Dental
Accidents – 90%
Benefits are provided for
services and supplies performed by a physician or dentist for the prompt repair
of sound natural teeth (as defined in number one below) when damaged as a result
of an injury. Covered services and supplies include only those dental procedures
completed within 270 days following the date of the accident, and only if the
individual remains eligible under this plan. Benefits are provided based on the
usual, customary and reasonable charge as determined by this plan.
The following limitations
apply to this benefit:
- Any
tooth being repaired must have been a sound natural tooth, meaning whole or
properly restored, without impairment or periodontal disease, and not in need of
treatment for reasons other than the dental injury. Repair or replacement of
existing crowns or prosthetic appliances will be covered under this benefit if
satisfactory proof is submitted documenting that the need for repair or
replacement is a direct result of the injury.
- If
crowns, dental implants, dentures, bridgework, or in-mouth appliances are
installed as a result of an injury, the plan allows only the first denture or
bridgework to replace lost teeth, the first crown or dental implant to repair
each damaged tooth, or the in-mouth appliance that is installed as the first
course of orthodontic treatment following the injury. A dental implant is
considered acceptable treatment when clear clinical evidence shows a
conventional fixed or removable prosthesis cannot provide clinically acceptable
treatment. If dental implant treatment is elected when a conventional fixed or
removable prosthesis provides acceptable clinical treatment, an allowance for
the implant will be provided based on the cost of a conventional fixed or
removable prosthesis as determined by this plan.
Benefits
are not
provided for:
- Services
or supplies related to the removal, repair, replacement, restoration, or
repositioning of teeth lost or damaged in the course of biting or
chewing.
- Procedures,
appliances or restorations that are primarily for cosmetic purposes, including
any direct or indirect complications thereof.
- Services
or supplies resulting from illness or disease, or that is in any way related to
an illness or disease.
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