Medical vs. Dental Insurance: What’s the Difference?

At VanSmileDesign, we have had 30 years of experience in working with dental insurance and have helped many patients navigate through the tricky landscape.

A question that sometimes come to mind is: "If this treatment is necessary, why won’t my insurance cover it?"

To answer that, it’s important to understand that dental insurance is fundamentally different from medical insurance—in how it’s designed, what it covers, and who determines the fee schedules and limits.

Medical Insurance - a protection plan

Medical insurance is intended to protect you from the high costs of unexpected or serious health issues—think surgeries, hospital stays, and emergency treatments.

Most medical plans offer:

• High or unlimited annual maximums

• Coverage for emergencies and chronic conditions

• A deductible and co-insurance model, with broader coverage once the deductible is met

Medical insurance acts as a safety net against large, unpredictable medical expenses.

Dental Insurance - a maintenance plan

Dental insurance is not designed as a safety net—it’s more of a maintenance plan, focused on prevention. It functions more like a coupon or discount program than traditional insurance.

Most dental plans include:

• Low annual maximums (typically $1,000–$2,000 per year)

• Partial coverage for preventive services like exams, cleanings, and X-rays

• Partial coverage for basic services like fillings or extractions

• Limited or no coverage for major treatments like crowns, implants, or orthodontics

Once your yearly maximum is met, you're responsible for 100% of any additional dental costs.

Coverage Decisions Are About Contracts—Not Clinical Necessity

One of the biggest misunderstandings about dental insurance is this:

If something isn’t covered, that must mean it’s not necessary.

Insurance companies don’t base their decisions on what’s clinically best for you. Instead, they follow the rules of your specific plan, which is a contract between the insurance company and your employer. That contract includes negotiated fee schedules that limit what the insurance will pay for certain procedures—and sometimes whether those procedures are covered at all.

This means:

• A crown may be denied because your plan only allows it every five years—even if your tooth needs one now.

• Periodontal (gum) treatment might not be covered until the disease is advanced—even though earlier care would be better for your health.

• Some procedures may be excluded entirely because your employer chose a lower-cost plan with fewer covered services.

So if a service isn’t covered, it’s not a reflection of whether you need it. It’s simply not included in the agreement between your employer and the insurance company.

Why Dental Insurance Hasn’t Kept Up

Dental insurance hasn’t significantly evolved since it was introduced in the 1950s. Back then, a $1,000 annual maximum covered most procedures. Today, that same maximum still exists on many plans—even though the cost of care has increased dramatically.

The result? Modern treatments and technologies may fall outside of what insurance plans will cover—leaving patients to pay out-of-pocket, even for necessary care.

What Can You Do?

Here’s how you can make the most of your dental benefits while still getting the care you need:

• Understand your plan. We’re happy to help you review your coverage.

• Don’t delay needed care. Postponing treatment often leads to more extensive (and expensive) problems later.

• Plan around your benefits. For more extensive treatment, we can help you phase care over time to work within your annual maximum.

• Explore payment options. We offer financing and in-house payment plans to make care more manageable.

  
  

Our Priority: Your Health, Not Just Your Insurance

At VanSmileDesign, we don’t let insurance companies dictate what’s best for your health. Our job is to follow a high standard of care and recommend the treatment that will preserve and protect your smile—not what fits within a fee schedule negotiated by a third party.

We’ll always take the time to walk you through your treatment options and work with you to make dental care manageable.

Call us today. We’re here to help you make confident, informed choices about your smile.

VanSmileDesign Dentistry of Vienna| Modern Dentistry. Personalized Care.