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Walter Boss\u00e9 says he can’t get a clear answer from Sun Life, which administers the CDCP and processes claims, about why he doesn’t qualify to get a crown covered under the Canadian Dental Care Plan. (Submitted by Walter Boss\u00e9)<\/p>\nAfter months of probing, Walter Boss\u00e9 is still trying to get to the bottom of why he doesn\u2019t qualify to get a crown covered under the Canadian Dental Care Plan (CDCP).\u00a0<\/p>\n
The public insurance program subsidizes the cost of dental care for Canadian residents with a household income below $90,000, if they don’t have access to a private insurance plan.\u00a0<\/p>\n
Insurance provider Sun Life administers the CDCP and processes claims.<\/p>\n
While most claims don\u2019t need pre-authorization, it\u2019s required for more expensive procedures, like crowns or partial dentures.<\/p>\n
In the last year, Boss\u00e9 said he\u2019s had multiple pre-authorization requests for crowns denied, even after his dentist submitted the proper documentation, X-rays and a detailed explanation to show why they’re medically necessary.<\/p>\n
\u201cI was quite surprised because the dentist was convinced it was straightforward,\u201d said Boss\u00e9, who lives in Kirkland, Que., a suburb of Montreal.<\/p>\n
Boss\u00e9 had a broken filling. Although his dentist repaired the base, the tooth needed a crown. A subsequent pre-approval request a few months later for a different tooth, which was cracked, was also denied.<\/p>\n
\u201cI\u2019m like, OK, what is Sun Life doing, they are playing games,\u201d Boss\u00e9 said.<\/p>\n
Walter Boss\u00e9 says he can’t get a clear answer from Sun Life, which administers the CDCP and processes claims, about why he doesn’t qualify to get a crown covered under the Canadian Dental Care Plan. (Submitted by Walter Boss\u00e9)<\/p>\n
Not one to take no for an answer, the retiree called Sun Life.\u00a0<\/p>\n
\u201cThere was no explanation,\u201d said Boss\u00e9. \u201cIt\u2019s just denied as per the plan criteria.\u201d<\/p>\n
According to Sun Life\u2019s expense estimate decision, which was reviewed by CBC, Boss\u00e9 did not meet the CDCP\u2019s policies and coverage criteria.<\/p>\n
He then escalated the situation to a Sun Life supervisor, but they also wouldn\u2019t specify the precise reason for the denial.<\/p>\n
\u201cI was flabbergasted,\u201d said Boss\u00e9.<\/p>\n
The Canadian Dental Care Plan was supposed to make dental care more affordable for millions of Canadians. To date, Health Canada says over $6 billion has been paid for claims under the plan.<\/p>\n
But Boss\u00e9 believes that\u2019s being undermined by how Sun Life is processing claims for more complex, costly procedures. He\u2019s worried the insurer is turning down claims to mitigate payouts. The estimate for his crown was a bit over $1,600.<\/p>\n
\u201cI\u2019ve been a taxpayer for what seems like forever and continue to pay taxes,\u201d said Boss\u00e9. \u201cI\u2019d like to get a little for my money.\u201d<\/p>\n
Complaints coast to coast <\/p>\n
Across the country in B.C, the NDP MP for Vancouver East has heard similar complaints from several of her constituents.\u00a0<\/p>\n
\u201cThey should not have to battle the insurance company to try and figure out what it is that they might be doing wrong,\u201d said Jenny Kwan.<\/p>\n
\u201cFor all we know, they might not be doing anything wrong.\u201d<\/p>\n
In one case, her office intervened after a resident\u2019s pre-authorization request for dentures was rejected.<\/p>\n
\u201cHe literally couldn\u2019t eat,\u201d said Kwan. \u201cWe had to fight tooth and nail to only get partial coverage.\u201d<\/p>\n
Other constituents in her riding were turned down for crowns. Kwan says neither her office nor the dentist clinics can \u201cmake heads or tails out of it.\u201d<\/p>\n
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NDP MP Jenny Kwan, who represents the riding of Vancouver East, has heard from several constituents who can’t understand why they were turned down for medically necessary dental work. She’s calling on Canada’s health minister to resolve the confusion. (Justin Tang\/The Canadian Press)<\/p>\n
She\u2019s concerned these denials may impact people\u2019s health, as many residents can\u2019t afford to pay out of pocket.<\/p>\n
Earlier this spring, Kwan sent an open letter to Canada\u2019s Health Minister Marjorie Michel, urging her to resolve the confusion around the CDCP\u2019s eligibility requirements.<\/p>\n
\u201cIt doesn\u2019t make any sense when dentists submit an application following all the rules, following the eligibility criteria for their patients and they\u2019re being rejected,\u201d said Kwan.\u00a0<\/p>\n
\u201cThey need to be transparent and tell people what the problem is.\u201d<\/p>\n
Dental associations call for more clarity<\/p>\n
In Quebec, approximately 1.8 million people are enrolled in the CDCP and 1.5 million have received care, said Dr. Marie-Claude Desjardins, president of the Quebec Association of Dental Surgeons.<\/p>\n
When it comes to basic care \u2014 general exams, cleaning, cavity filling and extractions \u2014 she said the program is running well.\u00a0<\/p>\n
\u201cThere are people who sometimes haven\u2019t seen a dentist in years or who have cavities that have been left untreated for years,\u201d said Desjardins.\u00a0<\/p>\n
But if it\u2019s a more complicated treatment or procedure, she acknowledges it\u2019s often unclear why coverage is being denied.<\/p>\n
\u201cSo that\u2019s something that we\u2019re asking to be improved,\u201d she said. \u201cWe\u2019re asking for it to be simpler, clearer and more predictable for both patients and dental teams.\u201d<\/p>\n
The Canadian Dental Association echoed Desjardins\u2019s call for more clarity, saying in an emailed statement that frequent denials were not only delaying timely care for patients, but creating an \u201cadministrative burden\u201d for dentists.<\/p>\n
Sun Life directed any questions about how the CDCP is being managed to Health Canada. The insurer would only say coverage is determined through a standardized assessment process that applies the CDCP\u2019s policies. The clinical eligibility criteria was developed by Health Canada.\u00a0<\/p>\n
Not all pre-authorization requests approved: Health Canada<\/p>\n
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Health Canada says Canadians should ask their dentist about any additional costs not covered by the CDCP. They should also be aware of the total amount they’ll need to pay directly to their provider before accepting or starting treatment. (Jean-Fran\u00e7ois Benoit\/Radio-Canada)<\/p>\n