DENTAL EXPENSE (FOR MEMBERS AND DEPENDENTS) (EXCLUDING PARENTS)
This benefit is equal to the actual charges made by a dentist for care and
treatment, but will not exceed the amount listed for each procedure in the
Summary of Benefits Schedule.
This benefit is administered through both closed and open panels of dentists.
Closed Panel: The Fund has contracted with a panel of dentists
practicing general dentistry as well as in the specialized fields of dentistry.
Dentists on this panel have agreed to accept the Fund's allowance for particular
dental services as payment in full with no balance billing to the patient. You
will, however, be responsible for services excluded from coverage or which
exceed the overall maximum benefit allowance for the patient for the plan year.
A listing of the panel members can be obtained, without charge, from the Fund
office.
Open Panel: Means any dentist of your choice. However, the Fund's
maximum allowance is that which is shown in the Summary of Benefits Schedule.
BENEFITS
The Fund has a complete "Dental Table of Allowances" - Please write
the Fund if you want to know the Schedule of Allowances for any procedure not
listed in the Summary of Benefits Schedule. You should contact the Fund office
before you start any non-emergency work to obtain the appropriate claim forms
and to insure that you are covered for benefits.
Orthodontic Care: Available only to your unmarried dependent children between
the ages of 10 and 18 inclusive. Full cases, requiring 24 or more months of
care, will be paid at the maximum benefit. Partial cases will be paid at a
lesser allowance. All cases must be rated by the Fund's orthodontic consultants.
The Fund maximum is shown in the Summary of Benefits Schedule. Orthodontic
benefits are a life time benefit and not included in calculating the patient’s
yearly dental maximum.
LIMITATIONS
EMERGENCY CARE: If you have a dental emergency, you may go directly to your
dentist for emergency treatment. However, the Fund will pay only for ELIGIBLE
COVERED EMERGENCY TREATMENT.
Be advised that the Fund is your secondary carrier when an automobile
accident claim arises. In other words, the Fund will only consider for payment
those charges not paid under your automobile insurance policy and in certain
cases only up to a certain limit. (See "Automobile Insurance" under
General Provisions and Definitions.)
Keep in mind that the Fund has the right of subrogation when you are involved
in any accident and where you recover any expenses which have been paid to you
under this Plan from a third party.
No dental expense benefits are provided for the following:
- Routine dental examinations performed more frequently than
once in any six (6) consecutive month period.
- Prophylaxis (cleaning of teeth) expenses in excess of the
amount shown in the Summary of Benefits Schedule more often than once during
any six (6) month period.
- Dental treatments and services in connection with dentures, bridgework,
and crowns will not be covered.
a. If the work in making the denture, bridge or crown started prior to the
effective date of coverage of the individual, or
b. If expenses are for more than one denture, either full or partial, or for
any bridge or crown within any five year period.
- Treatment by other than a licensed dentist, except charges
for dental prophylaxis (cleaning of teeth) under the direction of a licensed
dentist.
- Orthodontic and periodontal care falling outside of the age
and lifetime maximum limitations (See the Summary of Benefits Schedule for
details).
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