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Company does not provide coverage for: Services of any dentist other than a Participating General Dentist, except out-of-area emergency care as explained in the certificate; Procedures not specifically listed as a covered benefit in the certificate; You will not be entitled to receive Benefits, transfer Dental Facilities, or enjoy other privileges of a Member in good standing whenever any Contributions or Copayments are delinquent; Dental treatment started prior to the Member’s effective date for eligibility of benefits; Services which in the opinion of the Participating General Dentist or Company are not necessary treatment to establish and/or maintain oral health; Services that are not appropriate or customarily performed for the given condition, do not have uniform professional endorsement, do not have a favorable prognosis, or are experimental or investigational; Services that are not consistent with the normal and/or usual services provided by the Participating General Dentist or which in the opinion of the Participating General Dentist would endanger health; Services or procedures which the Participating General Dentist is unable to perform because of the general health or physical limitations of the patient; Procedures, appliances or restorations to change vertical dimension, or to diagnose or treat abnormal conditions of the temporomandibular joint (TMJ); or replacement of lost, missing or stolen appliances; Services performed primarily for cosmetic purposes; Services provided by a Participating Pediatric Dentist to children over the age of seven; Removal of asymptomatic third molars unless pathology (disease) exists; Services for treatment of bodily injury or sickness that arose from or was sustained in the course of any occupation or employment for compensation, profit or gain; Crowns, inlays, onlays, or veneers for the purpose of: altering vertical dimension of teeth; restoring/maintaining occlusion; splinting teeth, or replacing tooth structure lost as a result of wear.
Pages: 608
Publisher: CRC Press; 1 edition (June 19, 2002)
ISBN: 1566705967
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