Percentage Payable
The percentage payable is the maximum percentage of your costs that the plan will reimburse you, for you and your dependents’ Covered Expenses, after any deductible is satisfied.
Deductible
The deductible is the amount of Covered Expenses which you must pay each calendar year before benefits are payable under this plan.
Calendar Year Maximum
The Calendar Year Maximum is the maximum amount the plan will allow any one individual for Dental benefits in a single calendar year.
Lifetime Maximum
The Lifetime Maximum is the maximum amount allowed for any one individual for Dental benefits in their lifetime.
Free Choice of Dentist
You may choose any licensed dentist or licensed denturist practicing within the scope of his or her profession.
What the Insurance Covers
The dental benefits described in this section apply to both the member and their eligible dependents. The insurance covers work included in a comprehensive list of dental expenses, which appears later. Many dental conditions can properly be treated in more than one way. This Plan is designed to help pay your dental expenses but not on the basis of treatment that is more expensive than necessary for good dental care. Thus, if a condition is being treated for which two or more services included in the list are suitable under customary dental practices, the benefit under the Plan will be based on the least expensive of the services.
The final choice of treatment is always between the patient and the dentist. You are financially responsible to your dentist for the cost of dental work performed. This plan will reimburse you to the limits described herein.
If a dental service is performed that isn't in the list, but the list contains one or more other services that under customary dental practices are suitable for the condition being treated, then for the purpose of the Plan, the least expensive of the suitable services listed will be considered to have been performed. See "Charges Not Eligible for Dental Insurance" later in this section of the website for additional exclusions.
Pre-Determination of Benefits
Pre-determination of benefits permits the review of the proposed treatment in advance and allows for a solution of any questions before, rather than after, the work has been done. Additionally, both you and the dentist will know in advance what the Plan will allow assuming you, or the dependent, remain covered.
A “Treatment Plan” is strongly recommended when dental work is expected to exceed $500.
A "Treatment Plan" is the dentist's report that (a) itemizes the dentist's recommended services, (b) shows the dentist's charge for each service, and (c) is accompanied by supporting X-rays, or a letter of expertise.
The "Treatment Plan" will be returned to the dentist showing the estimated benefits
Termination of Benefits
No benefits for Covered Dental Expenses will be paid for expenses incurred after the policy terminates, or after the individual’s coverage terminates.
The following exceptions apply only if the treatments specified are covered under this policy and there is no replacement dental insurance coverage after such termination:
- Where an impression for a denture, bridge or crown was taken or root canal therapy was started prior to the termination of insurance, dental expense in connection with these procedures and incurred within 30 days of termination will be considered as incurred prior to termination.
- Where Orthodontic Treatment has commenced and a treatment plan has been submitted in advance to the Insurer, dental expenses in connection with such treatment and incurred within 30 days of termination will be considered as incurred prior to termination.