Insurance impasse costs woman her smile
28 01 08 - 11:26
By JO CIAVAGLIA
Bucks County Courier Times
Soon, Juliet Smith will be fitted for dentures. She is 22.
Nearly six months of back and forth involving state lawmakers, the state Attorney General's Office and the Philadelphia region's second largest health insurer haven't broken an impasse involving the Northampton Township woman, who needs what her doctors say is "medically necessary" dental treatment that her health insurer refuses to cover.
Recently, Smith started the process of having her remaining adult teeth removed to relieve some of her constant facial pain, said her father, Joe Smith.
"You get to a point where you have to do what's best for your daughter," said Joe Smith, who has fought his health insurer, Aetna, on behalf of his daughter. "She is realizing it's not going away. She can't take it anymore and she can't live full time in dentist offices."
Last year, the Courier Times, sister paper of The Intelligencer, wrote about Juliet Smith, who is stranded in an insurance limbo affecting millions of American adults with health insurance but little or no dental coverage.
After her story appeared, state officials attempted to persuade Aetna to reconsider its rejection. A local dentist stepped in to provide free care. The allied health program at Pennco Tech in Bristol raised $1,800 for the family.
Now, a local lawmaker says the Pennsylvania Legislature needs to take a deeper look at the dental-medical coverage gap.
Many states have some insurance mandates addressing the issue, but in Pennsylvania, treatment and coverage decisions are typically dictated by how insurers interpret language in medical health plans. And that language increasingly excludes or limits dental procedures that were once traditionally covered, dental and insurance experts say.
While Rep. Scott Petri, R-178, who interceded after learning about Juliet's plight, hasn't taken formal legislative action yet, he says he'll examine other states' language and statutes involving the medical-dental gap.
Petri also said he'll look at House bill 718, introduced this session, to see if its language could be expanded to cover cases like Juliet's. The bill would require that all insurance policies cover full treatment of congenital orofacial anomalies such as cleft palates. It is one of four bills introduced since 2000 seeking to require insurance mandates for some medically related dental care.
"This case has been particularly frustrating. Her situation opens your eyes pretty wide," Petri added. '"The unfortunate part is it is occurring and it happens. The important thing is it can happen to others."
At least 29 states require health plans to cover hospitalization, anesthesia and medically related expenses for some dental patients. Some states also require coverage to include medical expenses for some treatments performed in dental offices.
Nineteen states mandate that health care policies issued in their states cover the diagnosis and treatment of certain dental conditions, typically involving jaw disorders and craniofacial anomalies.
Juliet Smith started experiencing serious dental and related medical problems, including rotting teeth, abscesses and chronic facial pain, after jaw surgery in 2001. Doctors say she suffered a rare complication and nerve damage resulting in her chronic pain and dental deterioration.
She has endured more than 21 root canals since her surgery, and lost more than half of her natural adult teeth. Her mouth is filled with exposed nerves from numerous broken or fractured teeth, Smith's medical reports confirm. She needs general anesthesia for any mouth work because conventional local anesthetic doesn't numb her.
For years, the family has fought with insurance carriers over her medically related dental care. Last year, Aetna denied a doctor's request for what was described as "medically necessary" full mouth rehabilitation costing more than $50,000. Aetna cited an extensive dental exclusion clause in Joe Smith's health policy, under which his daughter is covered.
Her doctors also tie her other health problems to her dental deterioration, including chronic migraines, chronic pain, weight loss, facial numbness and anemia. The Smiths say they've accumulated debt in excess of $250,000 mostly due to Juliet's uncovered medical and dental expenses.
Social Security has classified Juliet as totally medically disabled since 2001. Medicaid is her primary health insurance, and Aetna is the supplement. The Smiths' dental plan covers only basic care, with $1,500 annual per person maximum.
Since August, Newtown Township dentist Dr. Randall Cohen has donated his services to Smith to stabilize her mouth, a process often involving weekly appointments. But the damage was so extensive that Cohen and another dental specialist recently determined the natural teeth cannot be saved.
Cohen said he plans to use a combination of dentures and implants to restore Juliet's smile.
"I feel for this girl," he added. "She'll be fine. Dentistry has come a long way."
Joe Smith hopes so. Doctors have told the family that removing her teeth won't eliminate her pain, but it should significantly reduce it, he said.
"We really tried everything," Smith added. "If I can't win this, I don't know who can."
Petri represents Northampton, Wrightstown and Ivyland and portions of Upper Makefield, Upper Southampton and Warwick.
Jo Ciavaglia can be reached at (215) 949-4181 or jciavaglia@phillyBurbs.com.