illinois health-insurance
How to interpret illinois SB 3242 &#39;covered services&#39; definition?
<p>Background: I did a dental procedure during the waiting period of a new dental plan. My dentist contest that contracted prices do not apply during this period despite the fact that the insurance company gave a letter explicitly saying otherwise.</p>
<p>The dentist interpret following definition of <em>covered services</em> in <a href="https://www.ilga.gov/legislation/fulltext.asp?DocName=09700SB3242sam001&amp;GA=97&amp;LegID=64290&amp;SessionId=84&amp;SpecSess=0&amp;DocTypeId=SB&amp;DocNum=3242&amp;GAID=11&amp;Session=" rel="nofollow noreferrer">Illinois SB 3242</a>  to say that procedures during <em>waiting period</em> are considered as <em>uncovered services</em>:</p>
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<p>&quot;Covered services&quot; means dental care services for which a reimbursement is available under an enrollee's plan contract, or for which a reimbursement would be available but for the application of contractual limitations such as deductibles, copayments, coinsurance, waiting periods,annual or lifetime maximums, frequency limitations, alternative benefit payments, or any other limitation.</p>
</blockquote>
<p>Is this interpretation correct? If I understand correctly, above means the opposite and the dentist is still bound by the prices contracted with the insurance company. (Pardon if this is more of a <em>English language</em> question than a <em>Law</em> question.)</p>

<p>The language is pretty clear but what you have is the dentist, for whatever reason, not wishing to honor the contract.</p>
<p>But I'm not sure how anyone's opinion here is going to sway your dentist.  Perhaps you should contact the insurer and seek their assistance.  Failing that, there is always the courts.</p>

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<p>Is this interpretation correct?</p>
</blockquote>
<p>Unless I am missing an implication from &quot;<em>the waiting period of [the] new dental plan</em>&quot;, it seems that the dentist's interpretation is accurate.</p>
<p>The given definition of &quot;covered services&quot; lists some limitations (see the &quot;<em>but for</em>&quot; particle). One of those limitations pertains to services performed during &quot;waiting periods&quot;.</p>
<p>Your description is unclear on the terms &amp; scope of your insurance policy as well as its relation to IL SB 3242. That information is necessary for putting in context the insurer's confirmation that the service is covered. For instance, maybe your insurance policy provides greater coverage than the statutory minimum, in which case the reimbursement might not involve the dentist at all. Hence the need for details on your insurance policy.</p>
