What is an Open Space Limitation on my Dental program and how does it apply to me?

Nov 26, 2012

If you have ever sought treatment for a missing tooth and not really understood the insurer’s decision, you are not alone.  Although not as common as many other dental insurance related questions, such as coverage for white fillings or crowns, this question does arise from time to time, and can be very frustrating as the answer varies by insurance carrier.  Coverage for treatment of a missing tooth is found under the Open Space Limitation, or Prior Extraction Clause.  This clause states that an employee is only considered for coverage for a dental appliance if one of the teeth missing was extracted or lost while the employee was insured under the plan.  In other words, if the missing tooth was accidentally lost or extracted prior to an employee’s enrolment on their benefit plan then they are not eligible for any benefits toward a bridge or denture.

If this limitation was not in place, once an employee has dental coverage or is employed with an employer that has a dental plan, it may then make sense financially to try and have the missing tooth replaced.  The dental claims expense subsequently increases the claims charged to the insurance company, which is eventually passed on at renewal, thereby increasing premiums to the plan, and often the rest of the employees if there is a cost sharing arrangement in place.

It is possible in certain circumstances to have this clause removed from the group insurance contract, which may come at an additional cost. Most employers however, leave the Open Space Limitation in place as ultimately the benefit plan is there to assist their employees and their families with dental conditions that arise while employed by the employer.

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