Legal

EXPENSES NOT COVERED: No benefits will be paid for expenses incurred:

In all states

• for services related to, performed in conjunction with, or resulting from a non-covered procedure.
• for charges in excess of the Contracted Fee Schedule or the Usual, Customary and Reasonable rate, whichever applies.
• for any treatment program which begins prior to the date the Insured is covered under the Policy.
• for crowns, inlays and onlays on teeth that can be restored by direct placement materials.
• for the replacement of crowns, bridges, inlays, onlays or prosthetic appliances within 5 years from the date of last placement.
• for any condition covered under any Workers’ Compensation Act or similar law.
• for services applied without cost by any municipality, county or other political subdivision or for which there would be no charge in the absence of insurance.
• for services that are applied toward the satisfaction of a Deductible, if any.
• for services subject to a Benefit Waiting Period.
• for charges resulting from changing from one provider to another while receiving treatment, or from receiving treatment from more than one provider for one dental procedure to the extent that the total charges billed exceed the amount incurred if one provider had performed all services.
• for Hospital facility charges for any dental procedure, including but not limited to: emergency room charges, surgical facility charges, Hospital confinement.
• for drugs or the dispensing of drugs.
• for oral hygiene instruction; plaque control; acid etch; prescription or take-home fluoride; broken appointments; completion of a claim form; OSHA/sterilization fees (Occupational Safety & Health Agency); or diagnostic photographs (except for orthodontic purposes).
• for implants (unless included in covered services); myofunctional therapy; athletic mouthguards; precision or semi-precision attachments; treatment of fractures, cysts, tumors, or lesions; maxillofacial prosthesis; orthognathic surgery; TMJ dysfunction; cleft palate; or anodontia.
• for orthodontia, unless included within the Benefit Schedule.
• for services to replace teeth that are missing (extracted or congenitally) prior to the Effective Date of the Policy. This limitation ends after 36 months of continuous coverage on the Policy. Abutment teeth will be reviewed for eligibility of prosthetic benefits.
• for composite, resin, or white fillings on posterior primary teeth. Benefits will be reduced to that of an amalgam or silver filling.
• for the replacement of a filling within 24 months of placement, unless for specific health reasons.
• for the replacement of retainers.
• for lab fees for higher metals or porcelain crowns, bridges, inlays, or onlays.
• during travel or activity outside the United States.

In Texas and Utah only

• for services and supplies not listed in the Benefit Schedule, not recognized as essential for the treatment of the condition according to accepted standards of practice or considered experimental, subject to the Right To Appeal provision contained in your Policy.
• for cosmetic procedures, including but not limited to veneers and bleaching of teeth and procedures performed primarily for cosmetic reasons, subject to the Right To Appeal provision contained in your Policy.
• for sealants not applied to permanent bicuspids or molars, applied at age 18 or older, applied 3 years from a previous sealant application, applied to a decayed tooth.

In all states, except Texas and Utah

• for services and supplies not listed in the Benefit Schedule, not recognized as essential for the treatment of the condition according to accepted standards of practice or considered experimental.
• for cosmetic procedures, including but not limited to veneers and bleaching of teeth and procedures performed primarily for cosmetic reasons.
• for sealants not applied to permanent bicuspids or molars, applied later than the end of the month in which a child reaches age 19, applied 3 years from a previous sealant application, applied to a decayed tooth.
  This insurance does not apply to the extent that trade or economic sanctions or other laws or regulations prohibit Us from providing insurance, including, but not limited to, the payment of claims.

This insurance does not apply to the extent that trade or economic sanctions or other laws or regulations prohibit Us from providing insurance, including, but not limited to, the payment of claims.