A. Enrollment and Eligibility
You may enroll yourself and your eligible dependents. Dependents named in the application must be approved by Renaissance 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
Renaissance 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 Service
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 (888) 791-5995 for specific emergency benefit information and procedures.
E. Cancellation Policy
The policy can be cancelled by submitting a written cancellation request, as indicated in your policy. Renaissance will refund any premium paid, but not yet earned due to policy cancellation. The refund will be based on the number of full months that remain in the 12 month policy period.
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 Renaissance Dental receives a written request from you to terminate the Policy, or any later date stated in your request; or
- The date Renaissance 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.
Renaissance 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. Renaissance 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.
Exclusions: 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.
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.