The Office of General Counsel issued the following informal opinion on August 14, 2001, representing the position of the New York State Insurance Department.
Re: Coverage of Congenital Dental Condition
Is an insurer, which has determined that a dental condition is congenital, and therefore covered under an insurance contract, obligated to cover a particular treatment of that condition, notwithstanding otherwise applicable exclusions?
Under the totality of the circumstances involved with the insureds condition and the insurers prior actions, the insurer is obligated to cover the treatment in question.
A family is insured under a group contract issued by a not-for-profit health insurer licensed pursuant to New York Insurance Law, Article 43 (McKinney 2000). The contract in question does not cover usual dental services.
An insured covered under the plan was diagnosed at age 3 with amelogenesis imperfecta. The insureds dentist, presumably because of the above condition, has since placed seven stainless steel crowns on the insureds teeth. It is anticipated that further crowns, as well as other reconstructive dental work, may be required in the future.
It was requested that this Office render a binding interpretation as to whether that portion of this Departments Regulation 62, which requires insurers to cover "dental cure or treatment necessary due to congenital disease or anomaly", N.Y. Comp. R. & Regs. tit. 11, §52.16(c)(9) (2000), required the insurer to cover treatment for the insureds amelogenesis imperfecta. The Department responded that after reviewing the history of the regulatory provision in question, it did not have the "expertise to determine whether the condition in question is such a condition so as to be encompassed within its provisions".
The Insurer has stated that coverage of the treatment in question was specifically excluded by the contract.
The contract is a "managed care health insurance contract," defined in New York Insurance Law § 4801(c) (McKinney 2001) as follows:
[A] managed care health insurance contract . . . shall mean a contract which requires that all medical or other health care services covered under the contract, other than emergency care services, be provided by, or pursuant to a referral from, a designated health care provider chosen by the insured (i.e. a primary care gatekeeper), and that services provided pursuant to such a referral be rendered by a health care provider participating in the insurer's managed care provider network . . . .
Except for denials because of lack of medical necessity, which are covered by New York Insurance Law Article 49 (McKinney 2001), an insurer is required, for an appeal of a denial of coverage pursuant to New York Insurance Law §4802(a) (McKinney 2001), to provide a grievance procedure. Pursuit of such a grievance does not, in accordance with New York Insurance Law §4802(o), preclude one from also pursuing a complaint with this Department
The insurer asserts that the crowns already placed on the insureds teeth and those to be placed in the future are not included within the covered services specified in § 6 of the contract and are specifically excluded by §10, ¶15 of the contract. The provision in question provides:
Except for post mastectomy prosthesis . . . we will not pay for prosthetic or orthotic appliances.
The contract does not define "prosthetic device". Insurer, however, states:
A prosthetic is an artificial replacement or partial replacement of any part of the body. As such, crowns are considered prosthetic devices and not covered in your contract.
The inquirer contends that the language of N.Y. Comp. R. & Regs. tit. 11, §52.16(c)(9) does not allow the Insurer to utilize such an exclusion. The language on which the insureds rely provides:
(c) No policy shall limit or exclude coverage by type of illness, accident, treatment or medical condition, except as follows: . . . (9) dental care or treatment, except for such care or treatment due to accidental injury to sound natural teeth within 12 months of the accident and except for dental care or treatment necessary due to congenital disease or anomaly; . . . .
While this Department does not believe the above quoted language is susceptible to as expansive interpretation as the insured has placed upon it (e.g. the insurer is precluded from refusing to pay for any treatment), for the reasons indicated below, this Department believes that Insurer is obligated to pay for the insureds crowns.
The Merriam-Webster Medical Dictionary (2001) defines "prosthesis" as "an artificial device to replace a missing part of the body". That Dictionary then defines "prosthetic":
Referring to a prosthesis, an artificial substitute or replacement of a part of the body such as a tooth, eye, a facial bone, the palate, a hip, a knee or other joint, the leg, an arm, etc. A prosthesis is designed for functional or cosmetic reasons or both.
That Dictionary further defines a "jacket crown" as "an artificial crown that is placed over the remains of a natural tooth".
The Stedmans Medical Dictionary (1995) defines "prosthesis" as "a fabricated substitute for a diseased or missing part of the body. That Dictionary then defines "dental prosthesis:
An artificial replacement of one or more teeth and/or associated structures.
The MEDLINE Medical Encyclopedia (2001) defines "prosthesis" as
A device designed to replace a missing part of the body, or to make a part of the body work better.
New York State, in establishing dental fee schedules under Medicaid, has a classification for crowns as restorative services separate from that of prostheses. N.Y. Comp. R. & Regs. tit. 18, §535.5 (2001).
The MEDLINE Encyclopedia defines "amelogenesis imperfecta" as:
An inherited condition which is transmitted as a dominant trait and causes the enamel of the tooth to be soft and thin. The teeth appear yellow, because the dentin is visible through the thin enamel. The teeth are easily damaged and susceptible to decay.
As to treatment of the condition, the Encyclopedia indicates that "full crowns will improve cosmetic appearance and protect the teeth from damage". Insurer has not indicated that it believes the chosen treatment is inappropriate, which would have generated appeal rights pursuant to New York Insurance Law Article 49, and relies solely on its definition of prosthetic device.
With respect to Dental care generally, the contract, §10, ¶13, provides:
We will not pay for any services (including hospitalization) in connection with dental care, care of the gums or structures supporting the teeth, or any form of dental surgery, regardless of the reasons such services are necessary. However, we will pay for services otherwise covered under this Contract in connection with accidental injury to sound natural teeth if the care is rendered within 12 months of the accident and you are still covered by the Contract.
While, under some circumstances, a dental crown might be considered a replacement of a bodily part, as asserted by Insurer in its June 7, 2001 letter and as defined above, it is not clear that such a crown would invariably be considered a prosthetic device. Accordingly, given the varying definitions of "prosthesis", and the probable inconsistent use of its definition by Insurer with respect to teeth, there is ambiguity as to whether, in the case of the insureds treatment, the crowns would be considered a prosthetic device.
It is the general rule in New York that ambiguities are to be construed against the insurer, which has drafted the contract. Blandford Land Clearing Corporation v. National Union Fire Insurance Company, 260 App. Div. 2d 86, 698 N.Y.S. 2d 237 (1st Dept. 1999). Accordingly, had Insurer desired to have crowns for amelioration of amelogenesis imperfecta considered as a prosthetic device, it could have defined "prosthetic device" in the contract so as to leave no doubt of its intention to exclude dental crowns.
In addition, once Insurer reviewed the circumstances of the insureds condition, consulted with whatever experts it believed were required, and determined that the insureds condition qualified a congenital disease; it is presumed to have also been aware of the accepted treatment for amelogenesis imperfecta, e.g. dental crowns. It is disingenuous of Insurer, therefore, to now assert that it will not cover such treatment.
Accordingly, while this Department does not have the expertise to express an opinion as to the validity of all of Insurers claim determinations, under the circumstances of the insureds case, it is the opinion of this Department that Insurer is obligated to pay for the dental crowns required to treat the insureds condition.
For further information, you may contact Principal Attorney Alan Rachlin at the New York City Office.