of income. I ha called back in Dec. of 2014 and expressed this and asked for my payment to not be withdrawn from my checking acct. because the funds will not be there. It was taken out anyway causing an overdraft charge. And once again this month, I have had nothing but people telling me there is nothing I can do, contract this, contract that. I was told that basically my account will be hit again causing yet another overdraft fee. When I pleaded to have some type of payment plan because I didn't want my policy to be canceled, I was told by [redacted] that there was nothing that could be done. When I asked to speak to a supervisor, [redacted] heartlessly said that it was I couldn't speak with a supervisor because they will tell me the same thing and they only will communicate with me through letter. I was so shocked of the lack of understanding. Why would a company continue to hit my account after expressing numerous of times that the funds will not be there and that I am unemployed?

I really enjoyed having this service until the switch was made and I feel like the company did not care that I was unable to pay but has no problem continuing hitting my checking account racking more fees that I have to struggle to pay. I have had so much help from other companies I have accounts with and some are EFT but they were willing to help me, set up payment plans, and stop transfers from coming out of my account but not Delta Dental. I'm sad that it came to this and was told if my payment don't go through for this month, my plan will be cancelled and I will not be able to apply for 2years. I don't have a credit card, I don't have another account, I don't have a slew of ppl to just throw money my way and its sad that a company can't recognize that and try to help their loyal customers because all they care about is contracts and what's written in them.Desired Settlement: I will like for my overdraft charges to be paid that was applied to my account due to Delta Dental proceeding to send payment through after my constant urges to stop and seek other options.

Business

Response:

This letter is in response to the complaint submitted to Delta Dental of Virginia. Please be advised thatthe policyholder has coverage with an individual plan that is administered by Delta Dental ofWisconsin. The following is their response to the complaint.On December 26, 2014, the policyholder contacted Customer Support requesting a stop on the EFTtransaction with her bank. We were unable to stop the transaction as the file was already sent throughthe Federal Reserve to the bank. To stop an EFT transaction, Delta Dental would need notification bythe 24th of the month to change payment method. At this time we cannot stop the transaction.On December 27, 2014, an attempt was made to draw $23.00 from the policyholder account forJanuary premium. A rejection from the bank was received on December 29, 2014 due to non-sufficientfunds.On January 23, 2015, the policyholder called and advised she does not have funds to pay for thepremiums and requested we not draw the premium due. The policyholder requested other options forpayment. We advised we also accept credit card payment. The policyholder said she does not have acredit card. She said she does not want the coverage terminated but is unemployed. We advised thatwe will attempt to draw again on January 27 and if the funds are not available the coverage wouldterm.On January 27, 2015, we attempted to draw $46.00 from the members account for January andFebruary premium. We received a rejection from the bank on January 30, 2015 due to non-sufficientfunds. The plan was then terminated due to nonpayment on January 31, 2015.Delta Dental processed and paid a claim for a January 27, 2015 date of service with a total payment of$100.10.Please contact me if you have any additional questions at ###-###-####.Respectfully,[redacted]Corporate Compliance AnalystDelta Dental of Virginia

Consumer

Response:

I have reviewed the response offer made by the business in reference to complaint ID [redacted], and have determined that this proposed action would not resolve my complaint. For your reference, details of the offer I reviewed appear below.

I don't really see how this situation is being resolved or providing any possible resolutions because the information provided is something I am already aware of. It just shows that the company did not try to provide other options when I explained that I was unemployed, didn't have the payment, and didn't have a credit card to make the payment. Despite this honest information, Delta still refused to help and continued to send the request to my bank causing my account to become overdrawn more and more causing more strain on me financially. I really feel like this is unacceptable, especially when I have been with the company for so long and stated that I didn't want the insurance to terminate but no assistance was even attempted to keep a loyal customer. I am stuck with a lot of overdraft fees that I have to struggle to pay when I made every attempt to prevent drafts.

Regards,

Review: I contacted Delta Dental a few weeks ago (early in February, 2015) to request cancellation of my dental policy as well as cancellation of the montly automatic withdrawal of my premium from my checking account, since I had lost my job and was unemployed. The customer service person said that I would have to send an email requesting cancellation of the policy and withdrawals. I did so that day. I received a two sentence response email from Delta Dental saying that my email had been received and the situation would be processed in a timely manner (i.e., a form letter type response)

Today (2/25/2015) I received an email informing me that an automatic withdrawal would be made on my checking account for my monthly Delta Dental premium. I called their customer service number and was told that unemployment was not valid grounds for cancellation of a policy. The notes on my account, according to the customer service representative, did not mention that I was told that this was the case. I asked to speak with a manager and was told that doing so would simply result in a letter stating that I could not cancel my policy due to unemployment.

Essentially, my initial contact with Delta Dental's customer service department failed to inform me that I would continue to have monthly premiums deducted from my checking account until the end of the current policy (9 months' worth).Desired Settlement: That customer service informed me that unemployment is not valid grounds for cancellng a policy when I first called to request my policy be cancelled. I am still unemployed and cannot afford the monthly premiums at this time. Cancel my policy.

Business

Response:

This letter is in response to the complaint submitted to Delta Dental of Virginia. Please be advised thatthe policyholder has Individual Clear coverage administered by Delta Dental of Wisconsin. Thefollowing is their response to the complaint.Subscriber’s request to terminate coverage due to loss of employment was received on 02/19/15 andprocessed on 02/20/15. Per the contract, loss of employment is not a qualifying event to terminatecoverage mid-contract.The policy was terminated for the end of the contract, 11/30/15, and notice of termination was mailedto the subscriber on 02/20/15.Please contact me if you have any additional questions at ###-###-####.Respectfully,[redacted]Corporate Compliance Analyst

Consumer

Response:

I have reviewed the response made by the business in reference to complaint ID [redacted], and find that this resolution would be satisfactory to me. I will wait for the business to perform this action and, if it does, will consider this complaint resolved.

Regards,

Review: I called in May of 2014 to check to see if there would be a price increase on my plan with delta dental that would take effect July 1, 2014. I was told by one of the customer service reps that I would not see an increase. He also explained that since this would be the completion of my 1 year contract with Delta that I could cancel at any time following July 1, 2014. The price of my premium did not increase however their inclusion of dentists in the plan changed drastically reducing any options local to me. I requested to end the insurance, however they denied my request and stated that I had another year contract because I did not cancel by July 1, 2014. I told them that it had been explained to me that I could cancel the insurance at any time since I had the insurance over a year. They said that whomever in their company told me that was wrong.Desired Settlement: I would only like for my insurance to be canceled and for Delta Dental to stop charging the premium to my account. I am not able to use their insurance since none of the local dentists in my area are now covered through Delta Dental due to Delta Dental changing their format. This is not what I agreed to a year ago when I first enrolled in July 2013. At that time my dentist was in the Delta Dental program, but due to Delta Dental changing my dentist is no longer in the program. I did not sign an agreement this year July 2014 and believe that Delta Dental has changed the coverage of the initial contract I did agree to. I do not believe it is right for a company to continue charging a customer that can no longer use their service due to the companies changes.

Business

Response:

This letter is in response to a customer complaint submitted to the Revdex.com (Revdex.com) by

[redacted].

Delta Dental of Virginia will respond directly to Ms. [redacted] as an authorization from her to release

protected health information was not submitted with your inquiry.

Please contact me if you have any questions at ###-###-####.

Respectfully,

[redacted]

Director, Legal and Compliance

Review: Dear Sir/Madam:

Delta Dental of Virginia issued an EOB of Claim No. [redacted] on 8/26/2015 that charged me deductible of $50.00. However, Delta Dental of [redacted] issued an EOB of Claim No. [redacted] on 4/8/2015 that already charged me deductible of $50.00. This is a double deductible charge. Delta Dental of Virginia needs to correct the EOB and to refund me the $50.00. Your assistance and reply will be highly appreciated.

Best,

[redacted]Desired Settlement: Delta Dental of Virginia needs to correct the EOB and to refund me the $50.00.

Business

Response:

October 15, 2015

This

letter is in response to the complaint Delta Dental of Virginia [DDVA] received

via email on October 12, 2015.

The

complainant has coverage through her spouse’s employer, [redacted] an Administrative Services Only [ASO] contract.

DDVA

processed the claim and applied the $50 deductible correctly for the D4910

periodontal maintenance. Complainant relates that we should have honored the

deductible satisfied with her primary carrier (DDKY).

DDVA

was unaware of another dental policy and we contacted the provider office. The

dental office explained the primary policy was not in effect when the D4910

[periodontal maintenance procedure] was rendered.

DDVA

was correct in applying the deductible according to the contract terms of the

spouse's policy.

Please

contact me if you have any additional questions at ###-###-####.

Respectfully,

[redacted]

Corporate Compliance Analyst

Consumer

Response:

I have reviewed the response offer made by the business in reference to complaint ID [redacted], and have determined that this proposed action would not resolve my complaint. For your reference, details of the offer I reviewed appear below.

Attached, please find my 2 EOBs that is the evidence of

Delta Dental having charged me twice the $50.00 deductible.

Regards,

Review: I obtained a Delta Dental Clear Choice Plea from Delta Dental. They provide you with a Delta Dental Covers Me - get a quote. It compares their 3 plans and costs and lists the major services and cost per procedure. CrownS (plural) cost the policy holder $700. Fixed Bridges (plural) are $700 per tooth.

I am now told that they only will cover ONE Crown per year or one fixed bridge per year.Desired Settlement: I would like them to change their Get a quote sheet so that it indicates that CROWNS means ONE per year, etc. Very misleading

Business

Response:

This letter is in response to the complaint submitted to Delta Dental of Virginia. Please be advised thatthe policyholder has Individual Clear coverage administered by Delta Dental of Wisconsin. Thefollowing is their response to the complaint.The member enrolled over the telephone so the member does not attest to having read the policydocuments. Those enrolling via telephone receive ID cards and a welcome letter that includesinstructions on how to access their policy via deltadentalcoversme.com or they may elect to return theenclosed post card for a paper policy.Attached is a copy of the Clear Plan summary of benefits, Welcome Letter, and Schedule of DentalBenefits, Limitations and Fixed Patient Copayments. Please note under Restorative Dental Proceduresthe policy indicates the fixed copayment for a crown is $500 and "Only one crown for each coveredperson every 12 months."Please contact me if you have any additional questions at ###-###-####Respectfully,[redacted]Corporate Compliance Analyst

Consumer

Response:

I have reviewed the response offer made by the business in reference to complaint ID [redacted], and have determined that this proposed action would not resolve my complaint. For your reference, details of the offer I reviewed appear below.

Attached please find the comparison sheet they provide to enable you to make a choice. The representative never mentions to check the actual policy as the comparison is not totally representative of actual coverage.

Additionally the other two plans on the sheet QUALIFY the cover but do not when it applies to their Clear Plan. If I would have known it represented only one crown per year, you can at least make a informed decision.

Finally when you buy the plan, you are not told to review the Contract Language as it specifies the actual benefits which may differ then the Get A Quote comparison plan sheet.

They use the word Crowns, Implants all plural meaning more than one. The sheet is a clear example of disinformation and false advertisement.

Business

Response:

Thank you for forwarding the rebuttal request regarding complaint ID [redacted] to our attention.Delta Dental of Virginia appreciates the feedback from our policyholder regarding the reference tocrowns and implants as plural in our Clear Policy.The policyholder was provided with an opportunity to receive a printed copy of his dental benefitpolicy over the phone or by returning a post card. Additional, all policy holders enrolling over thetelephone are directed to the website to print a copy of the policy and to carefully review it.In the first paragraph of the Clear Policy it it states: Please read this entire Policy carefully so you willbe aware of its Benefits, limitations and other terms and conditions. Listed Under the sectionSchedule of Dental Benefits, Limitations and Fixed Patient Copayments the Clear Policy statesOnly one crown for each covered person every 12 months.With regard to implant services, the Clear Policy states *Surgical placement of implant body (includesimplant, crown and abutment); one-(l) implant per site up to a maximum of two-(2) implant bodies perquadrant of the mouth per lifetime.DDVA upholds our position that we provided the policyholder with appropriate language in the ClearPolicy and an opportunity to cancel the policy within the first ten (10) days.In closing, if the policyholder is still dissatisfied with our determination, DDVA recommends he bereferred to the Office of Managed Care Ombudsman for further assistance.Address: Office of Managed Care OmbudsmanVirginia Bureau of Insurance[redacted]Telephone Toll-Free: ###-###-#### Richmond ###-###-#### E-Mail: [redacted]Web Page; [redacted]Please contact me if yuo have any additional questions at ###-###-####.Respectfully,[redacted]Director, Legal and Compliance

Consumer

Response:

I have reviewed the response offer made by the business in reference to complaint ID [redacted], and have determined that this proposed action would not resolve my complaint. For your reference, details of the offer I reviewed appear below.

Basically I am not satisfied as the operator that I spoke to never told me I had 10 days to read the policy because there were restrictions to the published comparison sheet and especially for the Clear Choice.

Additionally, could you provide a transcript of our conversation upon which I made my purchase. I ask because I mentioned that the Clear Plan appeared excellent as it spelled out all the cost's for each procedure. There was no mention to read the policy before signing up for this program. Additionally she indicated it was an excellent policy. However, if you can get the transcript, it would most appreciated as I totally didn't hear what she was saying or she didn't tell me sufficient information to provide a informed decision.

I referred to the comparison sheet a couple of times and was not corrected or directed to read the policy. I was told to sign the contract and return it!

Sincerely, [redacted]

Review: Filed insurance. After 60 day with no response I contacted Delta Dental, they responded saying they were waiting on Tax ID number from [redacted] I provided this information that same day and Delta Dental rep said this would be processed for payment in 7 - 10 business days. After no response, I contacted Delta Dental again and they said they were now waiting on x-rays from [redacted] She "attempted" to call [redacted] Dentures with no answer. Today I contacted [redacted] Dentures ([redacted]) and she said they had not received anything from Delta Dental regarding their need for ANYTHING. In contacting Delta Dental their response was that they had MAILED the request. In contacting Delta Dental again to see what notes were entered I spoke with [redacted]. Earlier today it was [redacted]Desired Settlement: I feel the company needs to have a policy to contact their customer when there is a problem in claim or when something is needed, This company left my claim lying dormant for 60 days with no notification to myself and then continue to come up with additional information needed. One person should go through claim to see what is needed and request at one time without delay tactics and disregard to their customer. It is hypocritical when they expect payment in a timely manner and then have no regard for monies owed to their customer.

Business

Response:

This letter is in response to the complaint submitted to Delta Dental of Virginia (DDVA) via email on January 6, 2016 for ID#[redacted].Please be advised that the subscriber has an Administrative Services Only (ASO) contract through his employer, [redacted].The subscriber sought treatment from a non-participating provider who did not submit x-rays for two surgical extractions. We received the claim on December 2, 2015 and requested the X-rays on December 23. We had no response from the provider and a second request for X-rays was sent on January 6.As soon as Delta Dental receives the requested information we will process the claim.Please contact me if you have any additional questions at [redacted] x [redacted]Respectfully,[redacted]Product Filing Analyst

Review: Appeal for Denial of Coverage for Crown

Insured/Subscriber: [redacted], Jr.

DOB: [redacted]

Group Number: [redacted]

Identification Number: [redacted]

Patient Name: [redacted], Jr.

Date of Service: 10/19/2015

Claim Number: [redacted]

Appealing that the above referenced claim that was denied coverage by Delta Dental. As per the EOB, Delta Dental is denying coverage for the crown replacement based on the age of the crown being less than 7 years old, as the current policy contract only covers one crown per tooth every 84 months. Please note that my current policy contract with Delta Dental, which went in force in May of 2015, has never paid for a crown on this tooth, or any other tooth for that matter. Therefore, the basis for denial of this claim is not valid.

While I understand that my crown is less than 7 years old, the claim for the prior crown was not submitted or paid on my current policy contract with Delta Dental, so it should not have any bearing whatsoever on coverage limitations of my current policy contact. As per the policy coverage from my current/active Delta Dental policy, my policy contract clearly states that it covers one crown per 84 months per tooth. Any claims paid by Delta Dental on prior, inactive insurance policy contracts through prior employers should have no impact whatsoever on coverage limitations for claims presented on my current/active policy contact.

Further, prior to proceeding with this crown replacement, my dentist’s office did their due diligence and called Delta Dental to confirm coverage for this crown replacement, and was told this claim was covered and that my out of pocket would be between $200 and $300. That Delta Dental is now dredging through old inactive insurance policies and old dental records that are not associated with my current/active policy contract (or current treatment for that matter) in order to wiggle out of paying this claim is disgraceful, and stinks of a HIPAA violation. Delta Dental did not have my permission to access dental records with dates of service not within the framework of my current policy contract, nor did they have my permission to access records from past dental claims processed under other inactive insurance policies.Desired Settlement: Claim paid in full. Apology for HIPAA violation.

Business

Response:

This letter is in response to the complaint submitted to Delta Dental of Virginia (DDVA) via email onDecember 28, 2015 for ID#[redacted].Please be advised that the subscriber has an Administrative Services Only (ASO) contract through hisemployer, [redacted]According to our records, the subscriber has not yet submitted an appeal per the Summary Plan Description.Below is the information found in the subscriber's Summary Plan Description regarding Delta Dental's internalclaims review and appeal process. The subscriber should request an appeal of this matter, at which time theclaim will be reopened and fully reviewed.How to Appeal an Adverse Benefit DeterminationIf you receive an adverse benefit determination, you have the right to file an appeal. An appeal must be sent tothe Claims Administrator no more than 180 days after receipt of such a determination. To initiate an appeal,send the Claims Administrator a letter stating why you disagree and including the following information:* Your member ID number* The claim number of the claim in question* A list of all the specific issues to be considered on appeal* Any additional dental informationClaims Administrator Corporate Address:Delta Dental of Virginia[redacted]Please contact me if you have any additional questions at [redacted].Respectfully,[redacted]Product Filing Analyst

Consumer

Response:

I have reviewed the response offer made by the business in reference to complaint ID [redacted] and have determined that this proposed action would not resolve my complaint. For your reference, details of the offer I reviewed appear below.

Our 'official' appeal letter was mailed to Delta Dental via USPS certified mail (return receipt) on 12/29/15. To date, we have not received any sort of response from Delta Dental. In checking USPS tracking this morning, it shows that the letter left the [redacted] post office on 1/31/15 for delivery to Delta Dental, yet we have not received signature confirmation. Online tracking shows the appeal letter mysteriously disappearing after delivery was attempted. I find this very suspicious. I am requesting that Delta Dental provide as with an email and fax to which we can immediately submit the appeal letter, since it appears there seems to be a problem with Delta Dental accepting certified mail from their customers. Further, once the appeal is submitted and received via either of these methods, we are requesting that they provide us with confirmation of receipt, in writing, within 24 hours of receipt.

Please note that regardless of the status of the certified appeal letter that seems to have gone 'missing', Delta Dental has been on notice of our issue and appeal via our complaint communications through the Revdex.com AND our complaint communications through the Insurance Commissioner for the Commonwealth of Virginia. So this equals two other modes of communication of our appeal that Delta Dental seems to be ignoring. Shall we try pony express? Bottom line, we've made every effort to communicate our appeal to Delta Dental. They are acting in bad faith by not accepting certified mail and by ignoring the copy of the complaint / appeal that was communicated via two additional methods. We are adding to our resolution sought that they reimburse us for the cost of the rejected certified mail, $6.96.

Regards,

[redacted]

Business

Response:

This letter is in response to the complaint submitted to Delta Dental of Virginia (DDVA) via email on January20, 2016 for ID#[redacted].The subscriber’s appeal has been overturned. His claim for the crown and buildup will be processed within thenext 7-10 business days.Please contact me if you have any additional questions at [redacted].Respectfully,[redacted]Product Filing Analyst

Consumer

Response:

I have reviewed the response offer made by the business in reference to complaint ID [redacted], and have determined that this proposed action would not resolve my complaint. For your reference, details of the offer I reviewed appear below.

The wording of the response from Delta Dental is extremely ambiguous ('The subscriber’s appeal has been overturned. His claim for the crown and buildup will be processed within thenext 7-10 business days') and does not clarify is the claim will actually be 'approved' or 'paid'. We are asking that Delta Dental provide clarification.

Regards,

[redacted]

Review: I had tooth restoration done on 4/6/2011, then I had the same tooth fracture and new restoration done on 3/20/2013. Delta Dental refused to provide coverage for dental expenses related to second tooth restoration based on the following dental plan rule "replacement restoration on the same tooth within 24 months is disallowed " (from Delta Dental letter, 5/23/2013). However this dental plan limitation cannot be applicable to my case since I had new problems with the same tooth, here is a quote for appeal letter of my dental office "restoration replaces due to fractured (no decal present) - stress area of the molar" (submitted to Delta Dental on 5/8/2013). Delta Dental never provided any reasons on why my appeal letter was denied except for the reason provided above. By doing so Delta Dental essentially claim that no matter what happened only one treatment for the same tooth allowed within 2 years. This is not acceptable and I consider such behavior as failure to honor contract by Delta Dental and unfair business practices.Desired Settlement: Delta Dental should send me check in amount to be defined by plan coverage provided along with apology letter.

Business

Response:

This letter is a response to the customer complaint submitted to the Revdex.com (Revdex.com) by Delta Dental of Virginia (DDVA) subscriber [redacted]. Thank you for the opportunity to review the complaint from Mr. [redacted] concerning the denial of a restoration performed on March 20,2013. DDVA's policy is to deny restorations for the same tooth, same surface(s) when performed by the same dentist within 24 months. However, upon reviewing the length of time when the original restoration was placed [April 6,2011] and the denied restoration on March 20,2013,I have determined that DDVA denied the claim in error since it was within 30 days of the 24 month time limitation. DDVA has made a correction to the denied claim. The submitted amount for the restoration performed on March 20, 2013 was $340.00. Mr [redacted]'s coverage for restorative treatment is 80% of the maximum plan allowance. DDVA allowed $195 for the restoration and paid a total of $116.00, Mr. [redacted]'s payment obligation is $224.00; of which $50 went toward his deductible. Unfortunately Mr. [redacted] did not see a participating DDVA provider; therefore, he is responsible for the difference up to the full submitted fee. Again, please accept our sincere apology for the inconvenience Mr. [redacted] experienced.Please contact me if you have any questions at ###-###-####. Sincerely, [redacted]Director, Corporate Compliance

Consumer

Response:

I have reviewed the response made by the business in reference to complaint ID [redacted], and have to notify Revdex.com that business response contain false information. In DDVA response we have (highlighting mine): "DDVA allowed $195 for the restoration and paid a total of $116.00, Mr. [redacted] payment obligation is $224.00;" I have no problem with amounts above but I did not receive any payments from DDVA in regards to claim in question. Also, I have not been contacted by DDVA with information that they reconsidered my claim and I should expect to receive payment in a future. So, from my point of view (from all I know about my case) they just provided false information to Revdex.com of WV. Regards,[redacted]

Review: I called customer service 3 times and asked why claim [redacted] was denied. I was informed that there is a once a lifetime exclusion on retreatment of a tooth. I explained that an instrument was left in my tooth and the caused the need for the retreat.

I asked to speak to a supervisor and she said she would send me documentation . It is not on the website or in my company plan documentation or exclusions.

I never received anything and its been 3 weeks

I am attaching the claim information and a copy of my benefits which do not state that fact. Please respond to me as soon as possible. My credit is good and I would like to avoid it getting bad because of an unpaid dental bill.Desired Settlement: I want them to pay the claim as orderded by the plan. There is no documentation in the plan guide that there is once in a lifetime maximum on a retreatment of a root canall,

Business

Response:

Delta Dental of Virginia is in receipt of a recent complaint for the above individual identified under IDnumber [redacted].The coverage for this individual is through an Administrative Services Only policy with the employer.Delta Dental of Virginia suggests that the individual work with the group administrator concerningthis complaint.Sincerely,[redacted]Corporate Compliance Analyst

Consumer

Response:

I have reviewed the response offer made by the business in reference to complaint ID [redacted], and have determined that this proposed action would not resolve my complaint. For your reference, details of the offer I reviewed appear below.I have provided them with adequate information of why the claim should be covered. They are unable to give me a valid response when I called there customer service. Review the documentation and explain what exclusions are listed. NoneRegards,[redacted]