Dental (orthodontic) insurance for *aesthetics*: an ordeal (KPT and Groupe Mutuel)

Family, Education, Health and Pets
1

I am getting crazy, so please tell me what am I doing wrong.

TL;DR: we are looking for orthodontic insurance for our kids (3 and 5), and all of them exclude treatments “for physical defects of an aesthetics nature”.

We started this ordeal last May. Our daughter was close to her 5th birthday, and we had heard that the longer you wait the more likely you get refused or asked for a dental certificate, so we did some search and we found a plan that was looking pretty good from KPT. We tried to apply from their website, it didn’t work because of some technical glitch, so we went through the phone, things went slow, and eventually we didn’t manage before our girl’s birthday, so we were asked to provide a medical assessment questionnaire from our dentist. Whatever, our fault, we didn’t account for delays, so we pay these 100 CHF to get the questionnaire done. The dentist says there are zero problems currently with our girls’teeth so it should go smooth.

The experience with KPT was… “frustrating” would be an euphemism. Things are constantly delayed, the attachments are lost, people are always on vacation or out of office and nobody seems to be availble as a replacement. Eventually they contact us, happily offering the coverage, without mentioning anything. But when we go to read the fine print, they had put a clause to exclude coverage for dental correction! Not only aestehtics, just every kind of dental correction! Throughout the many calls and emails we exchanged we were absolutely, pedantically clear that we were only interested in dental insurance for aestehtical (non-medical) correction, but the sneaky basterds tried to f**k us regardless.

That was just the beginning. We ask for clarifications, they say that’s something their risk department decides and cannot tell us why, but as an exception they will let us know it’s because the dental questionnaire was not completed on a certain field. We get back to the dentist, who is perplexed: “why would they need this information on baby teeth?” but, regardless, she updates the form and sends it again (for free). Things go mute again for ages despite our constant pings, then the response: denied because there were some numbers in a different field of the questionnaire missing again. We go back again to the dentist, who is again puzzled, but whatever, she updates again this field (for free) and we start pestering KPT again. The thing goes on forever, back and forth and refusing our requests to understand what the problem is, until at some point last October they just tell us “whatever you write in the form, we will not cover this”. From May until October just to tell us to f..k off.

At this point we are done with KPT, we actually spent even more time than reasonable with them TBH, so we try Groupe Mutuel. GP is more expensive than KPT, but they have a “no questionnaire needed” policy for this age. We are, again, super-crystal-clear what we need the coverage for. Again, things go slow, eventually we got our cheerful offer last week and, reading the fine print, at the section “EXCLUDED BENEFITS”, here you go again the dental treatments for aestehtics!

At this point I’m puzzled, because I’ve been almost 10 years in Switzerland and dealt with many sketchy and less sketchy insurers, but I have rarely seen such an obvious display of malice. Were we just unlucky or are they all like this? I mean, I know that there is a special place in Hell for insurers, but this is borderline scam.

Is the dental insurance industry all like this? Are there even plans that cover for aesthetics? Readers who opted for dental insurance for your kids’braces, how did it go? Did you find a complacent doctor/dentist who certified the braces are actually required for medical reasons and the insurance accepted it? Or what?

Thanks for any insightful reply and sorry for the rant.

2

Maybe just don’t bother. If there’s nothing actually wrong with the kids’ teeth then leave them alone. Believe it or not, they don’t need “pefect white teeth” to make their way in the world.

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3

Similar in Germany, as soon as it gets to “looking pretty” you pay through your teeth… as it were.

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In our experience, non-cosmetic correction is covered on health insurance anyway. My son needed fairly extensive realignment which, if left untreated, would have impacted his jaw later in life so it was covered.

You don’t need additional dental coverage for what (I understand) you are looking for.

If you just want pretty (but otherwise healthy and functioning) teeth, then you have to just pay for it.

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5

I mean, sorry if I don’t get the difference, I don’t come from a wealthy family and it was a big deal for us when I needed braces as a kid. What’s the difference between “misaligned but healthy” and “misaligned and in need of medical treatment”? I’m not talking about serious medical conditions, i.e. that seriously impact your quality of life, but I think it’s reasonable to desire straight teeths for your kids. I thought that’s what dental insurances are for? Because otherwise, as @ShirleyNot said, most of it is already covered by basic insurance. So, I guess my question is, what is dental insurance for then?

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On one hand, insurance doesn’t want to pay out if they can avoid it.
On the otherhand, orthodontics is a cash cow with many, many repeat visits.

Your child’s dentist will generally try and say that the treatment is absolutely necessary for medical reasons rather than aesthetic ones.

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For clarity, it doesn’t work like that, and the dentist cannot decide such things. They have to make a referral to a paediatric orthodontics clinic where it is then assessed for medical necessity.

Yes, a dentist can recommend corrective work for aesthetic reasons and the parents can then decide whether or not to pay for it or fund it through whatever supplemental dental insurance they might have, but if it’s deemed to be a medical reason where the health insurance is involved, then it needs further assessment.

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Not all dentists here are honest. That’s from experience.

For “normal” functional non-aesthetic misalignments (which probably covers most non-aesthetic child brace treatments), it’s the dentist who decides that and the supplementary insurance pays their percentage.

If you want it covered by basic insurance, this is reserved for only extreme cases, or accidents.

This has been our experince and is explained in the chart below:

Insurance Type Who Decides Eligibility? What is Covered?
Disability Insurance (IV/AI) The orthodontist submits proof that the child’s case matches a federally recognized congenital disorder. 100% covered up to age 20 for severe, severe dental and alignment issues.
Basic Health Insurance (KVG/LAMal) The medical examiner (Vertrauensarzt) of the health insurance company reviews the orthodontist’s report against OPAS guidelines. Covered only in extreme exceptions, such as severe illnesses of the masticatory system (jaw) or accidents.
Supplementary Dental Insurance (VVG) The patient’s private policy rules. Normal misalignments (aesthetic or functional but non-severe) fall here. Partially covered (usually 50% to 75% up to a yearly limit) depending on your policy.
9

Not to be dismissive, but you’re dealing with health insurers. The two key words are Health and Insurance.
They insure health conditions. They can’t ensure what your view of an aesthetic nature of your kids’ teeth might be.
You can’t “time” them either by trying to close such an insurance when the kids are younger: from the insurer’s perspective, that would be an even bigger risk.

Imaging getting a Zusatzversicherung for aestethic plastic surgery because your view of what a nose should look like.

Also, I’m very proud of myself I didn’t insert a picture of an Uruk Hai from LOTR who didn’t wear braces when they were raised bred.

10

You mention dental correction for aesthetic reasons. There is no such insurance, anything purely aesthetic is excluded from basic and complementary, more-or-less by definition (or even law). Hence the exclusion clause in your contract is normal, it would be always there. There has to be a “necessity” for any treatment, not purely “I like this improved”… otherwise there is no limit on what one can improve, and at what frequency.

In my view dental insurance is worth only if purchased at birth, when you are given discounts, anything later is probably not worth it.. especially since it is packaged with other complementary which you may not want.

Note that in the case of serious problems (serveral teeth impacted) 100% of the cost is paid by the invalidity insurance of the child (i.e free for you). There are rules, eg x teeth impacted by an angle larger than y degrees, but it is not that uncommon, the two people i know who had their children have orthodontics did not pay anything, and the dentist did all the paperwork.

This leaves the case in the middle where it is not important enough to get for free, but on the other hand, necessary according to some doctor, not purely easthetic. What would the cost be ? According to google pointing to swiss health insurers, chf 3000-10000. You have to compare this to the cost of complementary insurance for a child, it is better to just save your money for this eventuality, and forget insurance.

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