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Group Insurance Plan Dental Insurance
DENTAL HIGHLIGHTS
This page provides a quick guide to some of the Dental Expense Insurance plan features which people most often want to know about. But it's not a complete description of your Dental Expense Insurance plan. Read the following pages carefully for a complete explanation of what we pay, limit and exclude.
B497.0075
B497.0086
CGP-3-DENT-HL-90 B497.0105
This insurance will pay many of your and your covered dependents' dental expenses. What we pay and the terms for payment are explained below.
CGP-3-DNTL-90-1 B490-0036
Covered charges are reasonable and customary charges for the dental services named in the List of Covered Dental Services.
By reasonable, we mean the charge is the dentist's usual charge for the service furnished. But if more than one type of service can be used to treat a dental condition, we have the right to consider charges for the least expensive one which meets the accepted standards of dental practice. By customary, we mean the charge made for the given dental condition isn't more than the usual charge made by most other dentists with similar training and experience in the same geographic area.
We only pay for covered charges incurred by a covered person while he's insured. A covered charge for a crown, bridge or cast restoration is incurred on the date the tooth is prepared. A covered charge for any other prosthetic device is incurred on the date the master impression is made. A covered charge for root canal treatment is incurred on the date the pulp chamber is opened. A covered charge for orthodontic treatment is incurred on the date the active appliance is first placed. All other covered charges are incurred on the date the services are furnished.
CGP-3-DNTL-90-3 B490.0038
When the expected cost of a proposed course of treatment is $200.00 or more, the covered person's dentist must send us a treatment plan before he starts. This must be done on a form acceptable to The Guardian. The treatment plan must include: (a) a list of the services to be done, using the American Dental Association Nomenclature and codes; (b) the itemized cost of each service; and (c) the estimated length of treatment. Dental X-rays, study models and whatever else we need to evaluate the treatment plan must be sent to us, too.
A treatment plan must always be sent to us before orthodontic treatment starts.
We review the treatment plan and estimate what we will pay. The estimate will be sent to the covered person's dentist. If we don't agree with a treatment plan, or if one is not sent in, we have the right to base our payments on treatment suited to the covered person's condition by accepted standards of dental practice.
Pre-treatment review is not a guarantee of what we will pay. It tells the covered person and his dentist, in advance, what we would pay for the covered dental services named in the treatment plan. But payment is conditioned on: (a) the work being done as proposed and while the covered person is insured; and (b) the deductible and payment limit provisions and all of the other terms of this plan.
Emergency treatment, oral examinations, dental X-rays and teeth cleaning are part of a course of treatment, but may be done before the pre-treatment review is made.
CGP-3-DNTL-90-4 @90.0039
This plan supplements Guardian Major Medical .
This plan, and Guardian Major Medical may provide benefits for the same charges. If they do, we subtract what Guardian Major Medical pays from what we'd otherwise pay.
Other plans may furnish similar benefits, too. For instance, you may be covered by this plan and a similar plan through your spouse's employer. If you are, we coordinate our benefits with the benefits from these other plans. We do this so no one gets more in benefits than the charges he incurs. Read "Coordination of Benefits" to see how this works.
CGP-3-DNTL-90-5 B490.01 1 O-R
Group I, II and III Non-Orthodontic Services There is no deductible for Group I services. We pay for Group I services at
the applicable payment rate.
A benefit year deductible of $ 50.00 applies to Group II and III services. Each benefit year, each covered person must have covered charges from Groups II and III which exceed this deductible before we pay him or her benefits for such charges. These charges must be incurred while he or she is insured.
Once a covered person meets this deductible, we pay for his or her Group II and III covered charges above that amount at the applicable payment rates for the rest of that benefit year.
All charges must be incurred while the covered person is insured. We limit what we pay each benefit year to $1,000.00 . What we pay is based on all of the terms of this plan.
CGP-3-DNTL-90-7 B490.0114-R This pian provides benefits for Group IV orthodontic services only for
covered dependent children who are less than 19 years old when the active
appliance is first placed.
We pay for Group IV covered charges at the applicable payment rate. Using the treatment plan, we calculate the total benefit we will pay. We divide this into equal payments, which we spread out over the shorter of two years or the proposed length of treatment.
We make the initial payment when the active appliance is first placed. We make further payments at the end of each subsequent three month period.
But treatment must continue and the covered person must stay insured. And
we limit what we pay during a covered person's lifetime to $ 1,000.00 . What
we pay is based on all of the terms of this plan.
Orthodontic benefits won't be charged against the benefit year payment limit
which applies to all other services.
CGP-3-DNTL-90-8 B490.0161 No family must meet more than three benefit year deductibles in any benefit
year. Once this happens, we pay for covered charges incurred by any
covered person, at the applicable payment rate, for the rest of that benefit
year. But the charges must be incurred while insured. And what we pay is
subject to the benefit year payment limit and to all of the other terms of this
plan.
CGP-3-DNTL-90-9 B490.0137 Benefits for covered charges are paid at the following rates:
Benefits for Group I Services are paid at a rate of-100%
Benefits for Group II Services are paid at a rate of-80%
Benefits for Group III Services are paid at a rate of-50%
Benefits for Group IV Services are paid at a rate of-50%
CGP-3-DRATE-90 B497.0029
We won't pay for charges incurred after this insurance ends. But we pay for the following if all work is finished in the 31 days after this insurance ends: (a) a crown, bridge or cast restoration, if the tooth is prepared before the insurance ends; (b) any other prosthetic device, if the master impression is made before the insurance ends; and (c) root canal treatment, if the pulp chamber is opened before the insurance ends.
Benefits for orthodontic treatment will only be paid to the end of the month in which the insurance ends. The final payment will be pro-rated.
CGP-3-DNTL-90-1 0 B490.0045
Penalty For Late Entrants
We won't cover charges incurred by a late entrant for: (1) Group II services until 6 months from the date he is insured by this plan; (2) Group III services until 12 months from the date he is insured by this plan; and (3) orthodontic treatment done in the first 24 months he is insured by this plan. However, this limitation will not apply to covered charges due solely to an injury suffered while insured.
Charges not covered due to this provision are not considered covered dental services and cannot be used to satisfy this plan's deductibles.
A late entrant is a person who: (1) becomes insured more than 31 days after he is eligible; or (2) becomes insured again, after his coverage lapsed because he did not make required payments.
CGP-3-DNTL-90-1 1.0 B490.0046 A covered person may have lost one or more teeth before he became
insured by this plan. Except as explained below, we won't pay for a
prosthetic device which replaces such teeth unless the device also replaces
one or more natural teeth lost or extracted after the covered person became insured by this plan.
If This Plan Replaces Another Plan This plan may be replacing another plan your employer had with some other
insurer.
We don't want anyone to lose benefits when this happens. So we pay for certain charges incurred before this plan starts, if: (1) the covered person was insured by the old plan; and (2) the old plan would have paid for such charges. But this plan must start right after the old plan ends. And the covered person must be insured by this plan from the start.
We limit what we pay to the lesser of: (1) what the old plan would have paid; or (2) what we would otherwise pay. And we deduct any benefits actually paid by the old plan under any extension provision.
In the first benefit year of this plan, we also reduce this plan's deductibles by the amount of covered charges applied against the old plan's deductible. And, in the first benefit year, we charge benefits which were paid by the old plan against this plan's payment limits.
CGP-3-DNTL-90-1 1.1 B490.0053
We won't pay for: (1) oral hygiene, plaque control or diet instruction; or (2) precision attachments.
We won't pay for: (1) treatment which does not meet accepted standards of dental practice; or (2) treatment which is experimental in nature.
We won't pay for any appliance or prosthetic device used to: (1) change vertical dimension; (2) restore or maintain occlusion, except to the extent that this plan covers orthodontic treatment, (3) splint or -stabilize teeth for periodontic reasons; (4) replace tooth structure lost as a result of abrasion or attrition; and (5) treat disturbances of the temporomandibular joint.
We won't pay for any service furnished for cosmetic reasons. This includes, but is not limited to: (1) characterizing and personalizing prosthetic devices; and (2) making facings on prosthetic devices for any teeth in back of the second bicuspid.
We won't pay for replacing an appliance or prosthetic device with a like appliance or device, unless (1) it is at least ten years old and can't be made usable; or (2) it is damaged while in the covered person's mouth in an injury suffered while insured, and can't be fixed.
We won't pay for: (1) replacing a lost, stolen or missing appliance or prosthetic device; or (2) making a spare appliance or device.
We won't pay for treatment needed due to: (1) an on-the-job or job-related injury; or (2) a condition for which benefits are payable by Worker's Compensation or similar laws.
We won't pay for treatment for which no charge is made. This usually means treatment furnished by: (1) the covered person's employer, labor union or similar group, in its dental or medical department or clinic; (2) a facility owned or run by any governmental body; and (3) any public program, except Medicaid, paid for or sponsored by any government body. But if a charge is made and we are legally required to pay it, we will.
CGP-3-DNTL-90-12 B497.0039
The services covered by this plan are named in this list. Each service on this list has been placed in one of four groups. A separate payment rate applies to each group. Group I is made up of preventive services. Group II is made up of basic services. Group III is made up of major services. Group IV is made up of orthodontic services.
All covered dental services must be furnished by or under the direct supervision of a dentist. And they must be usual and necessary treatment for a dental condition.
CGP-3-DNTL-90-13 B490-0048
Prophylaxis and Fluoride Treatments Allowance
Prophylaxis limited to one treatment in any six consecutive month period) includes the complete removal of explorer-detectable calculus, soft deposits, plaque, stains, and the smoothing of tooth surfaces above the gingival attachment.
Topical application of fluoride, including prophylaxis, (limited to covered persons under age 14 and limited to one treatment in any six consecutive month period).
Space Maintainers (Limited to covered persons under age 16 and limited to initial appliance only) Allowance includes all adjustments in the first six months after installation:
- Fixed, unilateral, band or stainless steel crown type.
- Removal, bilateral type.
Fixed and Removable Appliances To Inhibit Thumbsucking - (Limited to covered persons under age 14 and
limited to initial appliance only) - Allowance includes all adjustments in the
first six months after installation.
Diagnostic Services
Allowance includes examination and diagnosis - X-Rays.
- Full mouth series of at least 14 films including bitewings, if needed (limited to once in any 60 consecutive month period).
- Bitewing films (limited to a maximum of four films, in one visit, in any twelve consecutive month period).
- lntraoral periapical or occusal X-Rays-single films.
- Extraoral superior or inferior maxillary film.
- Panoramic film, maxilia and mandible, allowable only when necessary to diagnose accidental injury, or in conjunction with cyst or tumor removal.
Dental Sealants (Limited to the unrestored permanent molars of covered persons under age 16 and limited to one treatment in any 36 consecutive month period).
Office Visits and Examination (Oral Examination limited to one examination in any six consecutive month
period).
Emergency palliative treatment and other non-routine, unscheduled visits. We pay for this only if no other service (except X-Rays) is rendered during the visit.
CGP-3-DNTL-90-14 @97.0057
Office Visits and Examinations
Diagnostic consultation with a dentist other than the one providing treatment
(limited to one consultation for each dental specialty in any 12 consecutive
month period) - We pay for this only if no other service is rendered during
the visit.
Diagnostic Services Allowance includes examination and diagnosis.
- Diagnostic casts, when necessary to diagnose complex restorative cases.
- Biopsy and examination of oral tissue.
Restorative Services
Multiple restorations on one surface will be considered one restoration. Also
see "Major Restorative Services". Allowance includes insulating base and local anesthesia.
- Amalgam restorations (primary or permanent teeth).
- Pins: Pin retention, exclusive of restorative material - used in lieu of cast restorations.
- Recementation: Inlay or onlay, Crown, and Bridge.
Endodontic Services
Allowance includes all endodontic treatment within 12 months.
- Pulp capping, direct, for full or new pulpal exposure.
- Remineralization (Calcium Hydroxide), as a separate procedure.
- Vital pulpotomy.
- Apexification, therapeutic apical closure.
- Root canal therapy on non-vital (nerve-dead) teeth. Allowance includes routine X-Rays and cultures, but excludes final restoration.
- Anterior, bicuspid, or molar teeth.
- Apicoectomy, as a separate procedure or in conjunction with other endodontic procedures. Allowance includes retrograde filling.
Periodontic Allowance includes the treatment plan, local anesthetics and post-operative Services care.
Non-Surgical Services
- Periodontal root planning - As necessary for substantial bone anci attachment loss (limited to one treatment per area in any 24 month period).
- Occlusal adjustment - Not involving restorations and done in conjunction with periodontic surgery, per quadrant (limited to a maximum of four quadrants in any twelve consecutive month period).
Surgical Services (limited to one treatment per area in any 36 month period).
- Gingivectomy, per tooth - Less than 3 teeth and not incidental to crown preparations.
- Osseous surgery, per quadrant - Including all necessary (associated) surgical procedures.
- Mucogingival Surgery (pedicle soft tissue graft, sliding horizontal flap, free soft tissue graft).
Oral Surgery
Allowance includes diagnosis, the treatment plan, local anesthetics and post-surgical care.
- Extractions:
- Alveolectomy, per quadrant.
- Stomatoplasty with ridge extension, per arch.
- Removal of mandibular tori, per quadrant.
- Excision of hyperplastic tissue.
- Excision of pericoronal gingiva, per tooth.
- Removal of palatal torus.
- Removal of cyst or tumor - not associated with the removal of impacted teeth.
- Incision and drainage of abscess.
- Closure of oral fistula or maxillary sinus.
- Reimplantation of tooth.
- Frenectomy.
- Suture of soft tissue injury.
- Sialolithotomy for removal of salivary calculus.
- Closure of salivary fistula.
- Dilation of salivary duct.
- Sequestrectomy for osteomyelitis or bone abscess, superficial.
- Maxillary sinustomy for removal of tooth fragment or foreign body.
CGP-3-DNTL-90-15.0 B497.0386 Specialized techniques and characterization are not covered. Also see "Major Prosthodontic Services".
- Denture repairs, acrylic: Repairing dentures, no teeth damaged; Repairing dentures and replace one or more broken teeth; and Replacing one or more broken teeth, no other damage.
- Denture repairs, metal - Allowance based on the extent and nature of damage and on the type of materials involved.
- Full or partial denture rebase, jump case (limited to once per denture in any 36 consecutive month period).
- Full or partial denture reline (limited to once per denture in any 12
consecutive month period): Office reline; Cold cure; Laboratory reline.
- Denture adjustments (limited to adjustments by a dentist other than the
one providing the denture, and adjustments are more than 6 months after
the initial installation).
- Tissue conditioning (limited to a maximum of 2 treatments per arch in any
12 consecutive month period).
- Adding teeth to partial dentures to replace extracted natural teeth.
- Repairs to crowns and bridges - allowance based on the extent and nature
of damage and the type of materials involved).
Other Services General anesthesia in connection with surgical procedures only.
- Injectable antibiotics needed solely for treatment of a dental condition.
CGP-3-DNTL-90-15.1 @97.0059
Restorative Services Cast restorations and crowns are covered only when needed because of decay or injury, and only when the tooth cannot be restored with a routine filling material. Allowance includes insulating bases, temporization and minor associated gingival involvement. AJso see "Basic Restorative Services".
- Inlays.
- Onlays, in the presence of an inlay.
- Crowns and Posts: Acrylic with metal. Porcelain, Porcelain with metal, Full cast metal (other than stainless steel), 3/4 cast metal (other than stainless steel), Cast post and core, in addition to crown (not a thimble coping), Steel post and composite or amalgam core, in addition to crown, and Cast dowel pin (one-piece cast with crown) - Allowance based on type of crown, Crown build-up - Necessitated by loss of natural tooth structure.
Prosthodontic Services Specialized technique and characterizations are not covered. Also see "Basic
Prosthodontic Services".
- Fixed bridges - Each abutment and each pontic makes up a unit in a bridge.
- Bridge abutments - See inlays and crowns under "Major Restorative Services".
- Bridge Pontics: Cast metal, sanitary, Plastic or porcelain with metal, and Slotted pontic.
- Simple stress breakers, per unit.
- Dentures - Allowance includes all adjustments done by the dentist furnishing the denture in the first 6 months after installation. Temporary dentures older than one year are considered to be a permanent appliance.
Orthodontic Services
- Any Group I, II, or III service in connection with orthodontic treatment.
- Surgical exposure of impacted or unerupted teeth in connection with orthodontic treatment - Allowance includes routine X-Rays, local anesthetics and post-surgical care.
- Active appliances - All types - Allowance includes diagnostic services, the treatment plan, the fitting, making and placing of the active appliance, and all related office visits including post-treatment stabilization.
CGP-3-DNTL-90-17 B490.0052 |