ESTRUCTURA DE LA ADMINISTRACIÓN DE LA SOCIEDAD

In addition to exclusions noted previously, the Plan will not provide benefits for any of the items listed in this section. This list is intended to give you a general description of expenses for services and supplies not covered by the Plan.

● Any portion of a charge which exceeds the maximum allowable fee or the filed fee, whichever is less, for the geographic area in which services are rendered.

● Any service, supply, or treatment which does not meet the standards accepted by the American Dental Association (ADA).

● Services or supplies for which there is no legal obligation to pay or charges which would not be made except for the availability of benefits under the Plan.

● Services furnished by or for the U.S.

government or any other government, unless payment is legally required.

● Any condition, disability or expense sustained as a result of being engaged in: an illegal occupation, commission or attempted

as a member of the armed forces of any state or country, or a war or act which is declared or undeclared.

● Services for injuries or conditions that are compensable under Worker’s Compensation or Employers’ Liability laws, and services that are provided to the eligible person by any federal or state or provincial government agency or provided without cost to the eligible person by any municipality, county, or other political subdivision, other than medical assistance in this state, under medical assistance RCW 74.09.500, or any other state, under 42 U.S.C., Section 1396a, section 1902 of the Social Security Act.

● Materials placed in tooth extraction sockets for the purpose of generating osseous filling. ● Experimental services or supplies. Experimental

services or supplies are those whose use and acceptance as a course of dental treatment for a specific condition is still under investigation/ observation. In determining whether services are experimental, Delta Dental/ Washington Dental Service, in conjunction with the American Dental Association, will consider if: ● the services are in general use in the dental

community in the State of Washington; ● the services are under continued scientific

testing and research;

● the services show a demonstrable benefit for a particular dental condition; and ● they are proven to be safe and effective.

Any individual whose claim is denied due to this experimental exclusion clause will be notified of the denial within 20 working days of receipt of a fully documented request. Any denial of benefits by Delta Dental/ Washington Dental Service on the grounds that a given procedure is deemed experimental, may be appealed to Delta Dental/Washington

documentation reasonably required to make a decision. The 20-day period may be extended only with written consent of the covered individual.

● Expenses for preparing dental reports, itemized bills, or claim forms.

● Mailing and/or shipping and handling charges. ● Patient management problems.

● Habit-breaking appliances.

● Charges for broken appointments or telephone calls.

● Services or supplies furnished, paid for or for which benefits are provided or required by reason of past or present service of any covered family member in the armed forces of a government.

● Professional services performed by a person who ordinarily resides in your household or who is related to the covered person, such as a spouse/Adult Benefit Recipient, parent, child, brother, sister, or in-law.

● Expenses eligible for consideration under any other plan of the employer.

● Expenses incurred for services rendered or devices ordered before the date of coverage under this Plan.

● Training, educational instruction, or materials relating to dietary counseling, personal oral hygiene, or dental plaque control.

● The replacement of a lost, stolen or missing prosthetic device.

● Services and supplies for personalization or characterization of prosthetic devices.

● Restorations or appliances necessary to correct vertical dimension or to restore the occlusion; such procedures include restoration of tooth structure lost from attrition, abrasion or erosion, and restorations for malalignment of

● General anesthesia/intravenous (deep)

sedation, except as specified for certain covered endodontic, periodontic, and oral surgery procedures. General anesthesia except when medically necessary, for children through age six or a physically or developmentally disabled person, when in conjunction with covered dental procedures.

● Athletic mouth guards.

● Duplicate prosthetic devices or appliances. ● Treatment, by any means, of jaw joint problems

including temporomandibular joint dysfunction syndrome (TMJ) and other craniomandibular disorders or other conditions of the joint linking the jawbone and skull, and the muscles, nerves, and other tissues related to that joint. ● Procedures or appliances to stabilize

periodontally involved teeth.

● Precision or semi-precision attachments. ● Expenses for services performed after the date

coverage ends under this Plan. However, if performed within 90 days of the date coverage ends, the following services will be provided: ● Installation or adjustment of dentures or fixed bridgework if the impressions were taken before coverage ended.

● Crowns, inlay, or onlay restorations if the tooth or teeth were prepared before coverage ended.

● Root canal therapy if the pulp chamber was opened before coverage ended.

● Any charge for dental services or supplies included in your selected Medical option, including surgery; hospitalization charges and any additional fees charged by the dentist for hospital treatment

● Application of desensitizing agents

● Analgesics such as nitrous oxide, conscious sedation, euphoric drugs, injections, or prescription drugs

● Charges for treatment not given by a legally qualified dentist, except for scaling or cleaning of teeth by a licensed dental hygienist, which is covered if rendered under the supervision and direction of the dentist.

● Charges for cosmetic dentistry.

● Charges for replacement of dentures or bridgework if less than five years from the last denture or bridgework replacement.

● Services that are payable under any automobile

medical, personal injury protection (“PIP”), automobile no-fault, homeowner, commercial premises coverage, or similar contract or insurance, when such contract or insurance

makes benefits or services available to you whether or not you make application for such benefits or services. Any benefits or services provided under this plan that are subject to this exclusion are provided solely to assist you and such assistance does not waive the Plan’s right to reimbursement or subrogation as specified under Third-Party Liability, page 5-7. This exclusion also applies to services and supplies after you have received proceeds from a settlement as specified in the Benefits From Other Sources section, pages 5-7 to 5-10. ● Copings

● Under the Delta Dental PPO 1500 Plan, orthodontic services and supplies

Glossary of Terms From