What dental work does medical aid usually not cover?

Medical aid schemes commonly limit or exclude cosmetic treatment, such as teeth whitening, and restrict specialised work such as implants and orthodontics to a set number or a once-off lifetime benefit. Root canal treatment on wisdom teeth and baby teeth is a common exclusion. The exact list differs by scheme and by plan, so check your own benefit table.

In short

• Cosmetic treatment, such as teeth whitening and crown or bridge work done for appearance rather than function, is commonly excluded, even on comprehensive plans.
• Implants are often excluded on entry-level and mid-range plans, and limited to a set number on higher plans.
• Root canal treatment on wisdom teeth (third molars) and on baby (primary) teeth is a common exclusion, even where root canal treatment on other teeth is covered.
• A repeat filling, X-ray or check-up on the same tooth, or within a set period, will generally not attract a further benefit until that period has passed.
• Laboratory delivery fees, gold or other precious metal in a restoration, and orthodontic re-treatment are typical named exclusions.

Which treatments are commonly excluded altogether?

Cosmetic treatment is consistently excluded across South African medical aid schemes. Teeth whitening is commonly excluded, along with crown or bridge work done for appearance rather than function. Snoring appliances, ozone therapy and gold foil restorations are also commonly excluded. Some schemes exclude specific administrative items too, such as a stand-alone oral hygiene evaluation or instruction session, separately from a covered check-up.

Which treatments are limited rather than excluded?

Implants, crowns, bridges and orthodontic treatment are usually available, but limited. These limits are the scheme’s own published caps, not a practice’s fee, and many dentists charge more than a scheme pays, so treatment costing more than the limit leaves a co-payment for the patient to settle. Implants are commonly limited to a small number per beneficiary within a set number of years, often with a separate cap on the cost of the implant components. Crowns, bridges and other dental appliances often draw on a single combined yearly limit instead. Orthodontic treatment is typically a once-per-lifetime benefit, and is sometimes limited to a certain age range.

Which teeth are typically excluded from root canal cover?

Root canal treatment on wisdom teeth (third molars) and on baby (primary) teeth is a specifically named exclusion on several schemes, which generally limit root canal treatment in the dentist’s chair to permanent teeth. This pattern is worth knowing before agreeing to treatment on one of these teeth, since How much does a dentist cost in Cape Town without medical aid? shows that root canal treatment can be one of the more expensive procedures to pay for privately.

What about repeat treatment on the same tooth?

Schemes typically limit how often the same treatment on the same tooth attracts a benefit within a set period, commonly around a year. These periods differ by scheme, so a repeat treatment falling inside the relevant period may not be covered, even if it would otherwise be.

Why do these exclusions and limits exist?

Schemes design each plan’s dental benefit to keep monthly contributions affordable for a defined level of cover, using tools such as managed care protocols, treatment plans, designated networks and pre-authorisation. This is generally described as balancing appropriate care against sustainable cost across a scheme’s members.

How do I reach Dr Davies?

For a figure for your own treatment, call the practice’s reception, where fees are discussed, and ask for a written quotation after an examination. BRS Dental is not registered with medical aids, so it does not claim from them directly, but reception can help you submit your claim to your medical aid. For anything clinical, contact Dr Davies. Cover differs from scheme to scheme and plan to plan, so check your own plan too.