1. Any loss that occurs while this policy* is not in force.
2. Amounts not reimbursed because of applicable Policy* Year Deductible, Coinsurance, benefit maximums, or frequency limitations.
3. Any loss that occurs during a Waiting Period.
4. Amounts in excess of the Reasonable and Customary Charge.
5. Items, treatments or services:
a. Not covered under this policy*, including any complications arising therefrom;
b. That are not prescribed by or performed by or under the direct supervision of a Physician in accordance with generally accepted dental or medical standards, to include services not rendered or that are not rendered within the scope of their license;
c. Not Medically Necessary as determined by Us;
d. Deemed to be Experimental or Investigational as determined by Us;
e. That would not routinely be paid in the absence of insurance; or
f. Performed by an Immediate Family member.
6. Separate fees for services that are considered an integral part of an entire service, such as pulp capping, surgical trays, sutures, or pre and postoperative care.
7. Services or procedures that have not been completed.
8. Any cosmetic items, treatments or services provided primarily for the purpose of improving appearance, self-esteem or body image, including characterizing and personalizing prosthetic devices, and correction of congenital malformation.
9. Any device, appliance, or service related to:
a. Altering vertical dimension;
b. Restoring or maintaining occlusion;
c. Splinting teeth or stabilizing teeth for periodontal reasons;
d. Abrasion, attrition, bruxism, erosion, abfraction;
f. Tooth desensitization; or
g. Maxillofacial prosthetics.
10. Any surgical or nonsurgical treatments or services, including myofunctional therapy and physical therapy for any jaw joint problems, including, but not limited to: temporomandibular joint disorder (TMJ), craniomandibular disorder, craniomaxillary or other conditions of the joint linking the jaw bone and skull or treatment of the facial muscles used in expressions and chewing functions, for symptoms including, but not limited to, headaches.
11. Occlusal, athletic, or night guards and related services.
12. Orthodontic treatment or orthognathic surgery and related services.
13. Ridge preservation, augmentation, bone grafts, and tissue regeneration when performed in edentulous sites (toothless areas).
14. Overdentures, precision or semi-precision attachments and related services.
15. Sealants, fluoride treatments, preventive resin restorations, or space maintainers and related services.
16. Supplies, including, but not limited to, services or supplies for temporary or provisional crowns, bridges or dentures, and duplicate or temporary devices, appliances, and prosthetics.
17. Replacing a lost, stolen or missing appliance or prosthetic device.
18. Oral hygiene instructions, behavior modification, diet instruction or infection control.
19. Sterilization of equipment; disposal of medical waste or other requirements mandated by the Occupational Safety and Health Administration (OSHA) or other regulatory agencies.
20. Treatment or diagnosis received while outside the continental United States, except Hawaii.
21. Work-related sickness or injury for which You are eligible for any workers’ compensation, employers’ liability or similar laws, whether or not benefits are claimed.
22. Services for which no charge is made or for which You are not legally obligated to pay, including, but not limited to, services furnished through: a. Your employer, labor union or similar group, in its dental or medical department or clinic; or b. A facility owned or run by any government body.
23. Services furnished by, or payable under, any public program (except Medicaid), or paid for or sponsored by any government body.
24. Telephone consultations, charges for failure to keep a scheduled appointment, copy fees, sales tax, charges for completion of a claim form, or any take-home supplies. If You use an external discount or coupon, the amount that is reduced from the Billed Charge is not a covered loss under this policy*.
25. Ancillary charges, including, but not limited to, hospital, ambulatory surgical center or similar facility; or use of provider office space.
26. Any loss resulting from:
a. War, declared or undeclared, or actively serving in the armed forces or their auxiliary units, including any country’s National Guard or Army Reserve or their equivalent;
b. Committing, attempting to commit, or participation in a felony or engaging in an illegal occupation;
c. Your participation in a riot, rebellion, or insurrection; or
d. An intentionally self-inflicted injury while sane or insane.
27. Impacted teeth.
28. Prescription and non-prescription drugs, whether dispensed or prescribed, including chemotherapeutic agents.
29. Speech therapy for any purpose.
30. Laboratory and pathology tests and examinations, except as specifically listed in the Benefits section of Your policy*.
31. Oral surgery and related services, except as specifically listed in the Benefits section of Your policy*.
32. Full mouth debridement.
33. Implantology and related services; implants, including removal of implants, and related services.
34. Any surgical procedure performed in the treatment of cataracts.
35. Vision surgery to correct visual acuity, including, but not limited to, LASIK and other laser surgery, radial keratotomy (RK) services or surgery to correct astigmatism, nearsightedness (myopia) and/or farsightedness (presbyopia), automated lamellar keratoplasty (ALK), conductive keratoplasty (CK) or other cosmetic procedures.
36. Orthoptic or vision therapy training and any associated supplemental testing, medical or surgical treatment or services of the eyes or supporting structures.
1. Items, treatments or services:
a. not listed as an Eligible Expense in the Coverage Schedule;
b. not prescribed by or performed by or under the direct supervision of a Dentist or a Provider;
c. not Medically Necessary;
d. any Experimental or Investigational procedure or treatment; or
e. performed by a member of your or your spouse’s family (family includes parents, step-parents, in-laws, spouse or former spouse, domestic partner, children, siblings, aunts, uncles, cousins, nieces, nephews, grandparents, and guardians).
2. Services furnished primarily for cosmetic reasons, including but not limited to:
a. specialized techniques, characterizing and personalizing prosthetic devices;
b. making facings on prosthetic devices for any tooth in back of the second bicuspid;
c. replacements of restorations performed for cosmetic reasons; or
d. charges for radial keratotomy (RK), automated lamellar keratoplasty (ALK), conductive keratoplasty (CK) or other cosmetic procedures.
3. Charges for any appliance or service that is used to:
a. change vertical dimension;
b. restore or maintain occlusion;
c. splint or stabilize teeth for periodontal reasons; or
d. Charges for any service performed as a result of abrasion, attrition, bruxism, erosion or abfraction.
4. Charges for any service performed as a result of abrasion, attrition, bruxism, erosion or abfraction.
5. Occlusal, athletic, or night guards.
6. Orthodontic treatment; implantology and related services; implants and all related procedures, including removal of implants.
7. Preventive root canal therapy.
8. Full mouth debridement.
9. Charges for any services that are considered to be an integral part of another service, such as pulp capping, surgical trays, or sutures.
10. Ridge preservation, augmentation, bone grafts and regeneration procedures performed in edentulous sites.
11. Overdentures or precision attachments.
12. Space maintainers and sealants.
13. Preparation and fitting of preformed dowel or post for root canal tooth; pulp cap either directly or indirectly.
14. Duplicate or temporary devices, appliances, and services except as listed as an Eligible Expense.
15. Replacing a lost, stolen or missing appliance or prosthetic device.
16. Application of chemotherapeutic agents.
17. Oral hygiene, plaque control, diet instruction or infection control.
18. Charges for sterilization of equipment; disposal of medical waste or other requirements mandated by OSHA or other regulatory agencies.
19. Treatment or diagnosis received while outside the territorial limits of the United States.
20. Treatment which is:
a. due to an on-the-job or job-related illness or injury; or
b. a condition for which benefits are payable by Workers’ Compensation or similar laws, whether or not benefits are claimed.
21. Treatment for which no charge is made or for which you are not legally obligated to pay including, but not limited to, treatment (or charges made) by:
a. your employer, labor union or similar group, in its dental or medical department or clinic;
b. a facility owned or run by any government body; or
c. any public program, except Medicaid, paid for or sponsored by any government body.
22. Telephone consultations, charges for failure to keep a scheduled appointment, X-ray copy fees, or charges for completion of a claim form.
23. Ancillary charges, including but not limited to, hospital, ambulatory surgical center or similar facility; or use of provider office space.
24. Treatment resulting from:
a. your participation in a war or an act of war, declared or undeclared;
b. your attempting to commit, or committing, an assault or felony;
c. your unlawful participation in a riot, rebellion, or insurrection; or
d. an intentionally self-inflicted injury while sane or insane.
25. Fluoride treatments.
26. Impacted wisdom teeth.
27. Prescription drugs.
28. Any surgical procedure performed in the treatment of cataracts.
29. Charges in excess of the Reasonable and Customary Charge.
30. Services for which you are not liable or for which no charge normally is made in the absence of insurance.
31. Loss that occurs while this policy* is not in force.
1. In the event you transfer from the care of one Dentist or Provider to that of another during the course of treatment, or if more than one Dentist or Provider performs services for one Eligible Expense, we shall be liable for not more than the amount we would have been liable for had but one Dentist or Provider performed the service.
2. In all cases involving Eligible Expenses in which the Dentist or Provider and you select a more expensive course of treatment than is customarily provided by the medical or dental profession, consistent with sound professional standards of medical or dental practice for the Eligible Expense concerned, payment under the plan will be based on the charge allowed for the lesser procedure.