Covered Expenses include: Orthodontic work-up including x-rays, diagnostic casts and treatment plan and the first month of active treatment including all active treatment and retention appliances. Continued active treatment after the first month. Fixed or Removable Appliances - Only one appliance per person for tooth guidance or to control harmful habits. Periodic observation of patient dentition to determine when orthodontic treatment should begin, at intervals established by the dentist, up to four times per calendar year. The total amount payable for all expenses incurred for orthodontics during a person’s lifetime will not be more than the orthodontia maximum shown in the Schedule. Payments for comprehensive full-banded orthodontic treatment are made in installments. Benefit payments will be made every 3 months. The first payment is due when the appliance is installed. Later payments are due at the end of each 3-month period. The first installment is 25% of the charge for the entire course of treatment. The remainder of the charge is prorated over the estimated duration of treatment. Payments are only made for services provided while a person is insured. If insurance coverage ends or treatment ceases, payment for the last 3-month period will be prorated.
replacement of a bridge, crown or denture within 60 consecutive months after the date it was originally installed unless: the replacement is made necessary by the placement of an original opposing full denture or the necessary extraction of natural teeth; or the bridge, crown or denture, while in the mouth, has been damaged beyond repair as a result of an injury received while a person is insured for these benefits; any replacement of a bridge, crown or denture which is or can be made useable according to common dental standards; procedures, appliances or restorations (except full dentures) whose main purpose is to: change vertical dimension; diagnose or treat conditions or dysfunction of the temporomandibular joint; stabilize periodontally involved teeth; or restore occlusion; porcelain or acrylic veneers of crowns or pontics on, or replacing the upper and lower first, second and third molars; bite registrations; precision or semiprecision attachments; or splinting; instruction for plaque control, oral hygiene and diet; dental services that do not meet common dental standards; services that are deemed to be medical services; services and supplies received from a Hospital; services for which benefits are not payable according to the “General Limitations” section.
HC-DEN6
04-10
V3
HC-DEX1
04-10
Class IX Services – Implants Covered Dental Expenses include: the surgical placement of the implant body or framework of any type; any device, index, or surgical template guide used for implant surgery; prefabricated or custom implant abutments; or removal of an existing implant. Implant removal is covered only if the implant is not serviceable and cannot be repaired. Implant coverage may have a separate deductible amount, yearly maximum and/or lifetime maximum as shown in The Schedule.
V1
General Limitations Dental Benefits No payment will be made for expenses incurred for you or any one of your Dependents: for or in connection with an injury arising out of, or in the course of, any employment for wage or profit; for or in connection with a Sickness which is covered under any workers' compensation or similar law; for charges made by a Hospital owned or operated by or which provides care or performs services for, the United States Government, if such charges are directly related to a military-service-connected condition; services or supplies received as a result of dental disease, defect or injury due to an act of war, declared or undeclared; to the extent that payment is unlawful where the person resides when the expenses are incurred;
HC-DEN8
04-10
V1
Expenses Not Covered Covered Expenses will not include, and no payment will be made for: services performed solely for cosmetic reasons; replacement of a lost or stolen appliance;
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