GRI-DEN3-OC-JR-48 Page 3 04/30/18
45631-G-1018
A new deductible amount must be met each calendar year.
The maximum benefit per covered person, per calendar year is
shown in the policy Data Pages.
Benefits for certain types of services will not be payable until
after the waiting period has been satisfied.
What Is Not Covered
No benefits will be paid for any service or treatment for which
charges incurred are not identified and included as covered
expenses under this policy. You will be fully responsible for
payment for any services for which charges incurred are not
covered expenses under this policy.
This policy does not pay benefits for any service or treatment
caused by, resulting from, for, which are, or relating to any of the
following:
A. Not a covered expense or for which no charge is made.
B. Fees/surcharges imposed on the covered person by a
provider but that are actually the responsibility of the provider
to pay.
C. In excess of the frequency limitations or maximum benefits as
shown in the policy Data Pages.
D. Covered expenses incurred during the waiting period.
E. Covered expenses which exceed the non-network provider
reimbursement, as shown on the policy Data Pages.
F. Which no benefit is described in this policy or on the Data Page.
G. A dental service that is not rendered or that is not rendered
within the scope of the dentist’s license.
H. Major services, which includes all procedures or services
related to endodontics, periodontics, major restorative
services (crowns, inlays, onlays and veneers), dental implants,
prosthetics (bridges and dentures, fixed or removable), and
oral surgery, unless your plan includes benefits for Major
Services.
I. Billed for incision and drainage if the involved abscessed tooth
is removed on the same date of service.
J. Telephone consultations or for failure to keep a scheduled
appointment.
K. Any service incurred directly or indirectly as a result of the
covered person being intoxicated, as defined by applicable
state law in the state in which the loss occurred, or under the
influence of illegal narcotics or controlled substance unless
administered or prescribed by a doctor or voluntary taking of
any over the counter drug unless taken in accordance with
the manufacturer’s recommended dosage.
L. Experimental or investigational treatment or for complications
there from, including expenses that might otherwise be
covered if they were not incurred in conjunction with, as a
result of, or while receiving experimental or investigational
treatment.
M. Which arise out of, or in the course of, employment for wage
or profit, if the covered person is insured, or is required to be
insured, by workers’ compensation insurance pursuant to the
applicable state or federal law.
N. Intentionally self-inflicted bodily harm (whether the covered
person is sane or insane, any act of declared or undeclared
war, a covered person taking part in a riot, or a covered
person’s commission or attempt to commit a felony, whether
or not charged.
O. Provided by a government plan, program, hospital or other
facility, unless by law a covered person must pay and it is
otherwise a covered expense or which by law must be
provided by an educational institution.
P. Provided without cost to a covered person in the absence of
insurance covering the charge.
Q. Provided by an immediate family member or someone who
ordinarily resides with a covered person.
R. Provided prior to the effective date or after the termination
date of this policy.
S. Received outside of the United States, except for a dental
emergency.
T. Related to the temporomandibular joint (TMJ), either bilateral
or unilateral. Upper and lower jaw bone surgery (including that
related to the temporomandibular joint). No coverage is
provided for orthognathic surgery, jaw alignment, or treatment
for the temporomandibular joint.
U. Teeth that can be restored by other means; for purposes of
periodontal splinting; to correct abrasion, erosion, attrition,
bruxism, abfraction, or for desensitization; or teeth that are not
periodontally sound or have a questionable prognosis as
determined by us.
V. Performed solely for cosmetic/aesthetic reasons. (Cosmetic
procedures are those procedures that improve physical
appearance such as internal/ external bleaching, veneers.)
W. Maxillofacial prosthetics and related services.
X. Reconstructive surgery, regardless of whether or not the
surgery is incidental to a dental disease, injury, or congenital
anomaly when the primary purpose is to improve
physiological functioning of the involved part of the body.
Y. Fixed or removable prosthodontic restoration procedures for
complete oral rehabilitation or reconstruction.
Z. Changing vertical dimension; restoring occlusion; bite
analysis, congenital malformation.
AA. Orthognathic surgery.
BB. Setting of facial bony fractures and any treatment associated
with the dislocation of facial skeletal hard tissue.
CC. Treatment of benign neoplasms, cysts, or other pathology
involving benign lesions, except excisional removal.
DD. Treatment of malignant neoplasms or congenital anomalies
of hard or soft tissue, including excision.
EE. Replacement of full or partial removable dentures, bridges,
crowns, inlays, onlays or veneers which can be repaired or
restored to natural function.
FF. Mouthguards; precision or semi-precision attachments;
duplicate dentures; harmful habit appliances; occlusal guard;
replacement of lost or stolen appliances; treatment splints;
bruxism appliance; sleep disorder appliance.
GG. Oral hygiene instructions; plaque control; charges for
completing dental claim forms; photographs; any dental
supplies including but not limited to take-home fluoride;
sterilization fees; diagnostic casts; treatment of halitosis and
any related procedures; lab procedures.
HH. Drugs/medications, obtainable with or without a
prescription, unless they are dispensed and utilized in the
dental office during the covered person’s dental visit.
II. Dental implants and any related procedures, including but not
limited to crowns, bridges, and dentures, unless your plan
includes benefits for implants.
JJ. Hospital or other facility charges and related anesthesia charges.
KK. Removal of sound functional restorations; temporary crowns
and temporary prosthetics; provisional crowns and
provisional prosthesis.
LL. Altering vertical dimension and/or restoring or maintaining
occlusion. Such procedures include, but are not limited to,
equilibrium, periodontal splinting, full mouth rehabilitation,
and restoration for misalignment of teeth.
MM. Non-intravenous conscious sedation, analgesia, anxiolysis,
inhalation of nitrous oxide and conscious sedation.
NN. Charges for dental services that are not documented in the
dentist records, that are not directly associated with dental
disease, or that are not performed in a dental setting.
OO. Orthodontic services, unless your plan includes benefits for
orthodontic services.
GRI-DEN3-OC-JR-48
45631-G-1018
THIS POLICY IS NOT A MEDICARE SUPPLEMENT POLICY.
If you are eligible for Medicare, review the Guide to Health
Insurance for people with Medicare available from the
Company.
Read Your Policy Carefully -- This outline sets forth a brief
description of the important aspects of your policy. This is not the
insurance contract. Only the actual policy will control. The policy
sets forth in detail your and our rights and obligations. For this
reason, it is important that you READ YOUR POLICY
CAREFULLY!
In this outline, “you” or “your” will refer to the person for whom
this outline has been prepared, and “we,” “our,” or “us” will refer
to Golden Rule Insurance Company.
Dental Coverage -- Plans of this type are designed to provide
the covered persons with coverage for dental care. The cost
must be due to a covered dental service. Coverage is provided
for preventive, basic, major services (If you plan includes major
services) and orthodontic services (if your plan includes
orthodontic services). Coverage is subject to any deductible
amounts, coinsurance amounts, or other limitations that may be
set forth in the policy.
Dental Benefits
DENTAL BENEFITS: Benefits are limited to the dental
services described below, but only when each service is a
covered expense:
PREVENTIVE SERVICES
A. Dental prophylaxis (cleanings), limited to 2-3 per calendar year
depending on the plan.
B. Oral evaluations, limited to 2-3 per calendar year depending
on the plan.
C. Problem focused oral evaluations.
D. Intraoral - Complete Series of radiograph images, limited to 1
per 36 months. Vertical bitewings not allowed in conjunction
with a complete series.
E. Panoramic radiographs image, limited to 1 per 36 months.
F. Oral/Facial photographic images, limited to 1 per 36 months.
G. Intraoral bitewing radiograph, single image, limited to 4 per
calendar year.
H. Intraoral bitewing radiographs, limited to 1 series per calendar
year.
I. Intraoral periapical and intraoral occlusal radiographs image.
J. Extraoral radiographs, limited to 2 per calendar year.
K. Vertical bitewings 7-8 radiograph images, limited to 1 per 36
months.
L. Diagnostic casts, limited to 1 per 24 months.
M. Pulp vitality tests, limited to 1 charge per visit regardless of
the number of teeth tested.
N. Adjunctive pre-diagnostic testing that aides in detection of
mucosal abnormalities including premalignant and malignant
lesions, not to include cytology or biopsy procedure, limited to
1 per calendar year.
O. Bacteriological and viral cultures.
P. Fluoride treatments, limited to covered persons under the age
of 16 years, limited to 2 times per calendar year.
Q. Sealant, limited to covered persons under the age of 16 and
once per first and second permanent molar every 36 months.
R. Preventive resin restorations in a moderate to high caries risk
patient, limited to 1 per permanent tooth every 36 months.
S. Space Maintainers, limited to covered persons under the age
of 16 years, once per 60 months. Benefit includes all
adjustments within 6 months of installation.
T. Re-cement Space Maintainers, limited to 1 per 6 months after
initial insertion.
BASIC SERVICES
A. Amalgam restorations, resin-based composite restorations,
and gold foil restorations, (multiple restorations on one surface
will be treated as a single filling).
B. Simple extractions.
C. Desensitizing medicament.
D. General anesthesia, in conjunction with oral surgery or the
removal of 7 or more teeth.
E. Local anesthesia.
F. Therapeutic drug injection, limited to 1 per visit.
G. Palliative treatment, only if no other services other than exam
and radiographs were done on the same tooth during the visit.
H. Consultations, when not performed with exams or
professional visits.
I. For all covered expenses, the following dental services will be
considered part of the entire dental service and not eligible for
benefits as a separate service: cement bases; study models/
diagnostic casts; acid etch; and bonding agents.
MAJOR SERVICES (if included)
The following are included if your plan includes benefits for
Major Services:
A. Apexification/recalcification/pulpal regeneration, limited to 1
time per tooth per lifetime.
B. Apicoectomy/periadicular surgery, limited to 1 time per tooth
per lifetime.
C. Retrograde filling, limited to 1 per tooth per lifetime.
D. Hemisection, limited to 1 time per tooth per lifetime.
E. Root canal therapy, limited to 1 time per tooth per lifetime.
Reimbursement not allowed for retreatment by original
performing dentist in first 12 months.
F. Retreatment of previous root canal therapy. Reimbursement
not allowed for retreatment by original performing dentist in
first 12 months.
G. Root resection/amputation, limited to 1 time per tooth per
lifetime.
H. Therapeutic pulpotomy, limited to 1 time per tooth per lifetime.
I. Pulpal therapy (resorable filling), limited to 1 time per tooth per
lifetime. Covered for anterior or posterior teeth only.
J. Pulp caps (direct/indirect excluding final restoration), not
covered if utilized solely as a liner or base underneath a
restoration.
K. Pulpal debridement - primary and permanent teeth, limited to
1 per tooth per lifetime. Not covered on the same day as other
endodontic services.
L. Pulpal regeneration (completion of regenerative treatment in
an immature permanent tooth with a necrotic pulp) does not
include final restoration, limited to 1 per tooth per lifetime.
M. Coping, limited to 1 per tooth per 60 months. Not covered if
done at the same time as a crown on same tooth.
N. Crowns - retainers/abutments, limited to 1 per tooth per 60
months. Not covered if done in conjunction with any other
inlay, onlay and crown codes except post and core buildup
codes.
Golden Rule Insurance Company Applies to policies issued in Wisconsin
Outline of Coverage for Policy Form GRI-DEN3-OC-JR-48
(Please retain this outline for your records.)
