Dental Exclusions

Plan Exclusions

Exclusions may vary by state. Refer to your Policy or contact Us.

Exclusions – Coverage is not provided for expenses incurred:

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

  1. for services and supplies not listed in the Coverage Schedule, not recognized as essential for the treatment of the condition according to accepted standards of practice or considered experimental.
  2. for services related to, performed in conjunction with, or resulting from a non-covered procedure.
  3. for charges in excess of the contracted Fee-for-Service schedule or the Usual and Customary rate, whichever applies.
  4. for any treatment program which began prior to the date the Insured is covered under the Policy.
  5. for crowns, inlays and onlays on teeth that can be restored by direct placement materials.
  6. for the replacement of crowns, bridges, dentures, inlays or onlays that can be restored to normal function.
  7. for the replacement of crowns, bridges, inlays, onlays or prosthetic appliance within 5 years from the date of last placement.
  8. for service or supplies payable under any medical expense plan.
  9. for any condition covered under any Worker’s Compensation Act or similar law.
  10. for services applied without cost by any municipality, county or other political subdivision or for which there would be no charge in the absence or insurance.
  11. during any Waiting Period We require.  This exclusion applies to employer-sponsored adult coverage only.  When You voluntarily end Your insurance without a Qualifying Event and re-enroll at a later date, Your Waiting Period is 2 years and begins on the date Your coverage first ended.
  12. for services that are applied toward the satisfaction of a Deductible, if any.
  13. for services subject to a Waiting Period that were incurred during the Waiting Period.
  14. 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.
  15. for hospital facility charges for any dental procedure, including but not limited to: emergency room charges, surgical facility charges, hospital confinement.
  16. for drugs or the dispensing of drugs.
  17. 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).
  18. for orthodontia, unless included within the Coverage Schedule.
  19. for cosmetic procedures, including but not limited to veneers and bleaching of teeth and procedures performed primarily for cosmetic reasons.
  20. for implants (unless included in the 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.
  21. for services to replace teeth that were missing (extracted or congenitally) prior to the effective date of coverage on Our Plan. This limitation ends after 36 months of continuous coverage on the Plan. Abutment teeth will be reviewed for eligibility of prosthetic benefits.
  22. for composite, resin, or white fillings on posterior primary teeth.  Benefits will be reduced to that of an amalgam or silver filling.
  23. for the replacement of a filling within 24 months of placement, unless for specific health reasons.
  24. for the replacement of retainers.
  25. for sealants not applied to a permanent bicuspid or molar; applied at age 15 or older; applied 3 years from a previous sealant application; applied to a decayed tooth.
  26. for lab fees for higher metals or porcelain crowns, bridges, inlays, or onlays.
  27. during travel or activity outside the United States.
  28. to replace lost or stolen appliances.
  29. for any procedure begun after the Policy terminates; or for any prosthetic dental appliances installed or delivered more than 90 days after the Insured’s coverage terminates.
  30. for appliances, restorations, or procedures to: (a) alter vertical dimension; (b) restore or maintain occlusion; or (c) splint or replace tooth structure lost as a result of abrasion or attrition.
  31. for initial placement of any prosthetic crown, appliance, or fixed partial denture unless such placement is needed because of the extraction of one or more teeth while the Insured is covered under this Policy.  But the extraction of a third molar (wisdom tooth) will not qualify under the above.  Any such prosthetic crown, appliance, or fixed partial denture must include the replacement of the extracted tooth or teeth.
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