Are dental records part of your insurance claim? Whether you’re a dental claims professional or an organization processing these claims as part of workers’ compensation board (WCB) or personal liability coverage, dental professionals aren’t immune to paperwork. In fact, dental records can be an essential part of a patient’s medical claim; slips, trips, and falls can lead to lost teeth or jaw damage, as can accidents that happen in a vehicle or on the job. 

Dental injuries can cost insurers a considerable amount of money. Payouts for dental liability claims don’t come cheap; in some situations, third party medical examiners might be called on to provide an independent medical evaluation (IME). Just like the neurologists or musculoskeletal professionals that insurers rely on to support their claim, dentists can also be called in to provide an expert opinion. In these cases, the dentist - and the insurer - can have just as much paperwork as their peers. 

Are dental records part of an insurance claim?

There are 3 areas where dental records can impact a medical insurance claim: oral surgery, dental trauma, and pathology (diagnosing issues such as oral cancers). Dental trauma refers to any injury to the mouth, including injuries to the lips, tongue, gums, jaw, or teeth. This means everything from chipped teeth to teeth that are knocked out, dislodged, fractured, or broken off can be included as part of a claim. Evaluation of injuries within this domain require the expertise of medical professionals, insurers, lawyers, and administrators to handle the records involved. 

Some jurisdictions have defined dental injuries from an accident as automatically falling outside the ‘minor’ injury threshold. In an automobile accident or an accident at work, any injury of the head can also result in an injury of the teeth or jaw. Broken glass, airbags, or whiplash can also cause trauma and create additional costs. 

What happens to dental costs in an insurance claim?

Dental injuries can happen as part of accidents at work, home, or on the road. This means they can also fall within the window of personal liability claims or workers’ compensation. However, unlike traditional dental work, only the portion of the treatment that results in getting the patient back to their pre-claim state would go to the insurable cost. 

For example, repairing a tooth knocked out in an accident at work might fall under the scope of workers’ compensation; filling in cavities at the same time would not. What happens if the patient had severe cavities prior to the accident? What if the trauma from the accident was secondary, and the cavities were the major contributing cause of the tooth loss? 

In these cases, it’s especially important for insurance professionals and IMEs to have accurate and clear medical records. The patient’s history before the accident could impact the outcome of a claim, so professionals involved in these cases (whether they are medical professionals or lawyers) could be looking at hundreds of pages of documents prior to resolution of the cause. 

Traditional forms of medical document processing are time consuming and costly. While dental claims might not come across insurers desks as often as other types of injury, dental claims are complex and require careful attention. In these cases, automating or digitizing the claims process can substantially reduce both errors and costs.