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Dental Care

Payment of Benefits

1. We pay benefits based on dental services and treatment frequencies in the Fee Schedule and the financial limits in the Fee Guide.
2. We apply the reimbursement percentage shown in the Schedule of Benefits to the fees shown in the Fee Guide as follows:
   a) for services performed in British Columbia or outside Canada, if your province of residence is British Columbia - the fees in the Fee Guide
   b) for services performed in Canada but outside British Columbia - the fees in the Fee Guide in the province/territory of service
   c) for services performed outside Canada if your province of residence is not British Columbia-the fees in the Fee Guide in your province/territory of residence.
3. Fees in excess of the amount shown in the applicable Fee Schedule/Fee Guide will be your responsibility.

Plan A – Basic Preventive & Restorative Services

Plan A covers services for the care and maintenance of teeth, including procedures to restore teeth to natural or normal function. Eligible expenses per person include, but are not limited to, the basic services shown below.

1. Diagnostic Services
   a) examinations:
   i) complete - provided we have not paid for any other exam by the same Dentist in the past 6 months –1 per 24 month period
   ii) recall - 1 per 5 month period
   iii) specific - 2 per calendar year
   iv) consultations (as a separate appointment)
   b) x-rays
   i) diagnostic
   ii) panoramic - 1 per 3 year period
   iii) complete mouth series - 1 per 24 month period
   All x-rays combined shall not exceed the dollar limit for a complete mouth series.
   c) diagnostic models - 1 set per calendar year.
2. Preventive Services
   a) scaling
   b) polishing - 1 per 5 month period
   c) topical application of fluoride - 1 per 5 month period
   d) oral hygiene instruction – 1 per lifetime
   e) fixed space maintainers
   f) preventive restorative resins and pit and fissure sealants.
3. Restorative Services
   a) fillings:
   i) amalgam (silver coloured) fillings
   ii) composite (tooth coloured) fillings
   b) stainless steel crowns
   c) inlays or onlays. Where other material would suffice, you will be responsible for the difference between the cost of the chosen material and the cost of alternative material.
4. Endodontics – for the treatment of diseases of the pulp chamber and pulp canal including, but not limited to root canals.
5. Periodontics – for the treatment of diseases of the soft tissue (gum) and bone surrounding and supporting the teeth:
   a) occlusal adjustment and recontouring – a combined yearly limit shown in the Fee Guide
   b) root planing
   c) gingival curettage
   d) osseous surgery
   e) bruxing guards – no benefit is payable for the replacement of lost, broken, or stolen bruxing guards.
6. Prosthetic Repairs
   a) removal, repairs, and recementation of fixed appliances
   b) rebase and reline of removable appliances - a combined limit of 1 per upper and 1 per lower prosthesis in a 36 month period
   c) tissue conditioning
   d) gold foil – only when used to repair existing gold restorations.
7. Surgical Services
   a) extractions
   b) other routine oral surgical procedures
   c) anesthesia.

Plan B – Major Restorative Services

You are eligible for Plan B services when your Dentist recommends replacement of your missing teeth, or reconstruction of your teeth (where basic restorative methods cannot be used satisfactorily).

Mounted x-rays and/or diagnostic casts may be required for our approval.

Plan B services include, but are not limited to, the following:

1. Prosthodontic Services
   a) removable
   i) complete upper and lower dentures
   ii) partial upper and lower dentures
   b) fixed bridges.
2. Restorative Services
   a) inlays or onlays involved in bridgework
   b) veneers
   c) crowns and related services.
   The initial insertion of dentures are covered only when the original teeth are extracted while you or your Dependents are covered under this Dental Plan.

Limitations

1. Only 1 fixed bridge involving the same tooth will be covered in a 5 year period.
2. Crowns and fixed bridges on permanent posterior (molar) teeth are limited to the cost of the gold restoration.
3. Only 1 upper and 1 lower denture (complete or partial) is eligible in a 5 year period.
4. No benefit is payable for the replacement of lost, broken, or stolen dentures. Broken dentures may be repaired under Plan A.
5. Veneers, crowns, bridges, inlays, and onlays are subject to the conditions outlined in our Fee schedule. Where other material would suffice, you will be responsible for the difference between the cost of the chosen material and the cost of alternative material.

Plan C – Orthodontics

Benefits are payable for orthodontic services performed after you have been enrolled under the Dental Plan for 18 months. Plan C covers orthodontic services provided to maintain, restore, or establish a functional alignment of the upper and lower teeth.

Limitations

1. The lifetime benefit maximum under Plan C is shown in the Schedule of Benefits.
2. No benefit is payable for the replacement of appliances which are lost or stolen.
3. Services done for the correction of temporomandibular joint (TMJ) dysfunction are not covered.
4. Treatment performed solely for splinting is not covered.

Emergency Treatment Outside Your Province of Residence

You are entitled to the services of a Dentist if, while travelling or on vacation outside your province of residence, you require emergency dental care. You will be reimbursed according to the applicable Fee guide.

Exclusions
The following are not Eligible expenses under your dental plan:

1. items not listed in our Fee schedule and fees in excess of those listed in the Fee guide
2. any item not specifically included as a benefit
3. charges for broken appointments, nutritional instruction, completion of forms, written reports, communication costs, or charges for translating documents into English
4. procedures performed for congenital malformations or for purely cosmetic reasons
5. charges for drugs and pantographic tracings
6. charges for implants and/or services performed in conjunction with implants, except as indicated in our Fee schedule
7. charges for facilities, equipment and supplies
8. charges for services related to the functioning or structure of the jaw, jaw muscles, or temporomandibular joint
9. incomplete or temporary procedures
10. recent duplication of services by the same or different Dentist
11. any extra procedure which would normally be included in the basic service performed
12. services or items which would not normally be provided, or for which no charge would be made, in the absence of dental benefits
13. travel expenses incurred to obtain dental treatment.

Claims

1. Present your ID card to your Dentist’s office. It is important to ask if your dental benefits will cover the entire cost of your treatment. To avoid any misunderstanding, we suggest that your Dentist submit an outline of the proposed services to us before you start treatment. This is important especially when your Dentist is recommending extensive dental work. This will help you understand what portion of the Dentist’s bill must be paid by you in the event that you wish to proceed with the treatment recommended by your Dentist.
2. We suggest that you submit claims within 90 days of the completed date of services (earlier if possible). Failure to submit a claim within the 90 day limit will not invalidate the claim if it is submitted as soon as reasonably possible. However, in no event will we pay any claim or adjustment submitted later than 1 year from the date the service is performed.
3. We require a separate claim form for each member of your family who has received dental services. Be sure to include the following information on the claim form:
   a) name of the Dentist
   b) name and birthdate of the person receiving the dental care
   c) your group, ID, and Dependent(s) numbers (this information is on your ID card)
   d) your home mailing address
   e) whether you have coverage through another plan. Claims information regarding the other carrier is not retained on our files. If you or your Dependents are covered by two plans, your Dentist must complete two separate dental claim forms (one for each plan). Incomplete claims will be returned for clarification.
4. Before your Dentist starts treatment, please ask them how billing is made. We may pay in either of two ways:
   a) We will pay the Dentist directly for services provided under this dental plan when we receive a claim form signed by the Dentist, certifying these services were performed and the fee charged.
   b) If you have paid your Dentist directly, we will reimburse you the benefit amount when we receive a claim form or receipts signed by your Dentist. We will send you a cheque when the claim is processed.
5. Orthodontic Claims Procedures
   a) Receipts
   Because we do not return original receipts, we will accept photocopies. Do not hold receipts until the completion of treatment.
   b) Claiming deadlines
   i) We suggest that you submit orthodontic claims within
   90 days of the date the payment was due to your orthodontist (the due date).
   ii) Reimbursement is made if the complete and correct claims information is received within 1 year of the due date. However, no benefit is payable for claims not received within 1 year of the due date.
   c) Treatment plan
   i) Have your orthodontist complete the “Certified Specialist in Orthodontics Standard Information Form” (the treatment plan) before treatment starts. The treatment plan must include a brief description of treatment to be performed, a breakdown of the fees to be charged, and the estimated length of treatment.
   ii) If the payment schedule or treatment changes, we require a revised treatment plan for review.
   iii) We will retain your treatment plan on file. If we do not have your treatment plan on file we are unable to pay:
   - your initial fee/down payment
   - your monthly/quarterly fees
   - one time appliance fees
   iv) Claims for consultations, exams and records (x-rays, study models, etc.) will be reimbursed without a treatment plan on file.
   d) Monthly or quarterly fees
   i) If you are paying in monthly or quarterly installments, submit receipts for the monthly or quarterly fees on a regular basis – as treatment progresses. Claims receipts received by us which are over 1 year old will not be reimbursed.
   ii) If you paid any amount to the Dentist before treatment is complete, we will allow an initial payment amount and then prorate the balance into monthly payments to you throughout the treatment plan period.
   iii) As long as your coverage is effective, monthly or quarterly reimbursements will be made to you until the dollar maximum is reached or the treatment is complete, whichever occurs first.