Limitations and Exclusions (What is Not Covered)

Transcription

1 Clrad Dental Family + Pediatric Plan Exclusins and Limitatins Limitatins and Exclusins (What is Nt Cvered) Excluded Services: Age 19 and lder Cvered Expenses d nt include expenses incurred fr: prcedures and services which are nt included in the list f Cvered Dental Expenses. prcedures which are nt necessary and which d nt have unifrm prfessinal endrsement. prcedures fr which a charge wuld nt have been made in the absence f cverage r fr which the cvered persn is nt legally required t pay. any prcedure, service, supply r appliance, the sle r primary purpse f which relates t the change r maintenance f vertical dimensin. prcedures, appliances r restratins whse main purpse is t diagnse r treat jaw jint prblems, including dysfunctin f the temprmandibular jint and cranimandibular disrders r ther cnditins f the jints linking the jawbne and skull, including the cmplex muscles, nerves and ther tissues related t that jint. the alteratin r restratin f cclusin. the restratin f teeth which have been damaged by ersin, attritin r abrasin. bite registratin r bite analysis. any prcedure, service, r supply prvided primarily fr csmetic purpses. Facings, repairs t facings r replacement f facings n crwns r bridge units n mlar teeth shall always be cnsidered csmetic. the initial placement f a full denture r partial denture unless it includes the replacement f a functining natural tth extracted while the persn is cvered under this plan (the remval f nly a permanent third mlar will nt qualify a full r partial denture fr benefit. the initial placement f a fixed bridge, unless it includes the replacement f a functining natural tth extracted while the persn is cvered under this plan. If a bridge replaces teeth that were missing prir t the date the persn's cverage became effective and als teeth that are extracted after the persn's effective date, benefits are payable nly fr the pntics replacing thse teeth which are extracted while the persn was insured under this plan. The remval f nly a permanent third mlar will nt qualify a fixed bridge fr benefit under this prvisin. the initial placement f an implant. the surgical placement f an implant bdy r framewrk f any type; surgical prcedures in anticipatin f implant placement; any device, index r surgical template guide used fr implant surgery; treatment r repair f an existing implant; prefabricated r custm implant abutments; remval f an existing implant. crwns, inlays, cast restratins, r ther labratry prepared restratins n teeth unless the tth cannt be restred with an amalgam r cmpsite resin filling due t majr decay r fracture. cre build-ups. replacement f a partial denture, full denture, r fixed bridge r the additin f teeth t a partial denture unless: (a) replacement ccurs at least 84 cnsecutive mnths after the initial date f insertin f the current full r partial denture; r (b) the partial denture is less than 84 cnsecutive mnths ld, and the replacement is needed due t a necessary extractin f an additinal functining natural tth while the persn is cvered

2 under this plan (alternate benefits f adding a tth t an existing appliance may be applied); r (c) replacement ccurs at least 84 cnsecutive mnths after the initial date f insertin f an existing fixed bridge (if the prir bridge is less than 84 cnsecutive mnths ld, and replacement is needed due t an additinal Necessary extractin f a functining natural tth while the persn is cvered under this plan. Benefits will be cnsidered nly fr the pntic replacing the additinally extracted tth). The remval f nly a permanent third mlar will nt qualify an initial r replacement partial denture, full denture r fixed bridge fr benefits. the replacement f crwns, cast restratin, inlay, nlay r ther labratry prepared restratins within 84 cnsecutive mnths f the date f insertin. The replacement f a bridge, crwn, cast restratin, inlay, nlay r ther labratry prepared restratin regardless f age unless necessitated by majr decay r fracture f the underlying Natural Tth. any replacement f a bridge, crwn r denture which is r can be made useable accrding t cmmn dental standards; replacement f a partial denture r full denture which can be made serviceable r is replaceable. replacement f lst r stlen appliances. replacement f teeth beynd the nrmal cmplement f 32. prescriptin drugs. any prcedure, service, supply r appliance used primarily fr the purpse f splinting. athletic muth guards. myfunctinal therapy. precisin r semiprecisin attachments. denture duplicatin. separate charges fr acid etch. labial veneers (laminate). prcelain r acrylic veneers f crwns r pntics n, r replacing the upper and lwer first, secnd and third mlars; treatment f jaw fractures and rthgnathic surgery. rthdntic treatment, except fr the treatment f cleft lip and cleft palate. charges fr sterilizatin f equipment, dispsal f medical waste r ther requirements mandated by OSHA r ther regulatry agencies and infectin cntrl. charges fr travel time; transprtatin csts; r prfessinal advice given n the phne. temprary, transitinal r interim dental services. any prcedure, service r supply nt reasnably expected t crrect the patient s dental cnditin fr a perid f at least 3 years, as determined by Cigna. diagnstic casts, diagnstic mdels, r study mdels. any charge fr any treatment perfrmed utside f the United States ther than fr Emergency Treatment (any benefits fr Emergency Treatment which is perfrmed utside f the United States will be limited t a maximum f $100 per cnsecutive 12-mnth perid); ral hygiene and diet instructin; brken appintments; cmpletin f claim frms; persnal supplies (e.g., water pick, tthbrush, flss hlder, etc.); duplicatin f x-rays and exams required by a third party; any charges, including ancillary charges, made by a hspital, ambulatry surgical center r similar facility;

3 services that are deemed t be medical services; services fr which benefits are nt payable accrding t the "General Limitatins" sub-sectin belw. General Limitatins: Age 19 and lder N payment will be made fr expenses incurred fr yu r any ne f yur Dependents: Fr services nt specifically listed as Cvered Services in this Plicy. Fr services r supplies that are nt Dentally Necessary. Fr services received befre the Effective Date f cverage. Fr services received after cverage under this Plicy ends. Fr services fr which Yu have n legal bligatin t pay r fr which n charge wuld be made if Yu did nt have dental insurance cverage. Fr Prfessinal services r supplies received r purchased directly r n Yur behalf by anyne, including a Dentist, frm any f the fllwing: Yurself r Yur emplyer; a persn wh lives in the Insured Persn's hme, r that persn s emplyer; a persn wh is related t the Insured Persn by bld, marriage r adptin, r that persn s emplyer. fr r in cnnectin with an Injury arising ut f, r in the curse f, any emplyment fr wage r prfit; fr r in cnnectin with a Sickness which is cvered under any wrkers' cmpensatin r similar law; fr charges made by a Hspital wned r perated by r which prvides care r perfrms services fr, the United States Gvernment, if such charges are directly related t a military-service-cnnected cnditin; services r supplies received as a result f dental disease, defect r injury due t an act f war, declared r undeclared; t the extent that payment is unlawful where the persn resides when the expenses are incurred; fr charges which the persn is nt legally required t pay; fr charges which wuld nt have been made if the persn had n insurance; t the extent that billed charges exceed the rate f reimbursement as described in the Schedule; fr charges fr unnecessary care, treatment r surgery; t the extent that yu r any f yur Dependents is in any way paid r entitled t payment fr thse expenses by r thrugh a public prgram, ther than Medicaid; fr r in cnnectin with experimental prcedures r treatment methds nt apprved by the American Dental Assciatin r the apprpriate dental specialty sciety; Prcedures that are a cvered expense under any ther dental plan which prvides dental benefits; T the extent that benefits are paid r payable fr thse expenses under the mandatry part f any aut insurance plicy written t cmply with a n-fault insurance law r an uninsured mtrist insurance law. Cigna will take int accunt any adjustment ptin chsen under such part by yu r any ne f yur Dependents.

4 Excluded Services: Up t Age 19 Cvered Expenses d nt include expenses incurred fr: prcedures and services which are nt included in the list f Cvered Dental Expenses. prcedures which are nt necessary and which d nt have unifrm prfessinal endrsement. prcedures fr which a charge wuld nt have been made in the absence f cverage r fr which the cvered persn is nt legally required t pay. any prcedure, service, r supply prvided primarily fr csmetic purpses. Facings, repairs t facings r replacement f facings n crwns r bridge units n mlar teeth shall always be cnsidered csmetic. the initial placement f an implant unless it includes the replacement f a functining natural tth extracted while the persn is cvered under this plan. The remval f nly a permanent third mlar will nt qualify an implant fr benefit under this prvisin. Except in cases where it is Dentally Necessary. the surgical placement f an implant bdy r framewrk f any type; surgical prcedures in anticipatin f implant placement; any device, index r surgical template guide used fr implant surgery; treatment r repair f an existing implant; prefabricated r custm implant abutments; remval f an existing implant. Except in cases where it is Dentally Necessary. replacement f lst r stlen appliances. replacement f teeth beynd the nrmal cmplement f 32. prescriptin drugs. any prcedure, service, supply r appliance used primarily fr the purpse f splinting. rthdntic treatment, except fr the treatment f cleft lip and cleft palate. charges fr sterilizatin f equipment, dispsal f medical waste r ther requirements mandated by OSHA r ther regulatry agencies and infectin cntrl. charges fr travel time; transprtatin csts; r prfessinal advice given n the phne. temprary, transitinal r interim dental services. any prcedure, service r supply nt reasnably expected t crrect the patient s dental cnditin fr a perid f at least 3 years, as determined by Cigna. any charge fr any treatment perfrmed utside f the United States ther than fr Emergency Treatment. ral hygiene and diet instructin; brken appintments; cmpletin f claim frms; persnal supplies (e.g., water pick, tthbrush, flss hlder, etc.); duplicatin f x-rays and exams required by a third party; any charges, including ancillary charges, made by a hspital, ambulatry surgical center r similar facility; services that are deemed t be medical services; services fr which benefits are nt payable accrding t the "General Limitatins" sub-sectin belw. General Limitatins: Up t Age 19 N payment will be made fr expenses incurred fr yu r any ne f yur Dependents: Fr services r supplies that are nt Dentally Necessary. Fr services received befre the Effective Date f cverage. Fr services received after cverage under this Plicy ends.

5 Fr services fr which Yu have n legal bligatin t pay r fr which n charge wuld be made if Yu did nt have dental insurance cverage. Fr Prfessinal services r supplies received r purchased directly r n Yur behalf by anyne, including a Dentist, frm any f the fllwing: Yurself r Yur emplyer; a persn wh lives in the Insured Persn's hme, r that persn s emplyer; a persn wh is related t the Insured Persn by bld, marriage r adptin, r that persn s emplyer. fr r in cnnectin with an Injury arising ut f, r in the curse f, any emplyment fr wage r prfit; fr r in cnnectin with a Sickness which is cvered under any wrkers' cmpensatin r similar law; fr charges made by a Hspital wned r perated by r which prvides care r perfrms services fr, the United States Gvernment, if such charges are directly related t a military-service-cnnected cnditin; services r supplies received as a result f dental disease, defect r injury due t an act f war, declared r undeclared; t the extent that payment is unlawful where the persn resides when the expenses are incurred; fr charges which the persn is nt legally required t pay; fr charges which wuld nt have been made if the persn had n insurance; t the extent that billed charges exceed the rate f reimbursement as described in the Schedule; fr charges fr unnecessary care, treatment r surgery; t the extent that yu r any f yur Dependents is in any way paid r entitled t payment fr thse expenses by r thrugh a public prgram, ther than Medicaid; fr r in cnnectin with experimental prcedures r treatment methds nt apprved by the American Dental Assciatin r the apprpriate dental specialty sciety. Prcedures that are a cvered expense under any ther dental plan which prvides dental benefits. T the extent that benefits are paid r payable fr thse expenses under the mandatry part f any aut insurance plicy written t cmply with a n-fault insurance law r an uninsured mtrist insurance law. Cigna will take int accunt any adjustment ptin chsen under such part by yu r any ne f yur Dependents.