Major Dental Insurance

What services are classed as major dental procedures?

• Wisdom teeth removal. This may be required if the tooth damages or pushes aside other teeth or the gums as it emerges.
• Tooth extraction. Tooth extraction is when a tooth is removed entirely due to extensive damage or decay. Whether this is a basic or major dental procedure generally depends on the tooth, how many are being removed and your fund. Wisdom tooth extraction is generally classified as major dental.

• Dentures. Dentures are removable prosthetic teeth that can be fitted to replace any number of missing teeth. In some cases dentures might replace an entire row of teeth, such as the top or bottom, with a single prosthetic device, or might replace as few as one or two.

• Dental crowns and bridges. Dental crowns and bridges are two different but very closely related types of dental implant. The main functional difference between them is that a dental crown is for a single tooth while a dental bridge is for multiple teeth. If a tooth has suffered partial damage such as chipping, decay, or damage from repeated replacement of fillings then a crown or bridge is installed. These act like partial fake teeth permanently installed on top of damaged existing teeth.

• Dental veneers. Dental veneers are very thin, specially made dental implants that are placed over the front of existing teeth. Costs vary depending on material and manufacture, and they are typically used for cosmetic rather than medical purposes. As such, most major dental insurance policies don’t cover veneers.

• Root canals. Root canals are a fairly common endodontic procedure. If a tooth has fissured or cracked then it is possible for the interior pulpy tissue to become infected and inflamed. A root canal involves digging into the tooth with very fine tools and extracting the inflamed tissue.

• Periodontics. Periodontics encompasses a variety of fairly specific treatments focused on the gums, such as treatment of gingivitis and attention to infection, inflammation or other oral tissue problems. Periodontic procedures are generally only covered by major dental plans, although you may be required to have been referred by a dentist.

How does private health insurance cover major dental and orthodontics?

• Complex and major dentistry
• Orthodontics

Are there any limits or waiting periods?

• Major dental benefit limits. A benefit limit is the most the insurer will pay per year, per person, per procedure and/or per policy.
  • For example, you may be able to claim a $50 benefit on a limit of two dental check-ups per person each year. Or you may be able to claim a maximum of $800 every three years for all denture-related costs.

• Major dental waiting periods. A waiting period is the amount of time you have to wait after taking out a private health insurance policy before you can make a claim. These times vary depending on the claim and the insurer.
  • The typical waiting periods for dentistry are 12 months for orthodontics and complex or major dentistry, and a two-month waiting period for basic dental work.

Is there any major dental specific exclusions?

Exclusions may vary between health funds, but some you may encounter include:

• No payout for claims made more than one or two years after a procedure
• No benefits payable for pre-existing conditions
• No cover for treatments or procedures that an independent medical professional deems unreasonable or inappropriate
• No benefits for services not provided face to face, such as phone or online consultation, unless stated otherwise
• No cover for cosmetic procedures without a specific condition being treated or the presence of symptoms, illness or injury
• No cover if you are visiting a dentist or specialist who is not registered with or approved by your private health fund

How do I claim dentistry from my health insurer?

The claims process can vary depending on your fund and practitioner. However, here are some general guidelines to claiming:

• If your dentist or specialist is associated with your health fund then they may be able to liaise directly with the insurer and arrange payment.
• Most funds will provide you with a membership card, which can be swiped at your treatment facility.
• You may be able to download a health insurance app to your phone which lets you claim and pay benefits on the spot.
• In some cases you will be required to fill out a claims form and send it to your insurer.

Full list of providers who offer cover for major dental

Health fund	Policies that cover major dental services and the annual benefit limits	Find out more
	Super Extras. Benefit limit of $1,100 per person. Family Extras. Benefit limit of $750 per person. Lifestyle Extras. Benefit limit of $750 per person and $1,500 per family. Black 60. Shared benefit limit of $600 per person and $1,200 per family.	More info
	Advanced 80% Extras. Benefit limit of $2,400 per person (includes orthodontics). Comprehensive Extras. Benefit limit of $2,400 per person (includes orthodontics). Intermediate Extras. Benefit limit of $300 per person. Standard Extras. Shared benefit limit of $600 per person with a sub-limit of $300 for crowns, bridges and dentures.	More info
	Top Extras 90. Benefit limit of $1,200 per person. Top Extras 75. Benefit limit of $1,100 per person. Top Extras 60. Benefit limit of $1,000 per person. Your Choice Extras. Initial benefit of $500 after 2 years of retaining cover, increasing by $100 for each additional year until it caps at $1,000 after 7 years.	More info
	Total Extras. Shared benefit limit of $1,500 per person. 75% Extras. Shared benefit limit of $800 per person.	More info
	GMHBA allocates varying sub-limits to each service that falls under major dental. You can find the details on each one below this table. Top Extras 75% Top Extras Set Benefits	More info
	Lots Extras Cover. Shared benefit limit of $2,000 per person and $4,000 per couple/family. Some Extras Cover. Shared benefit limit of $500 per person and $1,000 per couple/family.	More info
	Top 70. Benefit limit of $1,000 per person. Complete 60. Benefit limit of $800 per person. Flex 60. Combined limit of $1,000 per person. Flex 50. Combined limit of $800 per person.	More info
	HCF Platinum and Gold Extras benefit limits for major dental increase each year you retain your policy. The increase caps at year six. HCF Top Extras. Benefit limit of $1,000 per person. HCF Vital Extras. Benefit limit of $800 per person. HCF Mid Extras. Benefit limit of $650 per person.	More info
	Extras 50. Benefit limit of $750 per person.	More info
	Health Care Insurance allocates varying sub-limits to each service that falls under major dental. You can find the details on each one below this table. Premier Active Life	More info
	Freedom Max Extras. Benefit limit of $1,000 per person. Freedom Extras. Benefit limit of $900 per person.	More info
	The HIF major dental benefit will increase each year you retain your policy. The increase caps at year five. Premium Options. Initially $1,500 per person, capping at $3,000 per person. Super Options. Initially $1,300 per person, capping at $2,500 per person. Special Options. Initially $1,000 per person, capping at $2,000 per person. Saver Options. Initially $750 per person, capping at $1,250 per person.	More info
	All of Latrobe Health Services' extras policies, except for Premier Silver, increase their major dental benefit limits for each year you retain cover. Premier Extras. Benefit limit of $1,500 per person. Core Extras. Benefit limit of $1,000 per person. Basic Extras. Benefit limit of $500 per person. Premier Singles & Couples Extras. Benefit limit of $875. Premier Families Extras. Benefit limit of $875.	More info
	Top Extras. Benefit limit of $500 per person. Growing Family Extras Only. Initially $400 per person, increases by $50 each year until it caps at $600 after four years of continuous cover.	More info
	Five Star Extras. Shared benefit limit of $390 per person during the first year of cover, increases to $1,200 per person from year two onwards. Dental Cover. Shared benefit limit of $350 per person during the first year of cover, increases to $1,000 per person from year two onwards.	More info
	onemedifund allocates varying sub-limits to each service that falls under major dental. You can find the details on each one below this table. Gold Hospital - $250 Excess & Comprehensive Extras	More info
	Top Extras. Benefit limit of $1,300 per person. Core Extras. Benefit limit of $600 per person.	More info
	Premium Extras. Benefit limit of $1,500 per person. High Extras. Benefit limit of $1,000 per person. Mid Extras. Benefit limit of $500 per person.	More info
	Complete Extras 70. Benefit limit of $1,000 per person. Everyday Extras 60. Shared* benefit limit of $800 per person.	More info
	Super Extras. Benefit limit of $1,200 per person.	More info
	Top Extras. Initial benefit limit of $800 per person, increasing to $1,000 per person after three years and $1,200 per person after five years. Healthy Choice Extras. Benefit limit of $500 per person and $1,000 per policy.	More info
	Ultimate Extras. Benefit limit of $1500 per person. Advantage Pro Extras. Benefit limit of $1400 per person.	More info
Restricted fund*	CBHS allocates varying sub-limits to each service that falls under major dental. You can find the details on each one below this table. Top Extras Intermediate Extras	More info
Restricted fund*	Premier Extras. Benefit limit of $1,100 per person. Value Extras. Benefit limit of $900 per person.	More info
Restricted fund*	Premium Extras. Benefit limit of $2,000 per person. Healthy Living Extras. Benefit limit of $1,500 per person. Budget Extras. Shared benefit limit of $500 per person.	More info
Restricted fund*	Total Extras. Benefit limits vary depending on the service. You can find the amounts for each treatment below this table. Essential Extras. Shared benefit limit of $1600 per person.	More info
Restricted fund*	Rolling Extras. Benefit limit of $1,500 per person.	More info
Restricted fund*	Premium Extras Cover. Benefit limit of $1500 per person Smart Extras Cover. Benefit limit of $1200 per person	More info
Restricted fund*	RBHS allocates varying sub-limits to each service that falls under major dental. You can find the details on each one below this table. Premium Extras	More info
Restricted fund*	Top Extras. Initial benefit limit of $1,300 per person. Increases for each year you hold cover until it caps at $2,800 on year six. Essential Extras. Benefit limit of $300 per person.	More info
Restricted fund*	Comprehensive Extras. Overall benefit limit of $3,400 per person. Family Extras. Overall benefit limit of $2,000 per person. Everyday Extras. Overall benefit limit of $2,000 per person. Healthy Options Extras. Shared benefit limit of $1,000 per person. Mid Range Extras. Overall benefit limit of $1,000 per person.	More info

_{*Restricted funds only provide cover to members of specific industries, groups and organisations. In some cases family members may also be eligible to join.}

• Breakdown of providers who apply different sub-limits to each major dental service

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  Health Fund	Annual sub-limits for specific major dental services in each policy
  	Top Extras 75% Dentures have a benefit limit of $800 per person. Crowns/bridgework have a benefit limit of $800 per person. Indirect restorations have a benefit limit of $400 per person and $800 per family. Implants have a benefit limit of $800 per person. Top Extras Set Benefits Dentures have a benefit limit of $800 per person. Crowns/bridgework have a benefit limit of $800 per person. Indirect restorations have a benefit limit of $400 per person and $800 per family. Implants have a benefit limit of $800 per person.
  	Premier Extras Crowns/bridgework have a benefit limit of $1,000 per person. Periodontics have a benefit limit of $700 per person. Implants have a benefit limit of $1,000 per person. Dentures have a benefit limit of $1,200 per person. Active Life Includes all services listed above with each having a shared* benefit limit of $500 per person.
  	Gold Hospital - $250 Excess & Comprehensive Extra Crowns/bridges have a benefit limit of $1,000 per person/family with a loyalty limit of $1,500. Dentures have a benefit limit of $650 per person/family with a loyalty limit of $800. Implants have a benefit limit of $1,000 per person/family.
  	Top Extras Periodontics have a benefit limit of $630 per person per calendar year. Endodontics have a benefit limit of $660 per person per calendar year. Inlays/onlays/facings/veneers have a benefit limit of $1,440 per person for every five years. Dentures/implants have a benefit limit of $1,350 per person for every five years. Occlusal therapy has a lifetime benefit limit of $920 per person. Intermediate Extras Periodontics have a benefit limit of $400 per person per calendar year. Endodontics have a benefit limit of $400 per person per calendar year. Crowns/bridges have a benefit limit of $700 per person for every five years.
  	Total Extras Major dental restorations have a benefit limit of $1,000 per person. Endodontics/periodontics have a benefit limit of $1,000 per person. Crowns/bridges have a benefit limit of $1,200 per person. Dentures/prosthodontics have a benefit limit of $1,000 per person.
  	Premium Extras Major dental surgery has a benefit limit of $6,500 in any five years. Crowns/bridges have a benefit limit of $6,000 in any five years. Dentures have a benefit limit of $2,500 in any five years. Endodontics have a benefit limit of $1,700 in any two years.

• Benefit limit terms explained

  • Sub-limit. A sub-limit is the largest possible amount you can claim for a specific service, which is then deducted from a larger overall benefit limit. For example, your dental cover might include an overall benefit limit of $900 with sub-limits of $300 being applied to bridgework, endodontics and dentures. In this case, the maximum you could claim for any one of those services is $300.
  • Shared or combined benefit limit. This means that the benefit limit is shared amongst multiple services, rather than applying a limit to each one individually. While you are not restricted to claiming a capped amount like you are with sub-limits, your total overall benefit amount is spread over a wider range of treatments, so be sure not to claim excessively on one service and leave yourself without cover for others.
  • Lifetime benefit limit. This is the maximum amount you can claim for a service throughout your lifetime. Be aware that if you've reached your lifetime benefit limit with one insurer and switch to a new one, they may deduct that amount from your new policy. It is recommended that you check with your new provider to find out if these penalties apply.

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