While reviewing a self-insured dental plan for compliance with ERISA et al, I came across an exclusion for "charges for accident repair while in the hospital." "Accident repair" is not defined.

I imagine it would exclude dental work if, for example, a participant had a few teeth knocked out by a steering wheel in a car wreck and was treated in a hospital. The plan sponsor was not sure why the exclusion was put into the plan, or what it excludes. The plan already excludes work not performed by a "Dentist," and I see no reason to exclude dental work just because it was caused by an accident and done in a hospital.

I haven't reviewed many dental plans and haven't seen this exclusion before. Does anyone have any thoughts on why such a provision would be in a dental plan, what it would be designed to exclude, and whether it would be enforceable?

These types of exclusions are typically in dental plans because most health plans will cover accidental injury to sound natural teeth in the event of an accident.

Thanks, Kip.

Your reply was dead-on. Upon further review, their health plan covers injuries to teeth due to accidents.