A. Enrollment and Eligibility
You may enroll yourself and your eligible dependents. Dependents named in the application must be approved by Delta Dental as eligible. Specific criteria for dependent eligibility may vary by state.
B. Your Effective Date
Apply by the last day of the month prior to your requested effective date. Incomplete enrollment forms, or failure to submit the required initial premium amount may cause an initial delay in issuance of insurance. Do not cancel any other insurance or assume you are insured until you receive your policy.
C. Annual Deductible and Calendar Year Maximums
Delta Dental Plan III has a $1,000 contract year maximum per person per year; $50 deductible (per contract year) per person; and $300 TMD lifetime maximum per person.
D. Emergency Dental Services
If you have a dental emergency, contact your current dentist for an emergency appointment. If he or she is unable to see you, please contact Customer Service at (800) 971-4108 for specific emergency benefit information and procedures.
E. Cancellation Policy
If you are not satisfied, you may return the Policy within 10 days after you received it. Mail or deliver it to P.O. Box 1596, Indianapolis, IN 46206. Any premium paid will be refunded. This Policy will then be void from its start.
You may return the Policy after the first 10 days following receipt by giving written notice to us effective upon receipt or on a later date as may be specified in the notice. We shall promptly refund the excess of paid premium above the pro rata premium for the expired time. Cancellation is without prejudice to any claim originating prior to the effective date of cancellation.
F. Termination Policy
All insurance will cease on termination of the Policy. This Policy will terminate on:
- Nonpayment of premiums when due, subject to the Grace Period Provisions; or
- The date Delta Dental receives a written request from you to terminate the Policy, or any later date stated in your request; or
- The date Delta Dental declines to renew the Policy as provided by the above renewal clause; or
- The date of your death, if this Policy is an Individual Plan.
Delta Dental will refund any premium paid and not earned due to Policy termination. The refund will be based on the number of full months that remain in the premium period. If this Policy is other than an Individual Plan, it may be continued after your death: (a) by your spouse, if an Eligible Dependent; otherwise, (b) by the youngest Child who is an Eligible Dependent (if Children are covered under this Policy). The Policy will be changed to a plan appropriate, as determined by us, to the Eligible Dependents that continue to be covered under it. Your spouse, or youngest Child, will replace you as the Insured. A proper adjustment will be made in the premium required for the Policy to be continued. Delta Dental will also refund any premium paid and not earned due to the Insured’s death. The refund will be based on the number of full months that remain to the next premium due date.
Services for injuries or conditions paid pursuant to Worker's Compensation or Employer's Liability law; Services or appliances started prior to the covered person's effective date; Treatment by anyone other than a dentist or licensed dental hygienist; Services received from any governmental agency, political subdivision, community agency, foundation or similar entity other than Medicaid; Tests and laboratory examinations; Medications and prescription drugs; Charges related to hospitalization or general anesthesia and/or intravenous sedation; Services or supplies received as a result of dental disease, defect or injury due to an act of war, declared or undeclared; Cosmetic surgery or dentistry for aesthetic reasons; Dental services that are specialized techniques or investigational in nature.
Limitations: Coverage for services may be limited based on the age of the person receiving services; Coverage for certain services may be limited to a maximum number of occurrences during a specified time period (such as 2 times per year, or 1 time every 3 years); Coverage for temporomandibular disorders (TMD) is limited.
The above is a summary of exclusions and limitations. For complete details, please refer to your policy (in Oregon, refer to policy INVD-100A-OR v2, in Idaho refer to policy INVD-100A-ID v2 and in New Mexico, refer to policy INVD-100A-NM v2). Not all coverage provided under the policy is set forth above. The premium rate will vary between Plan 1 and Plan 2. The policy term is one year. Coverage may be terminated for reasons stated in the policy. Coverage ceases upon termination of the policy.
Please click here for a complete list of Exclusions and Limitations
Renaissance Life & Health Insurance Company of America P.O. Box 1596 Indianapolis, IN 46206
and in New York by:
Renaissance Health Insurance Company of New York, New York, NY.
Free American Senior Benefits Association Membership:
If you are age 55 and older membership in the American Senior Benefits Association is required, at no additional cost, in order to be eligible for insurance coverage. The Association is a membership organization for seniors that provides educational information and discounts on goods and services to its members. The Association benefits information will be sent under separate cover. I understand while covered by this product that I must at all times be a member of the Association.