Exclusions And Limitations

No Benefits will be paid for:

  1. Dental services not specifically described in the Policy as Dental Services and Emergency Services.
  2. Dental or emergency service for congenital malformations or for cosmetic or aesthetic purposes, except that the Plan will replace congenitally missing teeth.
  3. Bleaching of teeth for purely cosmetic reasons.
  4. Laboratory charges.
  5. Replacement of crowns (except for temporary or stainless steel crowns) unless at least five (5) years have elapsed since the date of the initial insertion.
  6. A personalized appliance or one involving specialized techniques beyond what is necessary to eliminate oral disease and restore missing teeth, if a satisfactory result can be achieved through the utilization of standard procedures and materials. The balance of cost for the selected appliance or technique shall be the responsibility of the Member.
  7. Replacement of an existing removable partial denture, full denture or fixed bridge by a new removable partial denture, full denture or a fixed bridge, or addition of teeth to an existing removable partial denture or bridge unless at least (5) years have elapsed since the date of the initial insertion of that appliance.
  8. Charges for any duplicate prosthetic device or any other duplicate appliance including orthodontic appliance whether lost, stolen or damaged. (If, upon enrolling in this Plan, the Participant’s existing bridge or denture is not satisfactory in the sole opinion of the Dental Clinic, the Plan will pay for its replacement minus the actual cost of any lab fees).
  9. Dental or emergency service which, if this Policy were not in effect: would be furnished to the Participant without charge; the Participant would be entitled to have furnished or paid for fully or partially under any law, regulation or agency of any government; or the Participant would be entitled, or would be entitled if s/he were enrolled, to have furnished or paid for under any voluntary medical or dental plan established by any government.
  10. Dental or emergency service for, or resulting from injuries, disease or conditions for which the Participant receives, or would have been eligible had benefits been applied for, any award or settlement under a Workers’ Compensation Act or any Employer Liability Law or Occupational Disease Act or Law.
  11. Dental Service provided after the date the Participant ceases to be covered except for the following:
    • Procedures commenced prior to and completed in one visit within 31 days following termination of coverage (e.g., root canal or crown). These are procedures that have been started while the Policy is in effect and are completed in one visit after coverage is terminated.
    • Prosthetic devices which are ordered and fitted prior to, and completed within 60 days following termination of coverage.
  12. Any charges for Dental Service received at a dental facility other than the Dental Clinic of Marshfield, S.C., except for Emergency Services as set forth in Article VI.
  13. Implants and implant prosthetics.
  14. Hospital or physician services of any kind whether or not related to covered services.
  15. IV sedation or oral sedation.
  16. Charges for treatment of or services related to temporomandibular joint dysfunction.
  17. Hospital or physician services of any kind whether or not related to covered Dental Services.
  18. Dental Service and Emergency Service resulting from diseases contracted or injuries sustained as a result of war, declared or undeclared, enemy action or action of the Armed Forces of the United States, or its allies, or while serving in the Armed Forces of any country; or any illness or injury occurring after the effective date of this Policy and caused by atomic explosion whether or not the result of war.
  19. Out of Area Services, unless due to an Emergency and then covered only to the extent of the Emergency Service benefit set forth in Article VI.
  20. Dental Service and Emergency Service received from a dental or medical department maintained on behalf of an employer, a mutual benefit association, a labor union, academic institution, trustee or similar person or group.
  21. If a satisfactory result can be achieved by a conventional removable partial denture in the case of bilateral edentulous areas, but the Participant selects a more complicated treatment (precision attachments or fixed bridgework), Benefits shall be limited to the appropriate procedures necessary to eliminate oral disease and restore missing teeth. The balance of the cost for the more elaborate selected procedure will be the responsibility of the Participant.
  22. Posterior composite restoration.
  23. Any service related to:
    • Altering vertical dimension
    • Restoration of occlusion
    • Splinting teeth including multiple abutments or any service to stabilize periodontally weakened teeth
    • Replacing tooth structures as a result of abrasions, attrition, or erosion
    • Bite registration or bite analysis
  24. Any service, or a related service, which is a benefit under a hospital and/or surgical-medical group benefit plan offered by the same Group that covers the Participant.
  25. Sleep apnea/snoring appliances.
  26. [Missed appointment charges].

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