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Madison Dental Plan
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EXCLUSIONS AND LIMITATIONS FROM COVERAGE
Benefits will not be paid for dental expenses arising from or in connection with:
1. 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.
2. Self inflicted injuries.
3. War or an act of war, whether or not declared.
4. A Covered Person's commission of a felony or an assault on another person.
5. Riot, nuclear accident, or a major disaster.
6. 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.
7. Treatment which began, before the Covered Person's Effective Date of coverage or after the Covered Person's termination of coverage.
8. Congenital or development malformations existing on the Covered Person's effective date as shown on the Schedule of Benefits.
9. Cosmetic procedures, unless the coverage is elected by the Insured Person and the required premium is paid.
10. 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.
11. Periodontal splinting.
12. Porcelain on crowns, or pontics posterior to the 2nd bicuspid.
13. Replacement of partial or full dentures, fixed bridge work, crowns, gold restorations and jackets more often than once in any 5 year period.
14. Relining of dentures more often than once in any 2 year period.
15. Lost, stolen, or missing dentures or bridges or for duplicates.
16. 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.
17. Prescription Drugs and analgesia pre medication.
18. 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.
19. Dental education or training programs including oral hygiene or plaque control programs.
20. Counseling on diet and nutrition.
21. Military service, including service in a military reserve unit.
22. Orthodontia, unless this coverage is elected by the Insured Person and the required premium is paid.
23. Prosthodontics, unless this coverage is elected by the Insured Person and the required premium is paid.
24. Charges payable under any medical insurance.
25. 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. 26. Use of materials, other than fluorides or sealants, to prevent tooth decay.
27. Bite registrations.
28. Bacteriologic cultures in connection with a covered dental service.
29. Therapeutic injections administered by a Dentist.
30. 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).
31. Replacement of 3rd molars.
32. Composites on teeth posterior to the 2nd bicuspid.
33. Crowns, inlays and onlays used to restore teeth with micro fractures or fracture lines, undermined cusps, or existing large restorations without overt pathology.
34. Temporomandibular joint syndrome.
ACCESSING AND ADMINISTERING YOUR BENEFITS
PREFERRED PROVIDER ORGANIZATIONS
Your Coverage includes access to a Preferred Provider Organization (PPO). A Covered Person is free to obtain dental care from the Dentist of his or her choice, but the Covered Person’s out-of-pocket expenses may be less in the case of treatment received from an In-Network Provider or an Out-of-Network Provider. The Co-Insurance payable for a Covered Charge is shown in the Schedule of Benefits. Services rendered to a Covered Person by an In-Network or an Out-of-Network Provider are paid under the Policy as shown in the Schedule of Benefits.
Covered Charges incurred in the event of an Emergency, shall be payable under the Schedule of Benefits as an In-Network Provider or an Out-of-Network Provider.
We do not make any representation or warranty as to the medical competence or ability of an In-Network Provider or an Out-of-Network Provider or to their respective staff or Dentists. We shall not have any liability or responsibility, either direct, indirect, vicarious or otherwise, for any actions or inactions, whether negligent or otherwise, of the In-Network Provider or Out-of-Network Provider, their staff or Dentists.]
COORDINATION OF BENEFITS
Applicability
1. The following provisions are applied to determine which insurance Plan pays benefits first when a Covered Person is covered by two or more plans. A Plan that pays first is called “primary”. All other plans are called “secondary”.
2. If these provisions apply, the order of benefit determination rules should be looked at first. Those rules determine whether the benefits of This Plan are determined before or after those of another plan. The benefits of This Plan:
- Shall not be reduced when, under the order of benefit determination rules, This Plan determines its benefits before another plan; but
- May be reduced when, under the order of benefits determination rules, another plan determines its benefits first. The above reduction is described under "Effect on the Benefits of This Plan."
Definitions
"Plan" is any of these which provides benefits or services for, or because of, dental care or treatment:
A. Group insurance or group-type coverage, whether insured or uninsured. This includes prepayment, group practice or individual practice coverage. It also includes coverage other than school accident-type coverage.
B. Coverage under a governmental plan, or coverage required or provided by law. This does not include a state plan under Medicaid (Title XIX, Grants to States for Medical Assistance Programs, of the United States Social Security Act (42 U.S.C.A. 301, et seq.), as amended from time to time).
Each contract or other arrangement for coverage under (1) or (2) is a separate plan. Also, if an arrangement has two parts and COB rules apply only to one of the two, each of the parts is a separate plan.
“This Plan" is the part of the group contract that provides benefits for dental care expenses. “Primary Plan/Secondary Plan:" The order of benefit determination rules state whether This Plan is a Primary Plan or Secondary Plan as to another plan covering the person.
When This Plan is a Primary Plan, its benefits are determined before those of the other plan and without considering the other plan's benefits.
When This Plan is a Secondary Plan, its benefits are determined after those of the other plan and may be reduced because of the other plan's benefits.
When there are more than two plans covering the person, This Plan may be a Primary Plan as to one or more other plans, and may be a Secondary Plan as to a different plan or plans.
4. “Allowable Expense" means a necessary, reasonable and customary item of expense for dental care; when the item of expense is covered at least in part by one or more plans covering the person for whom the claim is made.
When a plan provides benefits in the form of services, the reasonable cash value of each service rendered will be considered both an Allowable Expense and a benefit paid.
5. "Claim Determination Period" means a Calendar Year. However, it does not include any part of a year during which a person has no coverage under This Plan, or any part of a year before the date this COB provision or a similar provision takes effect.
Order of Benefit Determination Rules
1. General. When there is a basis for a claim under This Plan and another plan, This Plan is a Secondary Plan which has its benefits determined after those of the other plan, unless;
A. The other plan has rules coordinating its benefits with those of This Plan; and
Both those rules and This Plan's rules, in Subsection B below, require that This Plan's benefits be determined before those of the other plan.
2. Rules. This Plan determines its order of benefits using the first of the following rules which applies:
A. Non-Dependent/Dependent. The benefits of the plan which covers the person as a member or subscriber (that is, other than as a dependent) are determined before those of the plan which covers the person as a dependent; except that: if the person is also a Medicare beneficiary, Medicare is
i. Secondary to the plan covering the person as a dependent; and
ii. Primary to the plan covering the person as other than a dependent.
B. Dependent Child/Parents not Separated or Divorced. Except as stated in subsection (B)(3) below, when This Plan and another plan cover the same child as a dependent of different person, called "parents":
i. The benefits of the plan of the parent whose birthday falls earlier in a year are determined before those of the plan of the parent whose birthday falls later in that year; but
ii. If both parents have the same birthday, the benefits of the plan which covered the parents longer are determined before those of the plan which covered the other parent for a shorter period of time.
However, if the other plan does not have the rule described in subsection (2)(a) immediately above, but instead has a rule based upon the gender of the parent, and if, as a result, the plans do not agree on the order of benefits, the rule in the other plan will determine the order of benefits.
C. Dependent Child/Separated or Divorced. If two or more plans cover a person as a dependent child of divorced or separated parents, benefits for the child are determined in this order:
i. First, the plan of the parent with custody of the child;
ii. Then, the plan of the spouse of the parent with the custody of the child; and
iii. Finally, the plan of the parent not having custody of the child.
However, if the specific terms of a court decree state that one of the parents is responsible for the dental care expense of the child, and the entity obligated to pay or provide the benefits of the plan of that parent has actual knowledge of those terms, the benefits of that plan are determined first. The plan of the other parent shall be the Secondary Plan. This paragraph does not apply with respect to any Claim Determination Period or Plan year during which any benefits are actually paid or provided before the entity has that actual knowledge.
D. Dependent Child/Joint Custody. If the specific terms of a court decree state that the parents shall share joint custody, without stating that one of the parents is responsible for the dental care expenses of the child, the plans covering the child shall follow the order of benefit determination rules outlined in Paragraph III subsection B(2) above.
E. Active/Inactive Employee. The benefits of a plan which covers a person who is neither laid off nor retired (or as that employee's dependent) are determined before those of a plan which covers that person as a laid off or retired employee (or as that employee's dependent). If the other plan does not have this rule, and if, as a result, the plans do not agree on the order of benefits, this Rule (4) is ignored.
F. Continuation coverage. If a person whose coverage is provided under a right of continuation pursuant to federal or state law also is covered under another plan, the following shall be the order of benefit determination:
i. First, the benefits of a plan covering the person as a member or subscriber (or as that person's dependent);
ii. Second, the benefits under the continuation coverage.
If the other plan does not contain the order of benefits determination described within this subsection, and if, as a result, the plans do not agree on the order of benefits, this requirement shall be ignored.
G. Longer/Shorter Length of Coverage. If none of the above rules determines the order of benefits, the benefits of the plan which covered a member or subscriber longer are determined before those of the plan which covered that person for the shorter term.
Effect on the Benefits of this Plan
1. When This Section Applies. This Section IV applies when, in accordance with Section III "Order of Benefit Determination Rules," This Plan is a Secondary Plan as to one or more other plans. In that event the benefits of This Plan may be reduced under this section. Such other plan or plans are referred to as "the other plans" in (B) immediately below.
2. Reduction in this Plan's Benefits. The benefits of This Plan will be reduced when the sum of:
A. The benefits that would be payable for the Allowable Expense under This Plan in the absence of this provision; and
B. The benefits that would be payable for the Allowable Expenses under the other plans, in the absence of provisions with a purpose like that of this provision, whether or not claim is made;
exceeds those Allowable Expenses in a Claim Determination Period. In that case, the benefits of This Plan will be reduced so that they and the benefits payable under the other plans do not total more than those Allowable Expenses.
When the benefits of This Plan are reduced as described above, each benefit is reduced in proportion. It is then charged against any applicable benefit limit of This Plan.
Right to Receive and Release Needed Information
Certain facts are needed to apply these COB rules. We have the right to decide which facts We need. We may get needed facts from or give them to any other organization or person. We need not tell, or get the consent of, any person to do this. Each person claiming benefits under This Plan must give Us any facts We needs to pay the claim.
Facility of Payment
A payment made under another plan may include an amount which should have been paid under This Plan. If it does, We may pay that amount to the organization which made that payment. That amount will then be treated as though it were a benefit paid under This Plan. We will not have to pay that amount again. The term "payment made" includes providing benefits in the form of services, in which case "payment made" means reasonable cash value of the benefits provided in the form of services.
Right of Recovery
If the amount of the payments made by Us is more than We should have paid under this COB provision, We may recover the excess from one or more of:
1. The persons We have paid or for whom We have paid;
2. Insurance companies; or
3. Other organizations.
The "amount of the payments made" includes the reasonable cash value of any benefits provided in the form of services.]
SUBROGATION/RIGHT OF REIMBURSEMENT
As a condition to receiving benefits under this Policy, Covered Person(s) agree to transfer to Us their right to recover damages to the extent of benefits paid by Us when a loss occurs through the act or omission of another person. If a Covered Person received payment from another person or entity on account of, due to, or arising out of a dental injury, the Covered Person agrees to reimburse Us to the full extent of Covered Charges paid. If a repayment agreement is required to be signed, all rights of recovery are transferred to Us regardless of whether it is actually signed. It is only necessary that the dental injury occur through the act or omission of another person or entity. Our rights of full recovery may be from any other person or entity, any liability or other insurance covering such other person or entity party, the Covered Person’s own uninsured motorist insurance, underinsured motorist insurance, any medical payments, no-fault, workers compensation or school insurance coverages which are paid or payable. We may enforce Our reimbursement rights by requiring the Covered Person to assert a claim to any of the foregoing coverages to which the Covered Person may be entitled. Covered Person(s) shall provide all requested accident and insurance information to Us. We shall not be required to pay any portion of Covered Person’s attorneys’ fees or other costs associated with a claim/lawsuit.
TERMINATION
Insured’s Insurance
The Insured’s insurance shall terminate on the earliest of the following dates:
1. The date of termination of the Policy ;
2. The next premium due date after We receive Your written request to terminate coverage of the Insured Person under the Policy;
3. The last premium due date prior to a grace period, if the premium then due is not paid within the grace period;
4. The date the Insured Person has been determined by Us to have committed an act of fraud or made an intentional misrepresentation of material fact under the terms of the Policy;
5. The date the Insured reaches the Maximum Benefit while covered under the Policy as specified in the Schedule of Benefits; or
6. The date of Your death.
Dependent Insurance
The insurance coverage of a Dependent shall terminate on the earliest of the following dates:
1. The date of termination of the Policy;
2. The next premium due date after We receive Your written request to terminate coverage of the Dependent under the Policy;
3. The premium due date coinciding with or next following the date on which a Dependent ceases to meet the definition of Dependent;
4. The date the Dependent has been determined by Us to have committed an act of fraud or made an intentional misrepresentation of material fact under the terms of the Policy;
5. The date the Dependent reaches the Maximum Benefit while covered under the Policy as specified in the Schedule of Benefits; or
6. The date of the Dependent’s death.
The attainment of the limiting age by a covered Dependent will not cause coverage to terminate while that person is and continues to be both incapable of self-sustaining employment by reason of Mental or Physical Incapacity and Chiefly Dependent on You for support and maintenance.
“Chiefly Dependent” means the covered Dependent receives the majority of his/her financial support from You. If a covered Dependent is handicapped beyond the limiting age and You desire continued coverage for Your covered Dependent, You must provide written proof that the covered Dependent is Chiefly Dependent, at least thirty-one (31) days prior to the date upon which the covered Dependent would otherwise reach the limiting age. Thereafter, We may request such proof no more frequently than annually. In the absence of such proof, We may terminate the coverage of such person after the attainment of the limiting age.
GENERAL PROVISIONS
Entire Contract The entire contract is made up of: (a) the Policy; (b) the application of the Policyholder: (c) the applications of the Insured Persons for coverage under the Policy; and (c) any subsequent amendment, rider or endorsement to the Policy.
No agent, Insured Person or other individual, except Our President, Vice President, Secretary or Assistant Secretary, can extend the time for payment of any premium. A change to the Policy which requires the Policyholder’s consent will be valid only if signed by the Policyholder and Our President, Vice President, Secretary or Assistant Secretary. A change to the Certificate which requires Your consent will be valid only if signed by You and Our President, Vice President, Secretary or Assistant Secretary. A change to the Policy or a Certificate which does not require the consent of the Policyholder or You will be valid only if signed by Our President, Vice President, Secretary or Assistant Secretary.
Contestability
In the absence of fraud, statements made by an Insured Person are representations and not warranties. After the Insured Person has been covered under the Policy for two consecutive years, only fraudulent misstatements in the application may be used to void coverage under the Policy or deny any claim for loss incurred after the 2-year period. If a Covered Person’s age was misstated, We will provide the amount of insurance for the correct age and an equitable premium adjustment will be made so that We will receive the correct premium for the true age.
Notice of Claim
Written notice of claim must be given to Us: (a) within 20 days after the date on which the claim was incurred; or (b) as soon as reasonably possible thereafter. Notice can be sent to Our authorized administrator or Our Home Office. The notice should include the Covered Person's name and group policy number.
Proof of Loss
Written proof of loss must be given to Us or Our authorized administrator within 90 days of the date on which the charges are incurred. If it was not possible for proof to be given within the 90 days, We will not deny the charges provided proof is given as soon as reasonably possible. The date on which the charges are incurred is the date on which the services or supplies were provided. Notwithstanding the forgoing, proof must be sent no later than one year from the date on which the charges are incurred unless the Insured Person is legally incapacitated.
Time of Payment of Claims
Payments for Covered Charges will be paid as they accrue, subject to written proof of loss. Any balance unpaid at the end of liability will be paid on receipt of written proof of loss. Covered Charges paid by the Policy will be paid within 45 days following the date on which Our authorized administrator receives written proof of loss. Covered Charges for claims payable under the Policy are overdue if not paid within 45 days after We, or Our administrator, receives proof of loss and necessary medical information or other information required by Us essential to administer the provisions of the Policy. If such information is not supplied as to the entire claim, the amount supported by reasonable proof is overdue if not paid within 45 days. Any part or all of the remainder of the claim that is later supported by such proof is over due if not paid within 45 days.
Payment of Claims
Covered Charges will be payable to the Insured Person unless they are assigned to a Dentist or other health care provider. Any notice of assignment of benefits must be in writing and mailed to Us or Our authorized administrator. Notice of the assignment of benefits received from a Dentist or other health care provider will be sufficient to cause Covered Charges to be paid to such Dentist or other health care provider. You may revoke an assignment of benefits at any time by providing written notice of such revocation to Us or Our authorized administrator. Any such written revocation of an assignment of benefits shall be valid as to both You and the Dentist or other health care provider.
Recovery of Overpayments
We reserve the right to deduct from any benefits properly payable under this Policy the amount of any payment that has been made:
1. In error; or
2. pursuant to a misstatement contained in a proof of loss; or
3. pursuant to fraud or misrepresentation made to obtain coverage under this Policy within two (2) years after the date such coverage commences; or
4. with respect to an ineligible person; or
5. pursuant to a claim for which benefits are recoverable under any Policy or act of law providing coverage for occupational Injury or disease to the extent that such benefits are recovered.
Such deduction may be against any future claim for benefits under the Policy made by an Insured Person if claim payments previously were made with respect to a Covered Person.
Conformity with Federal and State Laws
Any provision of the Policy which is in conflict with Federal laws or any applicable state law, is hereby amended to meet the minimum requirements of the law.
Arbitration Action
No arbitration action may be brought to recover benefits under the Policy prior to the expiration of: (1) 60 days after written proof of loss has been furnished, (2) You have completed all administrative appeals required by the Policy, and (3) You notify Us of Your intent to demand arbitration 60 days prior to the filing of such demand for arbitration. No such action will be brought after the expiration of two years following the date written proof of loss was required to be furnished.
Arbitration
Disputes, disagreements or controversies arising out of, in connection with, or relating to the terms, conditions, limitations, exclusions or provisions of the coverage under the policy or breach thereof (including any issue related to arbitrability) which cannot be resolved to the satisfaction of all parties shall be resolved by arbitration. Arbitration shall be conducted in accordance with the rules of the American Arbitration Association (“AAA”), before a panel of three (3) neutral arbitrators who are knowledgeable in the field of insurance and appointed from a panel list provided by the AAA.
Each party waives the right to a jury trial with respect to any dispute, disagreement or controversy between them. The arbitration panel shall have no power to ignore or vary the terms of the policy.
The factual basis and legal conclusions of the award, including the law relied upon, must be identified. The decision in arbitration is confidential, final, binding and conclusive upon all parties and may not be disclosed by any party. The decision in arbitration cannot be reviewed in court by a judge and jury. Judgment upon the award rendered by the arbitration panel may be entered in any court have jurisdiction.
If any provision of this subsection is found to be unenforceable, such provision shall be considered severed from the remaining provisions of this subsection, which shall remain in full force and effect.
Ambiguities
Any terms or conditions specified in the Policy that are determined as a result of arbitration to be ambiguous or in conflict with State or Federal laws shall be considered separately and shall not void or affect the legality of the remaining terms and conditions that are included in the Policy.
Physical Examination
We have the right, at Our own expense, to have a Covered Person examined as often as is reasonable while a claim is pending.
Certificates/Booklets
We will issue a Certificate for delivery to each Insured Person, which shall not constitute a part of the Policy, but which shall merely state the essential features of the insurance to which each Covered Person is entitled, to whom benefits are payable, and the requirements for payment of benefits.
Waiver Of Rights
If We fail to enforce any provision of the Policy, such failure will not affect Our right to do so at a later date; nor will it affect Our right to enforce any other provision of the Policy. Any waiver of rights must be in writing and signed by Our President, Vice President Secretary or Assistant Secretary or an individual authorized by them to agree to such waiver.
Required Information
The Insured Person agrees to provide to Us any information or data that we reasonably request for the proper administration of the Policy including; but not limited to, information pertaining to medical history, medical records, the names of all health care providers from whom a Covered Person has received treatment or services, marriage license, documentation of adoption or placement for adoption, documentation of legal custody of a Dependent, student status information, and treating provider statements.
Effective Date
No insurance under the Policy shall become effective until notice in writing is given to the Insured Person by Us. Issuance of a Certificate with a Schedule of Benefits will be deemed proper notification, provided premium due has been paid in accordance with the terms of the Policy.
This site provides a brief description of the benefits, exclusions and other provisions of the policy or certificate Form Master Policy MNL ADEN-CER.010 0905. For a complete listing, see the policy or certificate. Benefits may vary in different states. This dental insurance plan may not be available in all states. ©2006 GroupLink. All rights reserved.
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