Eligibility and Effective Dates:

All completed membership applications received and processed on or before the 25th of any month will be effective on the first day of the following month. Membership applications received and processed after the 25th of any month will be effective 30 days from the 1st of the following month. Coverage for eligible dependents you acquire after your coverage will be effective on that date that your application for the additional dependent is approved except that coverage for adopted children, newborn children, foster children and children in your custody by a court order is effective for 31 days from the date of birth, date of adoption or placement. To continue coverage beyond 31 days for these children, you must provide notice of such children. For purposes of this benefit: an otherwise eligible dependent child must also reside in your home for more than 6 months a year and chiefly rely on you for support and maintenance to be covered; and eligible dependent includes a child past the age of 19 (25 if a full time student) who has a handicapped condition which renders the child incapable of self-sustaining employment and who is chiefly dependent on you or other care providers for lifetime care and supervision because of a handicapped condition that occurred before such age.

LIMITATIONS AND EXCLUSIONS:

COVERED DENTAL EXPENSES WILL NOT BE COVERED AND NO BENEFITS WILL BE PAYABLE:

1. For cosmetic dentistry or personalization or characterization of dentures.
2. To replace any prosthetic appliance, crown, inlay or only restoration, or fixed bridge within five years of the date of the last placement. But if a replacement is required because of an injury sustained while the covered person is covered by the policy, it will be a covered dental expense.
3. For initial placement of any prosthetic appliance or fixed bridge unless such placement is needed because of the extraction of one or more natural teeth while the covered person is covered under the policy. But the extraction of a third molar (wisdom tooth) does not qualify. Any such appliance of fixed bridge must include the replacement of the extracted tooth or teeth.
4. For any procedure begun before the covered person was covered under the policy, except as provided under the Takeover Benefits. 
5. For any procedure begun after the covered person’s coverage under the policy ends, except as provided by the Extension of Benefits. 
6. To replace lost, missing, stolen or duplicate appliances. 
7. For appliances, restorations, or procedures to:
   1. Alter vertical dimension;
   2. Restore or maintain occlusion; 
   3. Splint or replace tooth structure lost as a result of abrasion or attrition; or
   4. Treat disturbances of the temporomandibular or craniomandibular joint. 
   5. For any procedure which is not shown on the Description of Benefits.
   6. For education or training in, and supplies used for, dietary or nutritional counseling, personal oral hygiene or dental plaque control. 

10.  For the completion of claim forms or missed or broken appointment, for the review of a proposed treatment plan or case presentation by a dentist or any charges in connection with a covered person’s transfer to another dentist. 

11.  For sealants which are: 

1. Not applied to a permanent molar;
2. Applied after attaining the age of 17; or
3. Reapplied to a molar within 3 years from the date of a previous sealant application.

12.  For subgingival curettage or root planning (ADA code 4341) unless the presence of periodontaldisease is confirmed by both X-rays and pocket depth summaries of each tooth involved.

13.  Because of a dental condition or injury arising out of, or in the course of, work for wage or profit.

14.  To a covered person because of a dental condition or injury for which he is eligible for benefits under any Workers’ Compensation act or similar laws.

15.  For charges for which the covered person is not liable or which would not have been made had no insurance been in force.

16.  For services which are not recommended by a dentist or which are not dentally necessary. 

17.  Because of war or any act of war, declared or not. 

18.  For any services related to equilibration, bite registration or bite analysis. 

19.  For crowns for the purpose of periodontal splinting. 

20.  For charges for any:

1. implants;
2. precision or semi-precision attachment; 
3. endodontic treatment associated with it; or 
4. other customized attachments.

21.  For any dental condition or injury that is intentionally self-inflicted. 

22.  For care performed by other than a dentist, except that when such service is performed on a dependent (who has been covered under the policy from birth) because of congenital disease or anomaly which has resulted in a functional defect as determined by the attending doctor or dentist.

23.  For prescribed drugs, medications or for prescription or take-home fluoride.

24.  For oral surgery to correct congenital or developmental malformation, except when such service is performed on a dependent (who has been covered under the policy from birth) because of congenital disease or anomaly which has resulted in a functional defect as determined by the attending doctor or dentist.

25.  For devices such as, but not limited to, night guards, mouthguards, TMJ splints, and inhibiting appliances for thumbsucking or devices and supplies of the type normally intended for sport or home use.

26.  For any amount in excess of that amount that would have been paid if one dentist rendered the service in the following situations:

1. If a covered person transfers from one dentist to another during the course of treatment; or
2. If more than one dentist renders services for one dental procedure.

27.  For replacement of serviceable dental work for any reason except as may be determined by the American Dental Association.

28.  For any procedure or service a covered person requests to treat, modify, correct or change an existing dental condition which at the time the initial procedure was performed was then considered acceptable according to the standards of medicine or dentistry.

29.  For orthodontic care, unless Class IV Procedures are provided under Description of Benefits /optional Rider is in force.

ALTERNATIVE TREATMENT:

The carrier will only pay covered dental expenses for the less expensive treatment when a less expensive alternate procedure, service or course of treatment:

1. Can be performed in place of the proposed treatment to correct a dental condition, as determined by

us; and

2. Will produce a professionally satisfactory result.