GQ Corner
Q. I have a claimant who was involved in an MVA. He alleges one of his fillings fell out during the accident. I certainly have no way of proving otherwise as he has not been to a dentist in many years. I have confirmed with dental evaluation that an old filling is missing, but of course, the dentist says now it may result in possible root canal, which is a lot more expensive.
Question: Is the loss of a filling an injury under TX law such that it has damage or harm to the physical structure of the body? I see this almost like situations where prescription glasses are damaged in an accident and is not covered. There is not any noted damage to the tooth just the filling being gone.
A. If the damage was solely to the filling and not any physical part of the clmt’s mouth or teeth, then based on my analysis the carrier would not be liable for replacing the filling. If, however, there was an injury to the mouth or teeth that required some change in the filling from what it previously was, then the carrier would be liable for that medical expense.
Q. The Dr. is within the TX HCN; however, the only facility he is associated with for surgery is not in the network. Is it required the facility be network status?
A. The carrier is not liable for reimbursement to the facility unless the surgery was an emergency or if the network provider requested and received approval from the network.
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