Half of complex dental care claims being denied: Health Canada

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Nearly half of requests for complex dental treatment coverage under the Canadian Dental Care Plan are being denied, according to Health Canada.

In an exclusive interview with Canadian Affairs, Lindy Vanamburg, director general of the Oral Health Branch at Health Canada, said 49 per cent of claims for complex dental care were denied between Nov. 1 and June 20, 2025.

Dental associations across Canada have been raising concerns about the high rejection rate, as well as challenges both dentists and patients face to participate in the plan, Canadian Affairs recently reported. 

“Patients are coming to see us because they require care, and … this erodes trust and predictability of the program if much treatment isn’t being approved,” said Dr. Anita Gartner, president of the British Columbia Dental Association.

‘Not black and white’

In 2023, Ottawa announced the Canadian Dental Care Plan to cover dental costs for an estimated nine million Canadians. Canadians without dental insurance who have an annual family net income under $90,000 are eligible to participate.

Ottawa launched the plan to different age groups in stages, beginning in May 2024. Starting June 1 of this year, eligible Canadians of all ages could begin receiving coverage. 

Under the plan, complex dental work — such as root canals, dentures and crowns — needs to be pre-authorized by the insurer Sun Life. About half of these requests are being denied due to ineligibility.

Vanamburg says the 49 per cent denial rate is “not as black and white as it might seem, in terms of a ‘no being a no’.” 

‘If there’s new information [and] something changes in the patient’s mouth … you know, you don’t qualify for that partial denture because you’re only missing one tooth … and it’s not a tooth that would stop you from chewing or functioning. If that changes and the patient loses, they can resubmit again,” she said. 

“So it’s never like a hard, hard no.”

Many claims for complex care are also sent back to dentists with requests for more documentation.

“There are a lot of providers who were still learning the system, so we did get a lot of incomplete submissions,” said Vanamburg.

When accounting for claims that had incomplete documentation as well as those that were denied due to ineligibility, the total number of claims sent back to dentists is 68 per cent.  

This figure nearly matches a Canadian Dental Association survey in which dentists reported 70 per cent of complex dental care claims were denied or required more documentation.

“Only [an average of] 30 per cent of dentists report that their … pre-authorization treatment requests to Sun Life are actually being approved,” Gartner, of the British Columbia Dental Association, previously told Canadian Affairs in an interview. 

Vanamburg also noted complex dental care claims account for a small sliver of all treatments. Less complex dental treatment — such as cleanings and fillings — do not need to be pre-authorized by Sun Life.

“About one per cent of what we’re asked for is something that needs pre-authorization,” said Vanamburg.

“Most of what people really seem to need is stuff they can automatically get up to certain limits. So, you know, X rays, cleanings, exams and well, most things really.”

But Gartner says the rejections “puts us all in a bind.” 

“Patients are not receiving the care that they need,” she said.

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