Metlife will not pay Dental Insurance benefits for charges incurred for:
1. Services which are not Dentally Necessary, those which do not meet generally accepted standards of care for treating the particular dental condition, or which We deem experimental in nature;
2. Services for which You would not be required to pay in the absence of Dental Insurance;
3. Services or supplies received by You or Your Dependent before the Dental Insurance starts for that person;
4. Services which are primarily cosmetic (for residents of Texas, see notice page section in your plan certificate).
5. Services which are neither performed nor prescribed by a Dentist except for those services of a licensed dental hygienist which are supervised and billed by a Dentist and which are for:
• scaling and polishing of teeth; or
• fluoride treatments.
6. Services or appliances which restore or alter occlusion or vertical dimension.
7. Restoration of tooth structure damaged by attrition, abrasion or erosion, unless caused by disease.
8. Restorations or appliances used for the purpose of periodontal splinting.
9. Counseling or instruction about oral hygiene, plaque control, nutrition and tobacco.
10. Personal supplies or devices including, but not limited to: water piks, toothbrushes, or dental floss.
11. Decoration, personalization or inscription of any tooth, device, appliance, crown or other dental work.
12. Missed appointments.
• covered under any workers’ compensation or occupational disease law;
• covered under any Policyholder liability law;
• for which the Policyholder of the person receiving such services is not required to pay; or
• received at a facility maintained by the Policyholder, labor union, mutual benefit association, or VA hospital.
14. Services covered under other coverage provided by the Policyholder.
15. Temporary or provisional restorations.
16. Temporary or provisional appliances.
17. Prescription drugs.
18. Services for which the submitted documentation indicates a poor prognosis.
19. Services, to the extent such services, or benefits for such services, are available under a Government Plan. This exclusion will apply whether or not the person receiving the services is enrolled for the Government Plan. We will not exclude payment of benefits for such services if the Government Plan requires that Dental Insurance under the Group Policy be paid first. Government Plan means any plan, program, or coverage which is established under the laws or regulations of any government. The term does not include:
• any plan, program or coverage provided by a government as an Policyholder; or
20. The following when charged by the Dentist on a separate basis:
• claim form completion;
• infection control such as gloves, masks, and sterilization of supplies; or
• local anesthesia, non-intravenous conscious sedation or analgesia such as nitrous oxide.
21. Dental services arising out of accidental injury to the teeth and supporting structures, except for injuries to the teeth due to chewing or biting of food.
22. Caries susceptibility tests.
23. Precision attachments, except when the precision attachment is related to implant prosthetics.
24. Adjustment of a Denture made within 6 months after installation by the same Dentist who installed it.
25. Fixed and removable appliances for correction of harmful habits.
26. Appliances or treatment for bruxism (grinding teeth), including but not limited to occlusal guards and night guards.
27. Diagnosis and treatment of temporomandibular joint (TMJ) disorders and cone beam imaging. This exclusion does not apply to residents of Minnesota.
28. Orthodontic services or appliances (APPLIES TO STANDARD PPO OPTION ONLY)
29. Repair or replacement of an orthodontic device.
30. Duplicate prosthetic devices or appliances.
31. Replacement of a lost or stolen appliance, Cast Restoration, or Denture.
32. Intra and extraoral photographic images.
Where two or more professionally acceptable dental treatments for a dental condition exist, reimbursement is based on the least costly treatment alternative. If you and your dentist have agreed on a treatment that is more costly than the treatment upon which the plan benefit is based, you will be responsible for any additional payment responsibility. To avoid any misunderstandings, we suggest you discuss treatment options with your dentist before services are rendered, and obtain a pretreatment estimate of benefits prior to receiving certain high cost services such as crowns, bridges or dentures. You and your dentist will each receive an Explanation of Benefits (EOB) outlining the services provided, your plan’s reimbursement for those services, and your out-of-pocket expense. Procedure charge schedules are subject to change each plan year. You can obtain an updated procedure charge schedule for your area via fax by calling 1-800-942-0854 and using the MetLife Dental Automated Information Service. Actual payments may vary from the pretreatment estimate depending upon annual maximums, plan frequency limits, deductibles and other limits applicable at time of payment.
Cancellation/Termination of Benefits
Coverage is provided under a group insurance policy (Policy form GPNP99 / G.2130-S) issued by MetLife to the American Association of Business Networking (ABN). ABN membership is required to participate in this group plan. Coverage terminates when your membership ceases, when your dental contributions cease or upon termination of the group policy by the Policyholder or MetLife. The group policy terminates for non-payment of premium and may terminate if participation requirements are not met or if the Policyholder fails to perform any obligations under the policy. The following services that are in progress while coverage is in effect will be paid after the coverage ends, if the applicable installment or the treatment is finished within 31 days after individual termination of coverage: Completion of a prosthetic device, crown or root canal therapy. All premium payments, coverage changes, and cancellation requests must be submitted in writing or through the appropriate web form, directly to the plan administrator, Member Benefits. Change or cancellation requests submitted directly to MetLife will not be honored.
Like most group benefit programs, benefit programs offered by MetLife and its affiliates contain certain exclusions, exceptions, reductions, limitations, waiting periods and terms for keeping them in force. Please contact MetLife or your plan administrator for costs and complete details.
Metropolitan Life Insurance Company, New York, NY
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