1980 002 Ordinance - Laserfiche WebLink

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EXCLUSIONS AND LIMITATIONS (For ®ental Expense Insurance Option) Dental Expense Insurance under the plan does not cover- Occupational Injury or Disease-Charges in connection with injury or disease covered by any workers' compensation, occupational disease or similar law. Government Plan-Charges for a service or supply (a) furnished by or for any government, unless the government is other than the U.S. government and payment is legally required, or (b) to the extent any benefit is provided by any law or governmental program under which the person is or could be covered. Non-essentials-Services not reasonably necessary or customarily performed for the dental care of a covered individual; services not performed by a dentist, or licensed dental hygienist under the supervision of a dentist (except for an X-ray ordered by a dentist). Pre-existing Treatment-An appliance for which an impression was made, a crown, bridge or gold restoration for which a tooth was prepared, or root canal therapy for which the pulp chamber was opened prior to a person becoming covered under the plan. Certain Denture or Fixed Bridge Work-Charges for (a) a crown, gold restoration, or a denture or fixed bridge or addition of teeth to one, if the work involves a replacement or modification of a crown, gold restoration, denture or bridge installed less than five years before, or (b) a denture or fixed bridge involving replacement of teeth extracted before the individual was covered, unless it also replaces a tooth that is extracted while covered, and such tooth was not an abutment for a denture or fixed bridge installed during the preceding five years. Cosmetic Services-Unless necessitated as a result of accidental injuries while the person was a covered individual. Orthodontic Services-Including replacement of lost or stolen appliances, or appliances or restorations necessary to increase vertical dimension or restore occlusion or for the purpose of splinting. Excess Charge-The portion of any charge for any service in excess of the reasonable and customary dental charge. The reasonable and customary charge is the usual charge made by the provider for a like service in the absence of the insurance, but not more than the prevailing charges, as determined by Prudential, for the dental care of a comparable nature, made by providers of similar training and experience, within the area in which the service is actually provided. Coordination of Benefits with GSP Major Medical Plans-Eligible charges payable under any Major Medical Benefits of this plan. Coordination of Benefits with Other Plans-Dental Expense Insurance contains a provision coordinating it with coverage the person has under other plans. 12