Other Plan Information
The following plan information is designed to provide a very brief overview of some of the definitions, limitations and exclusions applicable to this policy. A complete listing can be found within the Certificate of Insurance, a copy of which may be provided upon request.
- Eligible expenses
- Means a covered service as defined by the policy. In order to be considered eligible, services must be performed by a licensed dentist (or licensed dental hygienist under supervision) or a licensed physician acting within the scope of his license.
- Expenses not covered
- No benefits will be paid for expenses incurred: in excess of those considered reasonable and customary; for cosmetic procedures;replacement of dentures, bridges, inlays/onlays, or crown unless deemed to be medically necessary; sealants; services while on full-time active duty in the armed forces; benefits eligible under any Workers' Compensation Act or similar law; or for services incurred prior to the date the insured is covered under the policy. This is not a complete list, a complete listing of expenses not covered can be found within the Certificate of Insurance.
- Calendar year maximum
- The maximum amount payable for all Eligible Dental Expenses in any calendar year as shown in the Coverage Schedule. The calendar Year Maximum will apply to each insured person.
- Pretreatment review
- If the Course of Treatment will exceed $300, We will request prior review. We must be given the Dentist's treatment plan consisting of a description of the planned treatment with estimated charges and diagnostic x-rays. We will determine Eligible Expenses and state how much We will pay for the treatment. Our determination may suggest an alternate, less expensive Course of Treatment if it will produce professionally satisfactory results. If You do not request a pretreatment review, We will pay for the least expensive method of treatment regardless of the method actually used.
- Coordination of benefits
- This Plan will be coordinated with any other group, blanket or franchise plan under which an individual will receive benefits. This helps keep the cost of the Plan reasonable.
- Termination of coverage
- Coverage terminates on the earliest of the following dates:
- The last day of the month in which You cease to be eligible for coverage;
- The last day of the month in which Your Dependent is no longer a dependent, as defined;
- Subject to the Grace Period, the last day of the month for which a premium has been paid by You or on Your behalf; or
- The date the Policy ends.
