Delta Dental Class Action Claims Company Misrepresents Out-of-Network Coverage—What Policyholders Need to Know
A class action lawsuit filed December 31, 2025, in the U.S. District Court for the Southern District of New York alleges Delta Dental misrepresents out-of-network dental coverage benefits to policyholders, leading to unexpected out-of-pocket costs when visiting non-network dentists. The lawsuit claims Delta Dental falsely represents it will cover 50% to 100% of out-of-network dental treatment costs when it actually covers far less by basing reimbursements on proprietary “usual and customary” rates significantly lower than what dentists charge.
Plaintiff Kevin Walsh, representing a proposed nationwide class, claims Delta Dental refuses to disclose its proprietary internal pricing to insureds even when requested, making it impossible for policyholders to determine what they’ll actually pay for out-of-network services. “Through this scheme, Delta Dental has profited tremendously at the expense of its insureds, who are left holding the bag for often exceptionally high dental bills,” the complaint states.
This Affects You If You’re a Delta Dental Policyholder Who Visited an Out-of-Network Dentist and Paid More Than Expected
If you’re a Delta Dental member who used an out-of-network dentist and received a bill far higher than what your policy coverage percentage suggested, understanding this lawsuit matters because you may have been misled about how your benefits work. The difference between what Delta Dental represents and what it actually pays can leave you with hundreds or even thousands in unexpected costs.
What the Delta Dental Class Action Lawsuit Alleges
Delta Dental’s Alleged Coverage Misrepresentation
The lawsuit claims Delta Dental represents in policy documents and communications that it covers a specific percentage of out-of-network dental care—commonly 50% to 100% depending on the service type. However, Delta Dental allegedly fails to clearly disclose that this percentage applies to its own proprietary “usual and customary” rates, not the dentist’s actual charges.
This creates a significant gap. Even if your policy states “80% coverage” for out-of-network care, you might receive far less reimbursement because Delta Dental’s internal usual and customary rate is often substantially lower than what your dentist actually charged.
The complaint alleges Delta Dental only covers a percentage of a proprietary internal price “almost always lower than what the provider charges the insured.” This leaves policyholders responsible for the difference between Delta Dental’s reimbursement and the actual bill—often an unexpectedly large amount.
Pro Tip: Before visiting an out-of-network dentist, call Delta Dental and ask for a “pre-authorization” showing exactly what they will pay based on their usual and customary rates. Get this in writing. The difference between what your dentist charges and what Delta Dental’s usual and customary rate allows can be hundreds or thousands of dollars—don’t find out after the procedure.
How Out-of-Network Coverage Actually Works Versus What Was Represented
Delta Dental typically offers PPO plans with both in-network and out-of-network benefits. In-network dentists have contracted rates with Delta Dental, so policyholders pay predictable copays or coinsurance percentages.
Out-of-network dentists don’t have contracts with Delta Dental and can charge their full fees. Delta Dental policies typically state they will reimburse a percentage—like 50%, 80%, or even 100%—of “usual and customary” charges for out-of-network care.
The key issue: “Usual and customary” rates are Delta Dental’s proprietary internal pricing, often significantly lower than what out-of-network dentists actually charge. This means even with “80% coverage,” a policyholder might only get 50-60% of their actual bill reimbursed.
Example: If an out-of-network dentist charges $1,000 for a procedure but Delta Dental’s “usual and customary” rate is $600, an “80% coverage” policy would reimburse $480 (80% of $600), leaving the policyholder to pay $520 out-of-pocket instead of the expected $200.
The lawsuit claims this calculation method and its impact on out-of-pocket costs was not properly disclosed to policyholders, who reasonably expected their coverage percentage to apply to actual charges, not hidden internal rates.
Delta Dental Allegedly Refuses to Disclose Internal Pricing
The complaint alleges Delta Dental refuses to disclose its proprietary usual and customary rates to insureds, making it impossible for members to determine actual out-of-pocket costs before receiving care. Walsh claims this practice is common among all Delta Dental entities across the United States, resulting in consumers paying considerably more than they should have.
Legal Claims Against Delta Dental
The lawsuit alleges breach of fiduciary duty and denial of benefits, violating the Employee Retirement Income Security Act (ERISA). ERISA governs employer-sponsored health and dental plans and requires plan administrators to act in participants’ best interests and provide accurate information about benefits.
The case is Walsh v. Delta Dental Plans Association, et al., Case No. 1:25-cv-10801, filed in the U.S. District Court for the Southern District of New York. Plaintiff representation includes Bursor & Fisher P.A.
Who Qualifies for the Delta Dental Class Action
Proposed Class Definition
Walsh seeks to represent a nationwide class of consumers insured under Delta Dental insurance plans who paid more for out-of-network dental care than they should have because of the company’s allegedly false and misleading representations.
The class likely includes Delta Dental policyholders who visited out-of-network dental providers, submitted claims for out-of-network services, paid out-of-pocket costs exceeding what they expected based on Delta Dental’s stated coverage percentages, and received reimbursements calculated on undisclosed usual and customary rates rather than actual charges.
Current Case Status
The lawsuit was filed December 31, 2025, making this a very recent development. The case is in early stages—the court has not yet certified the class action or approved any settlement. No claim forms are currently available, and no deadlines have been established.
Class members typically don’t need to take action during initial lawsuit stages. If the court certifies the class and reaches a settlement, affected policyholders would receive notice with instructions for filing claims.
What You Must Know About the Delta Dental Class Action
Common Misconceptions That Could Affect Your Rights
Misconception: I have to actively join the class action. Reality: If you’re a class member, you’re automatically included unless you opt out. You typically only need to file a claim form if there’s a settlement.
Misconception: The class action means I’ll get all my money back. Reality: Settlements typically provide partial reimbursement, and the amount depends on how much you paid out-of-pocket and how many people file claims.
Misconception: I can’t participate because I didn’t keep all my receipts. Reality: You may be able to provide other evidence like explanation of benefits statements, credit card records, or dental office billing records.
Misconception: Joining the class action means I can’t sue Delta Dental separately. Reality: True—class members typically give up the right to file individual lawsuits about the same claims.
What Delta Dental’s Alleged Practices Mean for Your Insurance Rights
Insurance companies have a legal duty under ERISA and state laws to clearly disclose coverage terms and limitations. Vague or misleading policy language can constitute breach of fiduciary duty or breach of contract.
You have the right to understand how your benefits are calculated before receiving care. “Usual and customary” rate methodologies must be reasonable and properly disclosed. If an insurer misrepresents coverage, you may have grounds to sue for the difference between what you paid and what you should have paid.
State insurance regulations require clear disclosure of benefit limitations. Consumer protection laws prohibit deceptive marketing or sales practices. You have the right to review your policy documents and explanation of benefits statements.
What to Watch Out For with Out-of-Network Coverage Going Forward
Always ask your dentist for a cost estimate before receiving care, especially for expensive procedures. Request a pre-authorization or pre-determination from Delta Dental showing exactly what they will pay based on their usual and customary rates.
Understand that “usual and customary” rates may be significantly lower than actual charges—ask Delta Dental to disclose their usual and customary rate for the specific procedure before proceeding.
Review your policy documents carefully to see how out-of-network benefits are calculated. Call Delta Dental customer service and ask specific questions about what percentage of the actual dentist charge you’ll receive, not just the coverage percentage.
Keep detailed records of all communications with Delta Dental about coverage. Save all explanation of benefits statements and receipts. Consider staying in-network to avoid surprise out-of-pocket costs.
What to Do Next
If You Believe You Were Affected
Gather documentation including your Delta Dental policy documents, explanation of benefits statements for out-of-network claims, receipts or billing statements from out-of-network dentists, and records of what you paid out-of-pocket. Document any communications with Delta Dental about coverage.
Monitor the case for updates. The lawsuit is in early stages, so no claim forms or deadlines currently exist. Check legal news websites or the court’s public docket (Case No. 1:25-cv-10801 in the Southern District of New York) for developments.
Consider filing a complaint with your state insurance department about Delta Dental’s coverage disclosure practices. State regulators investigate insurance companies for misleading representations and can take enforcement action.
Review your current Delta Dental policy and consider whether you want to continue coverage, especially if you frequently use out-of-network providers.
How to Participate If the Class Is Certified
If the court certifies the class action and approves a settlement, you’ll receive notice by mail or email with instructions. The notice will explain the class definition, settlement terms, claim filing procedures, deadlines for submitting claims, and your options to participate, opt out, or object.
To participate in a settlement, you would complete and submit a claim form by the deadline with required documentation. The settlement administrator would review claims and distribute payments according to the approved formula.
If you want to opt out and preserve your right to sue separately, you would follow the opt-out procedures and deadlines in the class notice. If you want to object to settlement terms, you would follow the objection procedures and consider attending the fairness hearing.
Keep copies of everything you submit. Note that you typically don’t need to hire your own attorney to participate as a class member—the class action lawyers represent all class members.
Protecting Your Rights with Dental Insurance
Understand the difference between in-network and out-of-network coverage before choosing a plan. Read policy documents carefully and ask questions about how out-of-network benefits are calculated—specifically, whether coverage percentages apply to actual charges or usual and customary rates.
Request written confirmation of coverage and reimbursement amounts before receiving expensive dental care. Keep detailed records of all insurance communications and claims.
File complaints with your state insurance department if you believe coverage was misrepresented. Know your state’s insurance laws and consumer protection rights. Consult an attorney if you have significant disputes with your dental insurer.
Frequently Asked Questions
What is the Delta Dental class action lawsuit about?
The lawsuit alleges Delta Dental misrepresents out-of-network coverage by claiming to cover specific percentages (50-100%) of dental care costs while actually basing reimbursements on much lower proprietary “usual and customary” rates. This leaves policyholders paying far more out-of-pocket than expected.
Who qualifies for the Delta Dental class action?
The proposed class includes all Delta Dental policyholders nationwide who paid more for out-of-network dental care than they should have due to the company’s allegedly misleading representations about coverage percentages and usual and customary rates.
When was the Delta Dental class action filed?
The lawsuit was filed December 31, 2025, in the U.S. District Court for the Southern District of New York (Case No. 1:25-cv-10801). The case is in very early stages with no settlement or claim deadlines yet.
How much money can I get from the Delta Dental settlement?
No settlement exists yet. If one is reached, compensation would likely reimburse policyholders for excess out-of-pocket costs paid due to misrepresentation. Settlement amounts typically depend on how much each class member paid and how many people file claims.
Do I need to do anything right now?
No. The lawsuit just filed and no claim forms or deadlines currently exist. If the case proceeds to settlement, you’ll receive notice with instructions. Monitor the case for updates if you believe you were affected.
What evidence do I need for a Delta Dental claim?
If a settlement is reached, you’ll likely need explanation of benefits statements showing Delta Dental’s reimbursements, dental bills showing actual charges, proof of out-of-pocket payments, and policy documents. Keep all dental insurance records now.
Can I sue Delta Dental separately if I’m in the class action?
If you remain a class member, you typically give up the right to file individual lawsuits about the same claims. You can opt out when you receive notice to preserve your right to sue separately, but you won’t receive any settlement benefits.
Last Updated: January 14, 2026 — We keep this current with the latest legal developments.
Important Disclaimer: This article provides informational content about the Delta Dental class action lawsuit alleging misrepresentation of out-of-network coverage. This is not legal advice. Class action participation is voluntary. For specific legal questions about your situation, consult a qualified attorney. AllAboutLawyer.com does not provide legal services or represent participants in this lawsuit.
Take Action: Monitor this lawsuit for updates. If you’re affected, file complaints with your state insurance department. Learn more about your rights at Progressive Class Action Lawsuits and Kaiser Class Action Settlement.
Stay informed, stay protected. — AllAboutLawyer.com
About the Author
Sarah Klein, JD, is a licensed attorney and legal content strategist with over 12 years of experience across civil, criminal, family, and regulatory law. At All About Lawyer, she covers a wide range of legal topics — from high-profile lawsuits and courtroom stories to state traffic laws and everyday legal questions — all with a focus on accuracy, clarity, and public understanding.
Her writing blends real legal insight with plain-English explanations, helping readers stay informed and legally aware.
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