will be identified on a case-by-case basis. This exclusion applies when orthodontics is covered under Your plan; • endodontic treatment and/or periodontal (gum tissue and supporting bone) surgery of teeth exhibiting a poor or hopeless periodontal prognosis; • intentional root canal treatment in the absence of injury or disease solely to facilitate a restorative procedure; • services to the extent You or Your enrolled Dependent(s) are compensated under any group medical plan; • house/extended care facility calls; hospital calls; office visits for observation (during regularly scheduled hours) when no other services are performed; office visits after regularly scheduled hours; and case presentations; • procedures performed by a Dentist who is a member of the Covered Person’s family except in the case of a dental emergency when no other Dentist is available. (Covered Person’s family is limited to a Spouse, siblings, parents, children, grandparents, and the Spouse’s siblings and parents); • dental services that do not meet commonly accepted dental standards; • replacement of teeth beyond the normal adult dentition of thirty-two (32) teeth; • services not included in The Schedule, unless We agree to accept such expense as a Covered Dental Expense, in which case payment will be made consistent with similar services which would provide the least expensive professionally satisfactory result; • to the extent that You or any of Your Dependents are in any way paid or entitled to payment for those expenses by or through a public program, other than Medicaid; • charges in excess of the Maximum Reimbursable Charge allowances; • procedures for which a charge would not have been made if the person had no insurance or for which the person is not legally required to pay. For example, if We determine that a provider is or has waived, reduced, or forgiven any portion of its charges and/or any portion of the Copayment, Deductible, and/or Coinsurance amount(s) You are required to pay for a Covered Dental Service (as shown on The Schedule) without Our express consent, We shall have the right to deny the payment of benefits in connection with the Covered Dental Service, or reduce the benefits in proportion to the amount of the Copayment, Deductible, and/or Coinsurance amounts waived, forgiven or reduced, regardless of whether the provider represents that You remain responsible for any amounts that Your plan does not cover. We shall have the right to require You to provide
proof sufficient to Us that You have made Your required cost share payment(s) prior to the payment of any benefits by Us. This exclusion includes, but is not limited to, charges of a Non-Participating Provider who has agreed to charge You or charged You at an In-Network benefits level or some other benefits level not otherwise applicable to the services received; • charges arising out of or relating to any violation of a healthcare-related state or federal law or which themselves are a violation of a healthcare-related state or federal law; • Covered Dental Services to the extent that payment is unlawful where the Covered Person resides when the expenses are incurred; • charges for or in connection with experimental procedures or treatment methods not recognized and approved by the American Dental Association or the appropriate dental specialty organization; • charges which would not have been made in any facility, other than a hospital or a correctional institution owned or operated by the United States Government or by a state or municipal government if the person had no insurance; • services for which benefits are not payable according to the "General Limitations" section; • charges for care, treatment or surgery that is not Medically Necessary and/or Dentally Necessary; • athletic mouth guards. Should any law require coverage for any particular service(s) noted above, the exclusion or limitation for that service(s) shall not apply.
HCDFB-DEX110
06-21 V1
Coordination of Benefits This section applies if You or any one of Your Dependents are covered under more than one Plan and determines how benefits payable from all such Plans will be coordinated. You should file all claims with each Plan. Any other health coverage plans for You or any of Your covered Dependents are taken into account when benefits are paid. Coverage under this Plan plus another Plan will not guarantee 100% reimbursement.
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