CARPENTERS HEALTH FUND OF
DENTAL CARE BENEFITS
PAYMENT:
Payment will be made at the
applicable percentage rates indicated below for the covered dental expenses
outlined herein and incurred by an eligible participant or dependent for those covered
charges up to the maximum amount of $1,000 per eligible person per calendar
year:
Preventive
Care
..100%
Basic/Routine
Care
..80%
Major
Care
...
50%
Except as
described in the section entitled "After Eligibility Terminates, such
expenses must be incurred and the services and supplies furnished while the
employee or dependent are eligible.
A charge will be deemed
incurred as of the date the service is rendered or the supply is furnished,
except that such charge will be deemed incurred:
with respect to fixed bridgework, crowns, inlays, onlays or gold restorations, on the first date of
preparation of the tooth or teeth involved;
with respect to full or partial dentures, on the date the
impression was taken; and
with respect to endodontics, on
the date the tooth was opened for root canal therapy.
COVERED DENTAL CHARGES:
Covered dental charges are
the charges of a dentist or physician for the services and supplies listed
below required for dental care and treatment of any disease, defect or
preventive dental care.
Not included is any charge in
excess of the Reasonable and Customary charges made:
for similar services and supplies by dentists or
physicians in the locality concerned or
where alternate services or supplies are customarily
available for such treatment, for the least expensive service or supply
resulting in professionally adequate treatment.
TREATMENT PLAN:
Participants are encouraged
to request a Pre-treatment Estimate of benefits payable, when the total cost
associated with the proposed dental work is expected to exceed $200. The dental claim form contains a provision
for requesting such information prior to the date treatment is rendered.
A treatment plan is a plan of
dental services (including x-rays) which indicates the patient's dental needs,
gives a written description of the proposed treatment necessary in the
professional judgment of the attending dentist, and shows the cost of the
proposed treatment.
The filing of a treatment
plan should help to avoid any misunderstanding as to the extent of
coverage. This process identifies
coverage and clarifies benefit specifications, such as deductibles, coinsurance
and limits. Also, it gives the patient
and dentist an opportunity to review the proposed treatment and the extent of
coverage before any work is started.
PREVENTIVE AND DIAGNOSTIC CARE:
Charges for
cleaning and scaling of teeth, but not more often than once every six (6)
months.
Charges for fluoride
application for dependent children's teeth through age eighteen (18), but not
more often than once a Calendar Year.
Charges for
space maintainers and their fittings.
Charges for
diagnostic x-rays.
Charges for emergency
treatment for relief of dental pain on a day for which no other benefit other
than for x-rays is payable hereunder.
Oral
examinations, but not more than once every six (6) months.
Charges for sealants for
dependent children through age eighteen (18).
Study models and diagnostic
casts (other than for orthodontics)
BASIC/ROUTINE CARE:
Initial
amalgam, silicate, acrylic or composite restorations.
Replacement
of an amalgam, silicate, acrylic or composite restorations.
Charges for
extraction of one or more teeth, cutting procedures in the mouth, and treatment
of fractures and dislocations of the jaw, but not including additional charges
for removal of stitches or post-operative examination.
Charges for
treatment of gums and supporting structure of the teeth.
Charges for
root canals and other endodontic treatment.
Charges for
general anesthetics and their administration in connection with oral surgery, periodontics, fractures or dislocations.
Local anesthesia (not in
connection with operative or surgical procedures), regional block and
trigeminal division block anesthesia or analgesia.
Charges for
injectable antibiotics administered by a dentist or
physician.
Charges for recementing inlays or crowns at least 90 days after the
date the inlay or crown was provided.
Relining, rebasing or
repairing of an existing prosthesis (fixed bridgework, removable partial or
complete dentures) at least ninety (90) days after the date the installation or
repair of the prosthesis was performed.
Consultation required by the
attending dentist.
MAJOR CARE:
Charges for fillings and
crowns necessary to restore the structure of teeth broken down by decay or
injury, but the charge for a crown or gold filling will be limited to the
charge for a silver, porcelain or other filling unless the tooth cannot be
restored with such other material and the charge for replacement of a crown or
gold filling is covered only if the crown or filling is over five (5) years
old.
Charges for full or partial
dentures, fixed bridges, or adding teeth to an existing prosthesis if required
because of loss of natural teeth while the person is covered for this benefit
and to replace such teeth or to replace an existing prosthesis which is over
five (5) years old and cannot be made serviceable.
Charges for specialized
techniques involving precision attachments, personalization or characterization
are not covered. Additional charges for
adjustments within six (6) months from installation are not included as covered
dental charges.
AFTER COVERAGE TERMINATES:
The benefits described herein
are also provided for covered dental charges:
For services or supplies
furnished within ninety (90) days after coverage terminates if the charges were
incurred while coverage was in force and incurred within ninety (90) days after
coverage terminates if an accident resulting in injury to natural teeth
sustained while coverage was in force causes continuous total disability from
the date of termination; provided benefits are not payable for such expenses
under any other group plan.
EXCLUSIONS (Services that are not covered):
Dental procedures, which are
included as covered medical expenses under any other comprehensive or major
medical plan provided by the Plan Administrator.
Treatment by someone other
than a dentist or physician, except where performed by a duly qualified
technician under the direction of a dentist or physician;
Dental treatment required as
a result of self-inflicted injury, war, whether declared or not, riot or
insurrection.
Charges for
broken appointments or form preparation.
Services
and supplies cosmetic in nature.
Training in or supplies used
for dietary counseling, oral hygiene or plaque control.
Replacement of an existing
prosthesis (fixed bridgework, removable partial or complete dentures), which
has been lost, mislaid or stolen.
Dental treatment involving
the use of gold if such treatment could have been rendered at a lower cost by
means of a reasonable substitute.
Installation of an initial prosthodontic appliance replacing any natural teeth
extracted prior to the effective date of coverage unless necessitated by the
extraction of at least one natural tooth while covered under this plan.
Replacement of existing prosthodontic appliances unless:
necessitated by the extraction of additional natural teeth while
covered under this plan;
the existing appliance is at least five years old and
cannot be made serviceable;
the existing appliance is temporarily installed after the
effective date of this plan;
the replacement appliance is made necessary as the result
of an initial placement of an opposing denture; or
the replacement is made necessary as a result of an
accidental injury.
Services or supplies, which
do not meet accepted standards of dental practice including charges for
services or supplies which are experimental in nature.
Examinations
for use by a third party.
Emergency
prescriptions or other drugs and/or medicaments.
Dental
procedures, which do not directly involve the teeth or the tissues or bones,
which support the teeth.
Surgical implants of any
type.
Charges for
athletic mouthguards.
Charges for any duplicate
prosthetic device or any other duplicate appliance.
Services and supplies
furnished in a U.S. Government Hospital.
Services which the employee
or dependent would not be required to pay if there were no plan.
Services and supplies
furnished in connection with injuries sustained while engaged in any occupation
for remuneration or profit, or disease for which worker's compensation or
similar benefits are payable.
Services
for which a dependent is entitled to benefits as an employee or former
employee.
Dental treatment received
from a dental or medical department maintained by an employer, association, or
similar type of group.
Services and supplies
rendered for full mouth reconstruction, orthognathic
surgery or for a correction of temporal mandibular
joint dysfunction (TMJ).
Veneers.
Orthodontic
treatment of any kind.