Schedule of Covered Services
The VIP 1250 plan is an Indemnity plan, which allows you complete freedom of dentist choice. Reimbursements are based on a percentage of the Usual, Customary and Reasonable Fees (UCR) charged by dentists in your area. It is your dentist’s responsibility to check the benefits provided by this plan and inform you of any amounts that you are responsible for.
|Schedule of Benefits|
|Year One||Year Two||Year Three|
|Preventive Dental Benefits||Routine exams, teeth cleanings, topical fluoride (children up to age 16).
No waiting period.
|Plan Pays 100%|
|Basic Dental Benefits||Fillings, X-rays, simple extractions.
Three (3) month waiting period..
|Plan Pays 50%||Plan Pays 65%||Plan Pays 80%|
|Major Dental Benefits||Oral surgery (surgical extractions & impactions), endodontics, periodontics, crowns, bridges, dentures.
Twelve (12) month waiting period.
|Plan Pays 0%||Plan Pays 40%||Plan Pays 50%|
|Dental Deductible||Per calendar year, per insured person for Basic and Major Services.
Calendar year deductible has a maximum of 3 per family each year.
|Maximum Dental Benefits||Per calendar year, per insured person.||$1250|
This provides a very brief description of some of the important features of this insurance policy. It is not the insurance policy and does not represent it. A full explanation of benefits, exceptions and limitations is contained in the Individual Dental Policy Form IP1000 (and state specifics) or One Life Group Dental Policy that may be issued to the group trust, GH-1112 (and state specifics) or Individual Dental Policy Form IP-1000-NY. Premium rates may change upon renewal. This policy is renewable at the option of the insured (IP1000); (IP1000-NY) or the Company (GH-1112). This product may not be available in all states and is subject to individual state regulations.
Underwritten by Security Life Insurance Company of America.
10901 Red Circle Drive, Minnetonka, MN 55343.