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Competitor Smile Dental
Exclusions
Index | Benefits | Exclusions & Limitations | Provider Network | Quote
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What services are not covered?
Treatment, services or supplies which:
A. Are not Medically Necessary;
B. Are not prescribed by a Dentist;
C. Are determined to be Experimental/ Investigational in nature by Us;
D. Are received without charge or legal obligation to pay;
E. Would not routinely be paid in the absence of insurance;
F. Are received from any Family Member;
G. Are not Covered Procedures.
- Self inflicted injuries.
- War or an act of war, whether or not declared.
- A Covered Person's commission of a felony or an assault on another person.
- Riot, nuclear accident, or a major disaster.
- Employment; whether caused by, related to, or as a condition of employment, including self employment. This exclusion applies even if Workers' Compensation or any Occupational Disease or similar law does not cover the charges.
- Treatment which began, before the Covered Person's Effective Date of coverage or after the Covered Person's termination of coverage.
- Congenital or development malformations existing on the Covered Person's effective date as shown on the Schedule of Benefits.
- Implants of any type, and all related procedures, removal of implants, precision or semi-precision attachments, denture duplication, overdentures and any associated surgery, or other customized services or attachments, unless the coverage is elected by the Insured Person and the required premium is paid.
- Periodontal splinting.
- Porcelain on crowns, or pontics posterior to the 2nd bicuspid.
- Replacement of partial or full dentures, fixed bridge work, crowns, gold restorations and jackets more often than once in any 5 year period.
- Relining of dentures more often than once in any 2 year period.
- Lost, stolen, or missing dentures or bridges or for duplicates.
- Fixed or removable bridgework involving replacement of a natural tooth or teeth which was lost prior to the Covered Person's Effective Date of coverage as shown on the Schedule of Benefits. Benefits may be payable for bridgework required for loss of teeth while covered under the Policy, if such bridgework is not an abutment for non-covered bridgework.
- Prescription Drugs and analgesia pre-medication.
- Telephone consultations, failure to keep a scheduled appointment, to complete claim forms or attending Dentist statements, and any other services or supplies which are not part of the direct treatment of the Covered Person.
- Dental education or training programs including oral hygiene or plaque control programs.
- Counseling on diet and nutrition.
- Military service, including service in a military reserve unit.
- Prosthodontics, unless this coverage is elected by the Insured Person and the required premium is paid.
- Charges payable under any medical insurance.
- Charges made by any government entity unless the Covered Person is required to pay; or by any public entity from which coverage could have been obtained by application or enrollment even if application or enrollment was not actually made.
- Use of materials, other than fluorides or sealants, to prevent tooth decay.
- Bite registrations.
- Bacteriologic cultures in connection with a covered dental service.
- Therapeutic injections administered by a Dentist.
- Cast restorations, inlays, onlays and crowns for teeth that are not broken down by extensive decay or accidental injury or for teeth that can be restored by other means (such as an amalgam or composite filling).
- Replacement of 3rd molars.
- Composites on teeth posterior to the 2nd bicuspid.
- Crowns, inlays and onlays used to restore teeth with micro fractures or fracture lines, undermined cusps, or existing large restorations without overt pathology.
- Temporomandibular joint syndrome.
- Cosmetic procedures
- Orthodontia
Brief Statement of Policy Provisions Relating to Premiums, Renewability, and Termination
The Policy is renewable at the option of the Association or the Insurer. The Insurer reserves the right (subject to state specific requirements) to change the premiums upon 31 days prior to written notice.
Coverage may be terminated by the Policyholder or the Insurance Company upon 31 days written notice to the other party, and for other reasons stated in the group policy, such as: failure by the Policyholder to pay the required premium; if you are no longer eligible for this insurance; or you are no longer in an eligible class.
Definitions?
The terms listed below, when used in relation to the Coverage, will have the following meanings:
Calendar Year: The period of time beginning January 1st and ending on December 31st of the same year. The first Calendar Year of the Certificate will begin on the date Your coverage becomes effective and end on the first December 31st after a Covered Person’s Effective Date of coverage.
Calendar Year Maximum Amount: The maximum amount of benefits payable under the Certificate in a Calendar Year. The Calendar Year Maximum is shown on the Schedule of Benefits page. Prosthodontics and orthodontia, if covered, have a separate Calendar Year Maximum Amount.
Certificateholder: The Insured Person under the Policy.
Child:
- An Insured Person’s natural child;
- An Insured Person’s lawfully adopted child;
- A child placed for adoption with an Insured Person;
- An Insured Person’s stepchild;
- An Insured Person’s foster child;
- A child for whom the Insured Person has been appointed legal guardian by a court of competent jurisdiction and who resides with and who is dependent upon the Insured Person in a regular parent-child relationship; or
- A Child of the Insured Person for whom the Insured Person is obligated to provide medical child support pursuant to a Qualified Medical Support Order, provided that the requirement for qualifications of the order as outlined in the Policy are met.
Co-Insurance: The percentage paid by the plan after the Deductible is met up to the Calendar Year Maximum Amount. The Co-Insurance percentage is shown in the Schedule of Benefits.
Company: Standard Security Life Insurance Company of New York. Also hereinafter referred to as We, Us and Our.
Copay/Copayment: The fixed dollar amount specified in the Schedule of Benefits that is payable by a Covered Person to a provider at the time of service in connection with specific Covered Charges.
Covered Charge: The Reasonable and Customary Charge for a Medically Necessary Covered Procedure which is performed by a Dentist or a Dental Hygienist acting under the supervision and direction of a Dentist.
Covered Person: A person who has satisfied all of the following requirements:
- he or she is eligible for coverage under the Policy, either as an Insured or as a Dependent;
- he or she has been accepted for coverage under the Policy or has been automatically added;
- premium has been paid for him or her; and
- his or her coverage has become effective and has not terminated.
Covered Persons are shown on the Identification Card.
Covered Procedure: The procedures listed in the Schedule of Covered Procedures. The procedure must be: (1) for Medically Necessary dental treatment to a Covered Person while his or her
coverage under the Policy is in force and (2) for treatment, which in Our opinion, has a reasonably favorable prognosis for the patient. The procedure must be performed by a:
- licensed Dentist who is acting within the scope of his or her license;
- licensed Physician performing dental services within the scope of his or her license; or
- licensed Dental Hygienist acting under the supervision and direction of a Dentist.
Deductible: The dollar amount for Covered Procedures that a Covered Person must pay in a Calendar Year before benefits are payable under this Certificate. The Deductible is shown on the Schedule of Benefits. Each Covered Person must satisfy the Deductible before benefits are payable. After three Covered Person's have each satisfied the Deductible, no additional Deductible will be required for other Family Members who are Covered Persons for the remainder of the Calendar Year.
Dentist: A person who is a legally licensed doctor of dental surgery, dental medicine or dental science in the state where services are rendered and is acting within the scope of that license.
Dental Hygienist: A person who is licensed to practice dental hygiene in the state where services are rendered and is acting under the supervision and direction of a Dentist and within the scope of that license.
Dependent: An Insured Person's: 1. Lawful spouse; 2. Unmarried Child who is primarily dependent upon the Insured Person for support and maintenance and is: A. Less than 19 years of age; or B. Between 19 and 23 years of age; provided however, that the Child is dependent upon the Covered Person for support and maintenance and a full-time student actively attending an accredited college, vocational or high school. Full-time, as used in this definition, means actively attending at least 12 hours of class a week or, if less, attending the minimum hours of class the school considers as full-time status;
Dependent does not include anyone who:
- lives outside the United States;
- is in the armed forces of any country; or
- has coverage under the Policy as a Certificateholder or Dependent of another person.
Domestic Same-Sex Partners: Two same sex adults who are in a committed relationship and mutually responsible for one another financially and otherwise. To qualify as a Domestic Same Sex Partner, or Dependent under the Certificate, the following conditions must all be met:
- You and the Domestic Partner are over the age of 18 and mentally competent to enter into contracts;
- You and the Domestic Partner reside in the same household together;
- You and the Domestic Partner have a committed relationship with each other for no less than 6 months; intend to continue the relationship indefinitely and have no such relationship with any other person;
- You and the Domestic Partner are not related by blood;
- You and the Domestic Partner are not married to any third party;
- You and the Domestic Partner are of the same sex;
- You and the Domestic Partner are not claiming Dependent status for the primary reason of gaining insurance coverage under this Certificate.
Emergency: A dental condition characterized by the sudden onset of acute symptoms of sufficient severity that the absence of immediate dental attention could reasonably result in: • permanently placing the Covered Person’s
health in jeopardy: • causing other serious dental or health consequences; or • causing serious impairment of dental function.
We will make the final determination as to whether or not a condition is an Emergency.
Experimental/Investigational: A drug, device or medical or dental care or treatment will be considered experimental/investigational if:
- The drug or device cannot be lawfully marketed without approval of the U.S. Food and Drug Administration and approval for marketing has not been given at the time the drug or device is furnished;
- The informed consent document utilized with the drug, device, medical or dental care or treatment states or indicates that the drug, device, medical or dental care or treatment is part of a clinical trial, experimental phase or investigational phase or if such a consent document is required by law;
- The drug, device, dental care or treatment or the patient informed consent document utilized with the drug, device or medical or dental care or treatment was reviewed and approved by the treating facility’s Institutional Review Board or other body serving a similar function, or if federal or state law requires such review and approval; Reliable Evidence shows that the drug, device or medical or dental care or treatment is the subject of ongoing Phase I or Phase II clinical trials, is the research, experimental study or investigational arm of on-going Phase III clinical
- trials, or is otherwise under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy or its efficacy as compared with a standard means of treatment of diagnosis; or
- Reliable Evidence shows that the prevailing opinion among experts regarding the drug, device or medical or dental care or treatment is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, its efficacy or its efficacy as compared with a standard means of treatment of diagnosis.
Reliable Evidence means only: published reports and articles in authoritative medical and scientific literature; written protocol or protocols by the treating facility studying substantially the same drug, device or medical or dental care or treatment; or the written informed consent used by the treating facility or other facility studying substantially the same drug, device or medical or dental care or treatment. Covered Procedures will be considered in accordance with the drug, device or medical or dental care at the time the expense is incurred.
Family Member: A person who is related to a Covered Person in any of the following ways: spouse, brother-in-law, sister-in-law, son-in-law, daughter-in-law, mother-in-law, father-in-law, parent (includes stepparent), brother or sister (includes stepbrother and stepsister), or Child.
In-Network Provider: A Dentist who is under contract with Us or Our subcontracted vendor.
Insured/Insured Person/Member: The individual named on the Schedule of Benefits as the Insured who has: (a) submitted an application for coverage on himself or herself, his or her Dependents, or both; (b) meets the eligibility and effective date provisions set forth in the Certificate evidencing coverage under the Policy; (c) is approved for coverage by Us; and (d) for whom all applicable premiums are paid, and therefore has coverage under the Policy.
Medically Necessary: A treatment, drug, device, procedure, supply or service that is necessary and appropriate for the diagnosis or treatment of a Covered Person’s condition in accordance with
generally accepted standards of dental practice in the United States at the time it is provided.
A treatment, drug, device, procedure, supply or service shall not be considered as Medically Necessary if it:
- is Experimental/Investigational;
- is provided solely for education purposes or the convenience of the Covered Person, a Family Member, Dentist, Hospital or any other provider;
- exceeds in scope, duration, or intensity the level of care that is needed to provide safe, adequate and appropriate diagnosis or treatment.
- is for maintenance or preventive care;
- could have been omitted without adversely affecting the person’s condition or the quality of dental care; or
- can be safely provided to the patient on a more cost effective basis or pursuant to a more conservative form of treatment.
The fact that a Dentist may prescribe, order, recommend, or approve a service, supply or level of care does not, of itself, make the treatment Medically Necessary or make the charge a Covered Charge
under the Policy. We reserve the right to determine whether a service, supply or drug is Medically Necessary.
Out-of-Network Provider: A Dentist, located within the PPO Service Area, who is not under contract with Us or Our subcontracted vendor.
Policy: The contract providing the benefits described herein issued to the Policyholder.
Policyholder: Means the Group, in whose name the Policy is issued, as shown on the Schedule of Benefits. PPO Service Area: The geographical area in which We have arranged to provide PPO
services to Covered Persons.
Preferred Provider Organization (PPO): A designated entity within the PPO Service Area under contract with Us or Our subcontracted vendors to provider certain services at a reduced reimbursement
rate within a PPO Service Area. We or Our subcontracted vendors will contract with In-Network Providers to provide services covered by the Policy.
Prescription Drugs: Drugs which may only be dispensed by written prescription under Federal law, and approved for general use by the Food and Drug Administration.
Reasonable and Customary Charge: The most common charge for similar professional services, drugs, procedures, devices, supplies or treatment within the Geographic Area in which the charge is incurred.
The most common charge means the lesser of:
the actual amount charged by the provider;
- the negotiated rate;
- the usual charge which would have been made by a provider (Dentist, Hospital, etc) for the same or a comparable professional services, drugs, procedures, devices, supplies or treatment within the same
Geographic Area, as determined by Us.
“Geographic Area” means the three digit zip code in which the service, treatment, procedure, drugs or supplies are provided; or a greater area if necessary to obtain a representative cross-section of charge for a like treatment, service, procedure, device drug or supply.
We, Our, Us, The Company: Standard Security Life Insurance Company of New York. You, Your: The person named on the Schedule of Benefits as the Insured Person.
Who is the Administrator?
Health Plan Administrators, Inc. (HPA) is a fully licensed, full service Third Party Administrator servicing business worldwide. HPA provides state of the art industry leading insurance services.
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