Other Important Plan Provisions
Dental Benefits are not payable for the following, unless such insurance is provided under the list of covered dental services:
Treatment or an appliance which is not dentally necessary, is experimental or temporary in nature, or does not have uniform professional endorsement, treatment related to procedures that are part of a service but are not reported as separate services, reported in a treatment sequence that is not appropriate or misreported or that represent a procedure other than the one reported, appliances, inlays, cast restorations, crowns, or other laboratory prepared restorations used primarily for the purpose of splinting, any treatment or appliance, the sole or primary purpose of which relates to the change or maintenance of vertical dimension, the alteration or restoration of occlusion, except for occlusal adjustment in conjunction with periodontal surgery or temporomandibular joint disorder provided under the adult plan, bite registration, bite analysis, attrition or abrasion, replacement of a lost or stolen appliance or prosthesis, educational procedures, including but not limited to oral hygiene, plaque control or dietary instructions, completion of claim forms or missed dental appointments, personal supplies or equipment, including but not limited to water piks, toothbrushes, floss holders, or athletic mouthguards, administration of nitrous oxide or any other agent to control anxiety, treatment for a jaw fracture, treatment provided by a dentist, dental hygienist, or denturist who is an immediate family member or a person who ordinarily resides with a covered person, an employee of the policyholder, or a policyholder, hospital or facility charges for room, supplies or emergency room expenses or routine chest x-rays and medical exams prior to oral surgery, treatment provided primarily for cosmetic purposes, treatment which may not reasonably be expected to successfully correct the person’s dental condition for a period of at least 3 years, crowns, inlays, cast restorations, or other laboratory prepared restorations on teeth which do not have extensive decay or fracture and can be restored with an amalgam or composite resin filling, any treatment required directly or indirectly to diagnose or treat a muscular, neural, or skeletal disorder, dysfunction, or disease of the temporomandibular joint or its associated structures except as provided under the adult benefits, treatment for implants, implant abutments, implant supported prosthetics (crown, fixed partial denture, dentures) or any other services related to the care and treatment of the implant except as provided under the pediatric benefits, treatment for the prevention of bruxism (grinding of teeth) except as provided under the pediatric benefits. Treatment performed outside the United States, except for emergency dental treatment (the maximum benefit payable to any person during a benefit year for covered dental expenses related to emergency dental treatment performed outside the United States is $100), treatment or appliances at which are covered under any Workers’ Compensation Law, Employer’s Liability Law or similar law (a person must promptly claim and notify us of all such benefits), treatment for which a charge would not have been made in the absence of insurance, treatment for which a covered person does not have to pay, except when payment of such benefits is required by law and only to the extent required by law.
State variations can exist; please contact Sun Life Financial for additional information.
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