S7 Dental Question

[FightingForFamily]

Greetings,

My son is 4 now and my ex brought him to the dentist for the first time. She gave me the invoice and her math on what I was supposed to pay. The dentist had also submitted the invoice to my insurance electronically at the same time.

What I noticed was that my insurance stated that according to the ODA expense guide, the service he received (A complete oral exam and fluoride) should cost $62 + $25 = $87. My insurance covers 80% of this total, so I will be reimbursed for about $70.

However my ex had taken my son to a pediatric dentist who charged her almost 3 times this amount ($200). My son has autism and can be hard to handle so to a certain degree I am not surprised, though I did not consent to this in advance.

Should I be rightly expected to pay towards the full $200 of the bill when a regular dentist would have charged half this or less?

In my opinion I can justly pay her what my insurance covers (since it went into my account), plus my share of what a normal dentist would charge based on the ODA guide.

As for the issue of autism, my ex is already receiving child disability benefits which should be used towards his special needs such as the more expensive dentist as well.

The nice part was that my son found the dentist a good experience and I had a huge blast talking to him about it, such as why they have funny chairs and why does it look like a space ship lol.

[shellshocked22]

Does your agreement specify on whether your ex needs you to approve IN ADVANCE any potential S7 claims ? Hopefully it does. If not, obviously its not enough $$ to warrant going to war over.

I can see both sides - that's quite a hit over what a "normal" dentist would charge. By the same token, it could be argued that given your son's medical situation, it is required.

My suggestion: perhaps you and your ex could split evenly the amount not covered by insurance ?

Other ideas for the future...

-try and find a "regular" dentist who is good with kids

-phone around and see if you can "negotiate" with a pediatric dentist for preferred rates

There's a lot of dentists these days and like any business, they all compete for your business.

[HammerDad]

Unless you fear this will become the standard, I would pay it.

Your child is special needs and the dentist here met and exceeded those needs. I would put the best interests of my child above what would amount to be like $75. It just isn't worth the battle.

I would ask that in future you be consulted prior to appointments to a) discuss the issues at hand (place, need, costs etc) and to b) see what you can do about attending as it is in the child's best interests to receive as much support as possible.

[Tayken]

Greetings,

My son is 4 now and my ex brought him to the dentist for the first time. She gave me the invoice and her math on what I was supposed to pay. The dentist had also submitted the invoice to my insurance electronically at the same time.

What I noticed was that my insurance stated that according to the ODA expense guide, the service he received (A complete oral exam and fluoride) should cost $62 + $25 = $87. My insurance covers 80% of this total, so I will be reimbursed for about $70.

However my ex had taken my son to a pediatric dentist who charged her almost 3 times this amount ($200). My son has autism and can be hard to handle so to a certain degree I am not surprised, though I did not consent to this in advance.

Should I be rightly expected to pay towards the full $200 of the bill when a regular dentist would have charged half this or less?

In my opinion I can justly pay her what my insurance covers (since it went into my account), plus my share of what a normal dentist would charge based on the ODA guide.

As for the issue of autism, my ex is already receiving child disability benefits which should be used towards his special needs such as the more expensive dentist as well.

The nice part was that my son found the dentist a good experience and I had a huge blast talking to him about it, such as why they have funny chairs and why does it look like a space ship lol.

This isn't even a matter of S7 expenses. Your child has a medical condition in which requires special needs. This medical encounter with the pediatric dentist should have been a referral from your child's Family Practitioner.

The insurance company is legally required to cover the costs for the special needs of your child if it is made upon referral from your child's family practitioner.

Furthermore you may have a "health wallet" or "health spending account" as part of your insurance that can cover the additional expenses that are not covered due to the fact there is no identified "need" on the clinical encounter with the pediatric dentist.

In the future, this appointment should have been done through referral from your Family Practitioner as a required service. If you had this in hand you could get full coverage.

Good Luck!
Tayken

[FightingForFamily]

Fair enough, but if the ex did NOT get the referral through my son's doctor and chose the more expensive dentist for other reasons (maybe suggested by a friend) it remains a bit unfair that I am on the hook.

As stated, she is receiving money for his disability, plus child support, plus spousal support. A more expensive dentist for his special needs should be coming from his special needs money.

I will suggest to her that she get a referral from his family doctor in the future, that's a good idea.

As HammerDad suggests, my ex already has a huge sense of entitlement and milks money from a wide range of sources. I do not want this to become the standard.

[FightingForFamily]

Additionally, are regular dental visits even S7 at all?

They specify orthodontic treatment, which would mean items like braces and surgery. I would not really expect a simple check up to fall under this category?

[financial woos]

Speaking from experience, been their, one of our children with special needs, not all insurance companys have the same coverages. Reality is your child needed the Dental visit. Unless your order for section 7 was very specific which most are not and even if you dont have an order, my x looked like a fool when he brought arguing section 7 prices to the table. The judge was ticked at him for this peice and he was ordered to pay all for coming in with same argument. Of course we have not seen any of the money. You dont want this to set precedence with your x but you may have bigger fish to fry.

[amazedbyitall]

In fairness to the child thats good but your right when people know how to milk the system, get support from other areas this shouldn't be take without discussion before doing it and I think some gov't money should be taken into account its not a pay cheque to the mother etc .There are ppl out there who get nothing !

[FightingForFamily]

I have also observed that ODSP may also allow her to send in a dental claim in addition to the disability allowance she receives for our son.

I will also point out that although my son is diagnosed with autism, he is very high functioning and attending normal school with no more involvement from therapists or specialists.

I will offer to pay her a bit more than half ($102) and suggest in the future she look into ODSP claims and a referral from the doctor to get better coverage.

[HammerDad]

The way these bills are supposed to be paid are like this:

$200 bill

Your insurance covers $75 = $125 remaining.

If she has insurance, it would then be used for the remaining (generally the party with the better insurance makes the first claim). So lets say hers also covers $75. That would leave $50 to split proportionally to income.

Is your insurance company denying the claim because it was a specialist, or are they only willing to cover the $75? Does your ex also have insurance? Has she put this claim to her insurer yet?

This info is important, because she can't put it through her insurance and be reimbursed from them, but also get you to pay proportionally for the whole bill. You are only obligated to pay your proportional share of the portion she doesn't get reimbursed form. Simple terms - she gets $75 herself from insurance, so the actual cost to her was $125. But she gives you the bill of the full $200 and asks for your 1/2 (or proportional share, but we'll use 1/2 cause it is easier). You give her $100. The cost to her just became $25.

[FightingForFamily]

Agreed HammerDad.

However my ex is directly receiving $200 a month in disability allowance for my son's special needs. If the more expensive pediatric dentist is an example of his special needs, then that needs to be factored into the equation as well.

$200 for a special dentist
minus what my insurance pays ($70 in this case)
minus what the goverment gives her to cover his special needs (???)

And the remainder to be split in proportion. For a normal child with a regular dentist I would agree, and I have paid other bills this way in the past. This one sticks in my craw because it's above and beyond what the dentist should cost based on ODA fee guide for 2012.

She may be able to make a dental claim through ODSP in addition to the income she receives for him. She has done neither...

[HammerDad]

She may be able to make a dental claim through ODSP in addition to the income she receives for him. She has done neither...

Why not call them yourself and find out? And if she can, pay her your proportional share after taking into consideration the amount she can claim. If it covers it all or even a portion of it, tell her she can claim the amounts through ODSP and that your obligation to reimburse her is only after she has taken all reasonable steps to be reimbursed by her insurers and ODSP. Once you have determined that amount, pay it.

[Tayken]

Fair enough, but if the ex did NOT get the referral through my son's doctor and chose the more expensive dentist for other reasons (maybe suggested by a friend) it remains a bit unfair that I am on the hook.

Are you a custodial parent (allowed to talk to your son's Family Practitioner)? If so you can probably get the referral letter from the FP yourself and provide the evidence to the insurance provider. If the FP is in agreement that the special dentist was required then, you can solve the problem without conflict.

As stated, she is receiving money for his disability, plus child support, plus spousal support. A more expensive dentist for his special needs should be coming from his special needs money.

I agree. Furthermore, he should qualify for the dental service possibly under OHIP. Double check with the FP on that one.

I will suggest to her that she get a referral from his family doctor in the future, that's a good idea.

You can also ask for a clarification letter from the FP. That covers two of your concern. 1) That it is required and if so demonstrates this to the insurance providers. 2) If you are correct that she did it to be annoying and the FP says no... Evidence as to why you shouldn't have to pay for it.

Don't position the information as #2 option. But, if the FP refuses to make the referral get that information IN WRITING from the FP. That way if they push you can provide it back to them and ask them for the "evidence based medicine" (google the concept) that required your son to see the pediatric dentist in contravention of the clinical opinion of the FP.

As HammerDad suggests, my ex already has a huge sense of entitlement and milks money from a wide range of sources. I do not want this to become the standard.

Agreed. But, don't take the opening position that this was the intent. Go with the low conflict #1 and ask for the FP's opinion and then escalate if needed.

Good Luck!
Tayken

[FightingForFamily]

Thanks for the good advice everyone.

I tried to be non-confrontational about it and sent her an e-mail. I noted that my insurance didn't cover much of the appointment because it was a specialist, and asked if she had been referred by his FP.

I advised her that she should submit a claim to ACSD (Assistance for Children with Severe Disabilities) which is the program providing her allowance for him.

I said if she wanted me to cover more than I have I would be willing to, provided she demonstrate that she tried to claim through ACSD first and could explain why his special needs allowance wasn't sufficient for this special need.

If she's exhausted her other options and his allowance elsewhere then of course I'll pay more, but she needs to try at least.

[amazedbyitall]

it really is hard to beleive if the gov't gives them these credit's it should be used for the children in situations like this . I know of someone who gets money for the child with autism and she used every possible thing for her own gain. Yet the child attends normal school , can be left with normal ppl and see milks it all - Im not saying its everyone but I wont give her anything unless she can prove she is paying out of pocket as well after her credits ... again in fairness to the child - both parents should be realistic and true