A. Enrollment and Eligibility
Who is eligible to apply:
Your acceptance into this plan is guaranteed as long as you are between the ages of 18-99 and live in an approved state. Both adults and children (family plan) can apply, regardless of current or past dental history. Coverage is available for children up to age 19 (up to age 25 if unmarried, full-time students).*
*Note: Dependent ages vary by state. Please see your policy/certificate for details.
Employment: You do NOT need to be currently employed to apply for this plan. Individuals who are self-employed, employed part-time, laid off, disabled, or retired are all eligible. No one will be turned down. There is NO rate difference based on age or employment status.
B. Your Effective Date
Once your Application Form and premium are received, your coverage will be issued. You can expect to receive your coverage materials in about 2 weeks. Your dental insurance is effective immediately – there is NO “WAITING PERIOD” for preventative and basic services.
C. How does the plan work?
Your coverage starts immediately. NO waiting. Basic dental services are covered right away at 50 percent of the eligible expense – including fillings, anesthesia, and other restorative services. Apply now and you can go to the dentist as soon as you receive your insurance coverage materials and Identification Card.
All eligible claims are typically paid within 10-15 working days. Additionally, if you use a dentist who works directly with this plan, they will submit the claim for you so you don’t have to handle any paperwork yourself.
D. Annual Deductible & Calendar Year Maximums
Each year, you will have an annual deductible which is the amount you will pay out-of-pocket before benefits are paid. This amount does not include co-payments. There is NO deductible for preventative and diagnostic dental care. For basic or major dental work, you pay the first $50 each year (your deductible). For family coverage, there is a $150 maximum deductible per family, per year.
The Calendar Year Maximum is $1000 per insured person.
E. Choice of Provider
You can use this insurance plan for dental care at your own personal dentist. You're free to use any dentist you choose, anywhere in the country. You never need a referral or "permission" to visit a dentist. If you like, you can visit any of the plan's 80,000 network dentist locations and reduce your out-of-pocket expenses even more benefits because these dentists guarantee pre-negotiated prices.
F. Specialty Care/Specialty Referrals
Specialty Care can be utilized and the benefits will be applied based on the type of service needed, provided the waiting periods have been satisfied. No referral needed.
G. Pre-Treatment Estimate
You should request from us a pre-treatment estimate if the charges for a recommended Dental Service(s) exceeds $300.00. We must receive the Dentist’s treatment plan that includes a description of the condition, the Dental Service(s) and the Dental Procedure(s) to be performed, and any supporting x-rays. We will inform you and the Dentist what Dental Service(s) and Procedure(s) that we cover and their Eligible Expense. If you do not request a pre-treatment estimate, we will determine the Dental Service(s) and Procedure(s), if any, that we cover when we review the claim for payment.
H. Rate Guarantee for First 12 Months
Your premium is guaranteed not to increase for the first 12 months of coverage. Thereafter, IF there is any change, it will be made on a uniform basis only, to all insureds in your class, (“Class” is defined as a group of people with the same rate classification and who resided in the same state when their Certificate is issued). Rates can NEVER increase because of age or how much you use your insurance. You will be given a 60 day notice of any increases in premiums or cancellation of coverage.
I. Cancellation Policy
You have a 30-Day, 100% Money-Back Review Period
When you receive your Policy/Certificate of Coverage, review it for 30 days. If you are not completely satisfied, return it within that time and your coverage will be cancelled and your premium will be refunded in full as long as you haven’t made any claims. You have the right to cancel this coverage at any time for any reason. To cancel, you will need to notify Transamerica Life Insurance Company that you wish to cancel and discontinue coverage. If you cancel this coverage, we can reject any new dental insurance application/enrollment form you submit during the one year period following the date of cancellation. Coverage can stop if 1) the Group Policy stops, 2) coverage is cancelled for everyone in your class, or 3) the insured performs an act of fraud or makes a material misrepresentation regarding this coverage. If coverage is to be discontinued due to reasons 1 or 2, we will notify you 60 days in advance.
We will not pay any benefits for any of the following:
- Dental Services that are not Necessary.
- Hospitalization or other facility charges.
- Any Dental Service or procedure performed solely for cosmetic/aesthetic reasons. (Cosmetic
procedures are those procedures that improve physical appearance.).
- 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.
- Any Dental Service not directly associated with a Dental Disease or condition.
- Any Dental Procedure not performed in a dental office, medical facility, or a similar facility whose primary function is to perform Dental Procedures. SLDT1000GC Page 9
- Procedures that are considered to be experimental, investigational or unproven. This includes pharmacological regimens not accepted by the American Dental Association (ADA) Council on Dental Therapeutics. This also includes any experimental, investigational or unproven procedure that is the only available treatment for a particular condition if the procedure is considered to be experimental, investigational or unproven in the treatment of that particular condition.
- Dental Services for injuries or conditions covered by Worker’s Compensation or employer liability laws, or which are provided without cost to the Insured by any municipality, county, or other political subdivision. This exclusion does not apply to any Dental Services covered by Medicaid or Medicare.
- Expenses for Dental Services begun prior to the date the Insured’s coverage under the Certificate starts.
- Dental Services received after the date an Insured’s coverage under the Certificate stops, including Dental Services for dental conditions arising prior to the date the insured’s coverage stops. This does not apply to any Dental Services that are covered under the Extended Coverage provision.
- Dental Services provided in a foreign country, unless required as an Emergency.
- Replacement of crowns, bridges, and fixed or removable prosthetic appliances inserted prior to plan coverage unless the patient has been eligible under the plan for 12 continuous months. If loss of a tooth requires the addition of a clasp, pontic, and/or abutment(s) within this 12 month period, the plan is responsible only for the procedures associated with the addition.
- Replacement of natural teeth lost prior to the date the Insured’s coverage starts may not occur until twelve months after coverage has been in force for 12 continuous months.
- Full mouth radiograph series in excess of once every 36 months. Panoramic radiographs in excess of once every 36 months, except when taken for diagnosis of third molars, cysts, or neoplasms.
- Hard tissue periodontal surgery and soft tissue periodontal surgery per surgical area in excess of once in any 36 month period. This includes gingivectomy, gingivoplasty, gingival curettage (with or without a flap procedure), osseous surgery, pedicle grafts, and free soft tissue grafts.
- Osseous grafts, with or without resorbable or non-resorbable GTR membrane placement in excess of once every 36 months per quadrant or surgical site.
- Root planing and scaling (ADA Code 4341) in excess of once every 24 months per quadrant.
- Full mouth debridement (ADA Code 4355) in excess of once every 36 months.
- Replacement of complete or partial dentures, fixed bridgework, or crowns previously submitted for payment under the Plan within sixty (60) months of initial or supplemental placement. This includes retainers, habit appliances, and any fixed or removable interceptive orthodontic appliances.
- Replacement of complete or partial dentures, crowns, or fixed bridgework if damage or breakage was directly related to provider error. This type of replacement is the responsibility of the Dentist. If replacement is necessary because the Insured did not follow instructions on proper use and care, the Insured is liable for the cost of replacement.
- Denture relines for complete or partial conventional dentures for the 6 month period following the insertion of a prosthesis. Tissue conditioning and soft and hard relines for immediate full and partial dentures for the first six 6 months after the insertion of a prosthesis. After the six month waiting period, relines are covered not more than once every 12 months.
- Fixed or removable prosthodontic restoration procedures for complete oral rehabilitation or reconstruction.
- Attachments to conventional removable prostheses or fixed bridgework. This includes semi-precision or precision attachments associated with partial dentures, crown or bridge abutments, full or partial overdentures, any internal attachment associated with an implant prosthesis, and any elective endodontic procedure related to a tooth or root involved in the construction of a prosthesis of this nature.
- Procedures related to the reconstruction of an Insured’s correct vertical dimension of occlusion (VDO).
- Placement of dental implants, implant-supported abutments and prostheses. This includes
pharmacological regimens and restorative materials not accepted by the American Dental
Association (ADA) Council on Dental Therapeutics.
- Placement of fixed bridgework solely for the purpose of achieving periodontal stability.
SLDT1000GC Page 10
- Billing for incision and drainage (ADA Code 7510) if the involved abscessed tooth is removed on the same date of service.
- Treatment of malignant or benign neoplasms, cysts, or other pathology, unless removed through an excision. Treatment of congenital malformations of hard or soft tissue, including excision.
- Setting of facial bony fractures and any treatment associated with the dislocation of facial skeletal hard tissue.
- Services 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.
- Acupuncture; acupressure and other forms of alternative treatment.
- General Anesthesia, except if required for Insureds under 6 years of age or Insureds with behavioral problems or physical disabilities.
- Drugs/medications, obtainable with or without a prescription, unless they are dispensed and utilized in the dental office during the patient visit.
- Occlusal guards except if prescribed to control habitual grinding, including those specifically used as safety items or to affect performance primarily in sports-related activities.
- Charges for failure to keep a scheduled appointment without giving the dental office 24 hours notice.
Policy/Certificate #: SLDT1000IP/SLDT1000GC/GC537/D491