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Dental |
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For Employees and
Eligible Dependents
The Plan covers certain Dental expenses incurred by Employees
and their eligible dependents, subject to the co-insurance arrangements
described below. The schedule of fees to be used is that which
is in
effect in the Employee's province of residence on the date the service is
rendered. The benefits are provided under three categories:
- Basic Services - 100% reimbursement
- Major Services - 100% reimbursement
Maximum of $2000 per person/calendar year for Basic and Major
Services combined
- Orthodontia - 50% reimbursement
Maximum of $2000/24 months per eligible depedent child
Examples
of each and the rules applying to each appear below.
Definition
of a Dentist
The term "dentist" means a legally
qualified dentist, practicing within the scope of his or her
license. For the purposes of this Plan, the term
"dentist" also includes a legally qualified physician
authorized to perform the particular service rendered, a denture
technician, denturologist, denturist, licensed dental hygienist
or dental mechanic, practicing within the scope of his or her
license.
Many Dental conditions can properly be treated in more
than one way. This Plan is designed to help pay Dental
expenses, but not on the basis of treatment that is more
expensive than necessary for good Dental care.
Therefore, if a condition is being treated for, and two or more services
included in the schedule are suitable under customary Dental
practices, the benefit paid by the Plan will be based on the least
expensive of services.
Pre-determination of Benefits
Pre-determination of benefits permits the review of the proposed
treatment in advance and allows for resolution of any questions
before, rather than after, the work has been done. Additionally,
both the Insured and the dentist will know in advance what is covered
and what the Plan will pay, assuming the Employee or the dependent
remains covered.
If the treatment that the dentist is proposing
will cost more than $1,000, the dentist’s Treatment Plan must
be submitted to the Plan Administrator for prior review. No
Treatment Plan is required if the proposed treatment is
for emergency care. A Treatment Plan is required for all Major
and Orthodontia services.
A "Treatment Plan" is the
dentist’s report that (a) details the recommended services,
(b) shows the charge for each service, and (c) is accompanied by
supporting x-rays.
What an "Eligible Charge" Is
An "eligible charge" is one the dentist makes to the
Insured for a covered Basic or Major Dental service furnished to
him or her or
a covered dependent, provided the service:
- is in applicable
Fee Schedule;
- is part of a "Treatment Plan" as
described above, and
- is not excluded by the section
"Limitations" below.
The
amount of the eligible charge for a covered service, with the
exception of Orthodontia, is equal to the charge made by the
dentist, but not to exceed the amount provided for that service
in the applicable Fee Schedule.
A charge will be considered to
be incurred on the date the service is received, rather than on
the date the charge is made.
The following is an outline of
the types of eligible expenses and the level of
payment within the Plan:
BASIC SERVICES – paid
at 100%*
- Visits and Examinations
- Standard or recall
examinations (limited to one per calendar year, two per calendar
year for children up to their 13th birthday)
- Visit during
office hours to treat injuries (other than for routine operative
procedures)
- Prophylaxis - including scaling and polishing
(limited to twice yearly)
- Topical application of fluorides
(limited to twice yearly)
- Emergency palliative treatment
- Consultation by specialist when diagnosis has been made by
general dentist
- X-Rays and Pathology
- Single film
- Additional films (up to 12)
- Complete series - 14 or more
films (limited to once every 3 years)
- Bitewings (limited to
twice yearly)
- Biopsy and examination of oral tissue
- Microscopic examination
- Restorations
- Amalgam and composite
restorations only if necessitated by decay or traumatic injury
- Oral Surgery (including local anaesthesia and routine
postoperative care)
Extractions
- Uncomplicated
- Surgical
removal of erupted and impacted teeth
- Postoperative visits
(sutures and complications) after multiple extractions and
impaction
- Other Oral Surgery
- Incision and drainage of
abscess
- Removal of cyst or tumor
- Surgical exposure of
tooth
- Alveoloplasty
- Gingivoplasty and/or stomatoplasty
- Osteoplasty
- Frenectomy
- Alveoplasty
- Maxillary sinusotomy
for removal of tooth fragment or foreign body
- Suture, soft
tissue injury
- Periodontics
- Subgingival curettage, root
planing (limited to 16 units per year)
- Gingivectomy
- Endodontics
- Pulp capping
- Root canals (including necessary
x-rays and cultures)
- Apicoectomy
- Denture Repairs (Acrylic)
- Denture rebasing and relining (limited to once every two years)
- Adding teeth to partial denture to replace extracted natural
teeth, only if teeth extracted while insured under this Plan.
- Space Maintainer, Fixed (Band Type) limited to children under 21
years of age.
- General Anaesthesia (Only with oral surgery)
MAJOR
SERVICES – paid at 100%* with the exception of (a), (b)
& (c) below.
As an exception a maximum reimbursement not to
exceed 70% of the amount shown in the Fee Schedule will apply
if:
(a) a replacement is made necessary by the initial placement
of an opposing full denture of the extraction of natural teeth
or;
(b) the denture is a stay-plate and is being replaced by a
permanent denture, or;
(c) the denture, while in the oral cavity,
has been damaged beyond repair as a result of an injury while
insured.
Inlays and Crowns - (Not covered if teeth can be
restored with a filling material)
- Inlays and onlays
- Crowns
- Acrylic, acrylic with metal, porcelain, porcelain with metal,
gold, gold dowel pin, veneers and metal post and core.
- Pontics (Artificial teeth)
- Cast gold, porcelain fused to
gold, plastic processed to gold.
- Removable Bridge
(Unilateral)
- One piece casting, gold or chrome cobalt alloy
clasp attachment (all types)
- Dentures (Specialized techniques
not eligible)
- Complete upper or lower
- Partial dentures
- Partial denture repairs limited to twice in a calendar year.
* The
maximum benefit payable for Basic and Major services (combined)
is $2,000 per Insured person per calendar year.
ORTHODONTIA -
paid at 50%
To be eligible for this benefit, the Employee must have been
covered for at least 3 consecutive months. This benefit applies
to Orthodontia (teeth straightening) treatment for an eligible
dependent child who is under the age of 21.
Eligible expenses will be
reimbursed up to 50% with a maximum benefit of $2,000 per
eligible dependent child, each 24 month period.
A "Treatment
Plan" must be submitted as outlined previously.
The Plan
will not pay for a Treatment Plan for which an active appliance
was installed before the patient becomes eligible for
Orthodontia benefits.
Limitations
Please note the following
exclusions:
- Anything not furnished by a dentist, except
x-rays ordered by a dentist. Anything not necessary or not
customarily provided for Dental care.
- Services (a) furnished
by or for any government unless payment is legally required, or
(b) to the extent provided under any government program or law
under which the individual is, or could be covered.
- A denture
or fixed bridge involving replacement of teeth extracted before
the individual was covered, unless it also replaces a tooth that
is extracted while covered, and such tooth was not an abutment
for a denture or fixed bridge installed during the preceding
five years.
- Services due to an accident related to employment
or disease covered under Workers’ Compensation or similar law.
- Replacement of lost or stolen appliances or restorations for the
purpose of splinting, or to increase vertical dimension or
restore occlusion.
- Any portion of a charge for a service in
excess of the applicable Provincial Dental Regulatory Authority Fee Schedule.
- Services for cosmetic
purposes unless made necessary by an accident occuring while
covered. (Facings on crowns or pontics, posterior to the second
bicuspid, are always considered cosmetic, as are plastic,
porcelain, or other materials fused to gold on molar crowns or
pontics).
- Services due to war, insurrection, participation in
a riot or civil commotion, commission of or attempted commission
of, a criminal offense or provoking an assault excluding charges
in connection with offenses related to the operation of a motor
vehicle with a blood alcohol content in excess of the legal
limit in the province of residence of the Insured, or a
self-inflicted injury.
- Recent duplication of services by same
or different dentist.
- Endodontics and coping with respect to
over-denture.
- Treatment which was furnished or commenced
prior to the date insured under the Plan.
If a particular charge
is covered under the Dental Insurance and also under another
part of the Plan, the Dental Insurance payment will be limited
to the excess, of any of the amount normally paid by that
insurance over the amount paid by the other benefit.
How to File a Claim
A claim form for Dental expenses must be completed for each
insured person in the family who has eligible expenses. Specify
the dependent’s name, the Employee’s name, address, policy
number and Social Insurance Number/certificate number.
Both the receipts and the forms should be sent to the
Administrator. Claims should be submitted once the course of
treatment has been completed.
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