Kentucky Health Insurance Practice Exam

In which situation would an insurer likely deny a claim related to a dental service?

1. If the service was not performed by an accredited dentist.

2. If the insured requested a service not covered by the plan.

3. If the claim is submitted after the filing deadline.

4. If the insured has not made payments in the last 3 months.

The correct answer is: If the insured requested a service not covered by the plan.

The scenario that illustrates a clear reason for an insurer to deny a claim related to a dental service is when the insured requests a service that is not covered by their health plan. Insurance policies are designed to cover specific services outlined within the policy terms. If a dental service falls outside of these specified coverages, the insurer has a valid basis for denying the claim. For example, if a policy explicitly states that it covers routine cleanings and basic fillings but does not include cosmetic procedures like teeth whitening or veneers, any claims for these non-covered services would be denied. Understanding the limitations and exclusions of one's policy is essential for both insured individuals and healthcare providers to ensure that claims align with what is included within the coverage. The reasons for denial based on other scenarios are also valid, but they pertain to compliance with policy stipulations rather than the coverage itself. Claims submission deadlines and the status of premium payments are administrative issues that, while important, do not address the fundamental aspect of whether the service itself is covered under the policy.