Dental Insurance

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Frequently Asked Questions About Short Term Dental Insurance


How Soon Can My Coverage Start?
What About Insured Person Insurance?
What About Dependent Insurance?
What About Newborns?
What About Adopted Children?
What About Rescission of Insurance?
Who Is Eligible For Coverage?
What Is The Calendar Year Maximum?
How Are Benefits Covered For Madison Dental?
What Is Madison Dental?
How Are Benefits Covered For Secure Dental One?
What Is Secure Dental One?
How Are Benefits Covered For IAIC Dental?
What Is IAIC Dental?
What Is Indemnity And PPO?
What Is The Premium Payment?
What About Reinstatement Of Insurance?
What Is Orthocare?
Where Can I Find A Listing Of Participating Orthodontists?
Who Are The Insurance Companies?
Who Are The Associations?
Who Is The IHC Group?
What About Definitions?
What About Preferrred Provider Organizations?
What About Coordination Of Benefits?
Are There Any Exclusions Or Limitations?
Who Is The Administrator?

How soon can my coverage start?

Coverage starts on the effective date, which varies by plan and insurance carrier. Coverage will begin at 12:00 a.m., following receipt of the electronic Enrollment Form and payment of the first month premium.

Insured Person Insurance

The insurance coverage under the Policy shall become effective for the Insured Person on the premium due date coincident with or next following the date on which We approve his or her written request for coverage and he or she pays the applicable premium.

Dependent Insurance

The insurance coverage under the Policy shall become effective for an eligible Dependent on the premium due date coincident with or next following the date on which We approve the Insured Person’s written request for coverage and the applicable premium is paid.

Newborns

Coverage will be effective for a newborn child of the Insured Person for thirty-one (31) days following the moment of birth. Coverage shall continue beyond the thirty-one (31) day period provided that the Insured meets the following requirements:

  1. makes a written request for coverage, on forms approved by Us, within thirty-one (31) days from the birth; and
  2. makes the required premium payment, if applicable.

If the above requirements are not met and the Insured desires to have the newborn covered under the Policy in the future, evidence of the newborn’s insurability must be provided at no expense to Us and the newborn must be insurable pursuant to Our then current underwriting guidelines and such Dependent must satisfy the requirements set forth in this Section 3. Coverage shall then take effect on the premium due date coincident with or next following the date on which We approve coverage and premium is paid, if applicable.

Adopted Children

Coverage will be effective for adopted children of the Insured for thirty-one (31) days following placement in the custody of the Insured. Placement means the assumption by the Insured of the physical custody of the adopted child. Coverage shall continue beyond the thirty-one (31) day period provided that the Insured meets the following requirements:

  1. makes written request for coverage, on forms approved by Us, within thirty-one (31) days from placement; and
  2. makes the required premium payment, if applicable.

If the above requirements are not met and the Insured desires to have the adopted child covered under the Policy in the future, evidence of the adopted child’s insurability must be provided at no expense to Us and the adopted child must be insurable pursuant to Our then current underwriting guidelines and such Dependent must satisfy the requirements set forth in this section. Coverage shall then take effect on the premium due date coincident with or next following the date on which We approve coverage and any applicable premium is paid.

Rescission of Insurance

False or missing information on Your enrollment applications may be the basis for rescission of coverage.

Rescission voids the coverage from the Effective Date. This means that no benefits will be paid for any claim submitted. Premiums already paid for the time period for which coverage was rescinded will be refunded less any claim payment adjustment, if any. If coverage is rescinded for any Covered Person, all Policy provisions with respect to that Covered Person are rescinded and become null and void.

Who is eligible for coverage?

This plan is offered to individuals ages 18 and over, their spouses, and their eligible dependents (unmarried children from birth to age 19 or 25 if a full-time student – this is subject to state requirements). Coverage may also be obtained by individuals and their spouses ages 65 and older.

Insured Person

An individual will become eligible for coverage under the Policy upon meeting all the following requirements:

  1. the individual is a member of the Group to which the Policy is issued;
  2. the individual has submitted a written request, upon a form approved by Us, seeking to apply for coverage under the Policy as an Insured Person;
  3. the individual is insurable pursuant to Our then current underwriting guidelines; and
  4. the individual must be a permanent resident of the United States.

Dependent Insurance

A Dependent of the Insured Person will become eligible for coverage under the Policy upon meeting all of the following requirements:

  1. the individual otherwise meets the definition of Dependent;
  2. the Insured Person has submitted a written request, upon a form approved by Us, seeking to apply for coverage on the individual, under the Policy as a Dependent;
  3. the individual is insurable pursuant to Our then current underwriting guidelines; and
  4. the individual must be a permanent resident of the United States.

Under this Section, all evidence that the individual is insurable pursuant to Our current underwriting guidelines shall be provided without expense to Us.

What is the calendar year maximum

The maximum amount payable for all Covered Dental Charges in any calendar year as shown in the Coverage Schedule. The Calendar Year Maximum will apply to each insured person.

How are benefits covered for Madison Dental?

Madison Dental pays benefits for each covered person in the following manner:

First, you meet the $50 Calendar Year Deductible per person. Over age 65, you meet the $100 Calendar Year Deductible per person.

Then Madison Dental pays a percentage of covered expenses based on the 90th percentile of Reasonable and Customary (R&C) fees for those Covered Expenses.


Value Plan
Primary Plan
Superior Plan

$500 Annual Maximum
$1000 Annual Maximum
$1250 Annual Maximum
Preventative Care
80/100%* Co-Insurance
No Waiting Period
80/100%* Co-Insurance
No Waiting Period
100% Co-Insurance
No Waiting Period
Diagnostic Care
80/100%* Co-Insurance
No Waiting Period
60/80%* Co-Insurance
No Waiting Period
90% Co-Insurance
No Waiting Period
Basic Care
25/80%* Co-Insurance
No Waiting Period
25/75%* Co-Insurance
No Waiting Period
80% Co-Insurance
4-Month Waiting Period
Major Care
PPO Discounts
No Waiting Period
10/40%* Co-Insurance
No Waiting Period
50% Co-Insurance
15-Month Waiting Period

* 1st year/2nd year benefits

Plans feature $50 deductibles per person per year. Over age 65 feature $100 deductibles per person per year.

Plans feature $10 office visit copays. Over age 65 feature $25 office visit copays.

Preventative: Cleanings, exams, sealants, fluoride
Diagnostic: Bitewing X-rays, full mouth X-rays
Basic: Fillings, extractions, repairs
Major: Endodontics, Periodontics, Oral Surgery, Crowns, Bridges

What is Madison Dental?

Madison Dental offers you access to high quality, affordable dental coverage for your entire family. Coverage is provided for preventative, diagnostic, basic and major dental services.

Exclusive Features:

  • Freedom to choose Indemnity or PPO Network
  • Choice of $500, $1,000 or $1,250 maximum per person
  • No waiting period on Value or Primary Plans
  • No age limits
  • Benefits for preventative, diagnostic, basic, and major services
  • OrthoCare benefits available as an option
  • Automatic Bank Draft, Visa, MasterCard, or Discover
  • Choose from our Value, Primary, or Superior plans

How are benefits covered for Secure Dental One?

Secure DentalOne pays benefits for each covered person in the following manner:

First, you meet the $100.00 Lifetime Deductible per covered person.

Then Secure DentalOne pays a percentage of covered expenses based on the Reasonable and Customary (R&C) fees for those Covered Expenses.

BasicOne*ClassicOnePremierOne
Waiting Periods
Preventative000
DiagnosticN/A00
BasicN/A6 months0
MajorN/A12 months0
CoinsuranceGraded Benefit
Preventative80%80%100%
DiagnosticN/A80%100%
BasicN/A50%25/50/75%**
MajorN/A50%10/20/40%**
Office Co-payN/AN/A$10
DeductibleN/A$100 lifetime applies
to all services
$100 lifetime applies
to all services
Calendar Year
Maximum
N/A$750$1250
*BasicOne option subject to PPO MAC pricing
**Year 1/Year 2/Year 3

Preventive Care
Routine oral exams—limited to 2 per calendar year
Prophylaxis (the cleaning and scaling of teeth) — limited to 2 per calendar year
Topical application of fluoride—for dependent children under age 19; limited to 1 per calendar year (not applicable in all states)

Diagnostic Care*
Intra-Oral Occlusal Film
Bitewing X-rays (up to a set of 4)—limited to 1 per calendar year
Full mouth X-rays (Panoramic film or Full series)— no less than 36 months apart

Basic Care*
Simple extraction
Pin retention—per tooth, in addition to restorations
Fillings (restorations)
Amalgam restorations
Composite restorations—limited to anterior teeth and bicuspids
Sedative fillings
Antibiotic injections administered by a Dentist
Maintenance Prosthodontics
Denture repairs/Adjustments
Denture Rebase—no less than 24 months apart
Denture Reline—no less than 24 months apart

Major Care*
Endodontic treatment
Periodontic services
Inlays, onlays and crowns
Prosthetic services—dentures or bridges
Oral surgery

*Applies only to ClassicOne and PremierOne options

What is Secure Dental One?

Secure Dental One offers you access to quality, affordable dental coverage for your entire family. Coverage is provided for preventive, basic and major dental services.

Exclusive Features:

  • Choice of $750 or $1,250 maximum per person
  • No waiting period for Preventative Care
  • Eligible for ages 18 years and older
  • Benefits for preventive, diagnostic, basic, and major services
  • Automatic Bank Draft, Visa, MasterCard, or Discover

Three plan options available:

  • Choose from our BasicOne, ClassicOne and PremierOne plans

One deductible, for life:

  • Save in the long-term through our unique $100 lifetime deductible

How are benefits covered for IAIC Dental?

IAIC Dental pays benefits for each covered person in the following manner:

First, you meet the $50 Calendar Year Deductible per person. Over age 65, you meet the $100 Calendar Year Deductible per person.

Then Independence American Dental pays a percentage of covered expenses based on the 85th percentile of Reasonable and Customary (R&C) fees for those Covered Expenses.

 Value PlanSuperior Plan
 $500 Annual Maximum$1250 Annual Maximum
Preventative Care80/100%* Co-Insurance
No Waiting Period
100% Co-Insurance
No Waiting Period
Diagnostic Care80/100%* Co-Insurance
No Waiting Period
90% Co-Insurance
No Waiting Period
Basic Care25/80%* Co-Insurance
No Waiting Period
80% Co-Insurance
4-Month Waiting Period
Major CarePPO Discounts
No Waiting Period
50% Co-Insurance
15-Month Waiting Period
* 1st year/2nd year benefits

Plans feature $50 deductibles per person per year. Over age 65 feature $100 deductibles per person per year.

Plans feature $10 office visit copays. Over age 65 feature $25 office visit copays.

Preventive: Cleanings, exams, sealants, fluoride Diagnostic: Bitewing X-rays, full mouth X-rays Basic: Fillings, extractions, repairs Major: Endodontics, Periodontics, Oral Surgery, Crowns, Bridges

What is the calendar year maximum

The maximum amount payable for all Covered Dental Charges in any calendar year as shown in the Coverage Schedule. The Calendar Year Maximum will apply to each insured person.

What is IAIC Dental?

IAIC Dental offers you access to high quality, affordable dental coverage for your entire family. Coverage is provided for preventive, diagnostic, basic and major dental services.

Exclusive Features:

  • Choose from either our Value or Superior plans
  • Choice of $500 or $1,250 maximum per person
  • No waiting period on the Value Plan
  • Benefits for preventive, diagnostic, basic, and major services
  • Monthly Automatic Bank Draft and Credit Card

What is Indemnity and PPO?

Preferred Provider Organization (PPO) : A designated entity within the PPO Service Area under contract with Us or Our subcontracted vendors to provider certain services at a reduced reimbursement rate within a PPO Service Area. We or Our subcontracted vendors will contract with In-Network Providers to provide services covered by the Policy. PPO network is Dentemax. To check provider listings click here www.dentemax.com

PPO MAC: MAC stands for Maximum Allowable Charge. With this option, the benefit is payable as a percentage of the network fee schedule regardless of whether the treatment is provided by a network provider. Out of network charges in excess of the network fee schedule are the responsibility of the insured.

Indemnity: This plan allows you to see any dentist you wish with no network restrictions. Reimbursement is made on a Usual, Customary and Reasonable basis. What are my payment options? You can pay Monthly installments by auto bank withdrawal or pay monthly by credit card. Your subsequent monthly credit card/ach premium deductions will occur based upon the effective date of coverage. If your coverage effective date is the 1st - 14th, your premium will be deducted on the 1st of the month. If your coverage effective date is the 15th - 31st, your premium will be deducted on the 15th of the month.

What is the premium payment?

Payment Of Premium

Premiums are payable to Us or Our authorized representative. No insurance agent, insurance broker or insurance consultant is authorized to accept any premium payment on Our behalf. You must timely pay the monthly premium in order to maintain the Policy. The payment of any premium will not keep the Policy in force beyond the due date of the next premium, except as provided in the Grace Period. If any premium is not received by Us before or at the end of the Grace Period, the Policy will automatically end at the end of the period for which the last premium payment has been paid.

Grace Period

After payment of the first premium, We will allow a Grace Period of thirty-one (31) days following the premium due date to pay subsequent premiums. Charges incurred during the Grace Period are not covered unless the premium due is paid by the end of the Grace Period. The payment of any premium will not keep the Coverage in force beyond the due date of the next premium. If the premium due is not paid by the end of the Grace Period, then coverage will lapse as of the due date.

Premium Changes

We reserve the right to change premiums, on a class basis, on any premium due date by giving the Insured at least thirty-one (31) days prior written notice.

Reinstatement of Insurance

If Your Certificate lapses due to non-payment of premium, reinstatement of coverage may be considered if You notify Us of Your intention to reinstate. Upon such notice, We will furnish You an application to be completed and submitted along with premiums necessary to pay the Certificate to a current status. Your premium payment and Your completed application for reinstatement must be received by Us within sixty (60) days from the premium due date. Reinstatement will not be effective unless approved by the Company.

What is OrthoCare?

ORTHOCARE PROGRAM REDUCES THE COST OF ORTHODONTIC TREATMENT The OrthoCare Orthodontic Discount Program is a program for orthodontic care. When using a contracted OrthoCare Orthodontist, you could save up to 20% on the services performed. This results in meaningful savings when compared to the Usual and Customary (UCR) fees charged by Orthodontists. HIGHLIGHTS No Deductibles No Waiting Periods No Claim Forms No Prior Authorization Required Afordable Rates Coverage for Children and Adults ELIGIBILITY The OrthoCare program has been designed to offer orthodontic benefits to both individuals and families, providing benefits for the routine orthodontic treatment for children and adults. Children who are dependents are covered under the family plan up to their 23rd birthday. OrthoCare has no waiting periods before the benefits begin.

Where can I find a listing of participating orthodontists?

Visit our web site www.amdps.com

  • No Deductibles
  • No Waiting Periods
  • No Claim Forms
  • No Prior Authorization Required
  • Affordable Rates
  • Coverage for Children and Adults

*The optional Orthocare Program is not an insurance benefit, nor is it affiliated with Independence American Insurance Company or a part of the Independence American Dental Plan. Note- The OrthoCare Program is not available in the following states: AK, DE, MT, SC, VT or WY. This program is NOT a health insurance policy and the program does not make payments directly to the providers of health services. This program provides discounts at certain locations for health services. The program member is obligated to pay the provider for all the health care services that the member will receive, but the member will receive a pre-negotiated discount from the providers listed in the network, in accordance with the specific pre-negotiated discounted fee schedule. This program does not guarantee the quality of the services or procedures offered by the providers. Discounts vary by provider. The Discount Medical Plan Organization that operates this program is American Dental Professional Services, LLC located at 9054 N. Deerbrook Trail, Milwaukee, WI 53223.

Who are the Insurance Companies?

Madison National Life Insurance Company, Inc. is licensed in 49 states, the District of Columbia, and the U.S. Virgin Islands, and is accredited as a reinsurer in New York, and is rated A- (Excellent) by Best. Standard Security Life Insurance Company of New York Rated A- (Excellent) for financial condition by A.M. Best Company. Independence American Insurance Company (IAIC), is a member of the IHC group. In business since 1973, IAIC is domiciled in Delaware and headquartered in New York. IAIC is licensed to conduct business in 48 states and the District of Columbia. Other IAIC insurance products include: Short-Term Health, Employer Medical Stop-Loss, Provider Excess Loss, Small Group Major Medical, and Major Medical for Individuals and Families. Product availability varies by state.

Who are the Associations?

Communicating for America, Inc.** (CA) provides many benefits and discounts to its members of Secure DentalOne and Madison Dental. Your enrollment as a member of CA is completed upon receipt of the association annual dues. Your membership information will be mailed shortly thereafter.

**CA is not affiliated with Madison National Life Insurance Company or Standard Security Life Insurance Company, nor is it a part of the insurance coverage. CA is a 501c5 non-profit association headquartered in Fergus Falls, Minn., providing members valued benefits and savings since 1972.

America’s Business Benefit Association (ABBA) provides many benefits and discounts to its members of IAIC Dental. ABBA is a national not-for-profit association that provides volume-driven savings on many health-related purchases and valuable group health care insurance benefits. ABBA offers a variety of member benefit packages, to provide you choices of the savings and benefits you select. Discuss these choices with your agent or visit www.abbaplans.com. ABBA membership is not an insurance policy.

Who is the IHC Group?

The IHC Group is an insurance organization comprised of Independence Holding Company (NYSE: IHC) and its operating subsidiaries. The IHC Group has been providing life, health and stop-loss insurance solutions for over 25 years. For more information on Independence Holding Company and the IHC Group, visit www.ihcgroup.com.

What about definitions?

The terms listed below, when used in this Certificate, will have the following meanings:

Calendar Year: The period of time beginning January 1st and ending on December 31st of the same year. The first Calendar Year of the Certificate will begin on the date Your coverage becomes effective and end on the first December 31st after a Covered Person’s Effective Date of coverage.

Calendar Year Maximum Amount: The maximum amount of benefits payable under the Certificate in a Calendar Year. The Calendar Year Maximum is shown on the Schedule of Benefits page. Prosthodontics and orthodontia, if covered, have a separate Calendar Year Maximum Amount.

Certificate holder: The Insured Person under the Policy.

Child:

  1. An Insured Person’s natural child;
  2. An Insured Person’s lawfully adopted child;
  3. A child placed for adoption with an Insured Person;
  4. An Insured Person’s stepchild;
  5. An Insured Person’s foster child;
  6. A child for whom the Insured Person has been appointed legal guardian by a court of competent jurisdiction and who resides with and who is dependent upon the Insured Person in a regular parentchild relationship; or
  7. A Child of the Insured Person for whom the Insured Person is obligated to provide medical child support pursuant to a Qualified Medical Support Order, provided that the requirement for qualifications of the order as outlined in the Policy are met.

Co-Insurance: The percentage paid by the plan after the Deductible is met up to the Calendar Year Maximum Amount. The Co-Insurance percentage is shown in the Schedule of Benefits.

Company: Independence American Insurance Company. Also hereinafter referred to as We, Us and Our.

Copay/Copayment: The fixed dollar amount specified in the Schedule of Benefits that is payable by a Covered Person to a provider at the time of service in connection with specific Covered Charges.

Covered Charge: The Reasonable and Customary Charge for a Medically Necessary Covered Procedure which is performed by a Dentist or a Dental Hygienist acting under the supervision and direction of a Dentist.

Covered Person: A person who has satisfied all of the following requirements:

  • he or she is eligible for coverage under the Policy, either as an Insured or as a Dependent;
  • he or she has been accepted for coverage under the Policy or has been automatically added;
  • premium has been paid for him or her; and
  • his or her coverage has become effective and has not terminated.

Covered Persons are shown on the Identification Card.

Covered Procedure: The procedures listed in the Schedule of Covered Procedures. The procedure must be: (1) for Medically Necessary dental treatment to a Covered Person while his or her coverage under the Policy is in force and (2) for treatment, which in Our opinion, has a reasonably favorable prognosis for the patient. The procedure must be performed by a:

  1. licensed Dentist who is acting within the scope of his or her license;
  2. licensed Physician performing dental services within the scope of his or her license; or
  3. licensed Dental Hygienist acting under the supervision and direction of a Dentist.

Deductible: The dollar amount for Covered Procedures that a Covered Person must pay in a Calendar Year before benefits are payable under this Certificate. The Deductible is shown on the Schedule of Benefits. Each Covered Person must satisfy the Deductible before benefits are payable. After three Covered Person's have each satisfied the Deductible, no additional Deductible will be required for other Family Members who are Covered Persons for the remainder of the Calendar Year.

Dentist: A person who is a legally licensed doctor of dental surgery, dental medicine or dental science in the state where services are rendered and is acting within the scope of that license.

Dental Hygienist: A person who is licensed to practice dental hygiene in the state where services are rendered and is acting under the supervision and direction of a Dentist and within the scope of that license.

Dependent:

  1. Lawful spouse;
  2. Unmarried Child who is primarily dependent upon the Insured Person for support and maintenance and is:
    A. Less than 25 years of age; or
    B. Between 19 and 25 years of age; provided however, that the Child is dependent upon the Covered Person for support and maintenance and a full-time student actively attending an accredited college, vocational or high school. Full-time, as used in this definition, means actively attending at least 12 hours of class a week or, if less, attending the minimum hours of class the school considers as full-time status;

Dependent does not include anyone who:

  • lives outside the United States;
  • is in the armed forces of any country; or
  • has coverage under the Policy as a Certificateholder or Dependent of another person.

Domestic Same-Sex Partners: Two same-sex adults who are in a committed relationship and mutually responsible for one another financially and otherwise. To qualify as a Domestic Same-Sex Partner, or Dependent under the Certificate, the following conditions must all be met:

  • You and the Domestic Partner are over the age of 18 and mentally competent to enter into contracts;
  • You and the Domestic Partner reside in the same household together;
  • You and the Domestic Partner have a committed relationship with each other for no less than 6 months; intend to continue the relationship indefinitely and have no such relationship with any other person;
  • You and the Domestic Partner are not related by blood;
  • You and the Domestic Partner are not married to any third party;
  • You and the Domestic Partner are of the same sex;
  • You and the Domestic Partner are not claiming Dependent status for the primary reason of gaining insurance coverage under this Certificate.

Emergency: A dental condition characterized by the sudden onset of acute symptoms of sufficient severity that the absence of immediate dental attention could reasonably result in:

  • permanently placing the Covered Person’s health in jeopardy
  • causing other serious dental or health consequences; or
  • causing serious impairment of dental function.

We will make the final determination as to whether or not a condition is an Emergency. Experimental/Investigational: A drug, device or medical or dental care or treatment will be considered experimental/investigational if:

  • The drug or device cannot be lawfully marketed without approval of the U.S. Food and Drug Administration and approval for marketing has not been given at the time the drug or device is furnished;
  • The informed consent document utilized with the drug, device, medical or dental care or treatment states or indicates that the drug, device, medical or dental care or treatment is part of a clinical trial, experimental phase or investigational phase or if such a consent document is required by law;
  • The drug, device, dental care or treatment or the patient informed consent document utilized with the drug, device or medical or dental care or treatment was reviewed and approved by the treating facility’s Institutional Review Board or other body serving a similar function, or if federal or state law requires such review and approval;
  • Reliable Evidence shows that the drug, device or medical or dental care or treatment is the subject of ongoing Phase I or Phase II clinical trials, is the research, experimental study or investigational arm of on-going Phase III clinical trials, or is otherwise under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy or its efficacy as compared with a standard means of treatment of diagnosis; or
  • Reliable Evidence shows that the prevailing opinion among experts regarding the drug, device or medical or dental care or treatment is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, its efficacy or its efficacy as compared with a standard means of treatment of diagnosis.

Reliable Evidence means only: published reports and articles in authoritative medical and scientific literature; written protocol or protocols by the treating facility studying substantially the same drug, device or medical or dental care or treatment; or the written informed consent used by the treating facility or other facility studying substantially the same drug, device or medical or dental care or treatment. Covered Procedures will be considered in accordance with the drug, device or medical or dental care at the time the expense is incurred.

Family Member: A person who is related to a Covered Person in any of the following ways: spouse, brother-in-law, sister-in-law, son-in-law, daughter-in-law, mother-in-law, father-in-law, parent (includes stepparent), brother or sister (includes stepbrother and stepsister), or Child.

In-Network Provider: A Dentist who is under contract with Us or Our subcontracted vendor. Insured/Insured Person/Member: The individual named on the Schedule of Benefits as the Insured who has: (a) submitted an application for coverage on himself or herself, his or her Dependents, or both; (b) meets the eligibility and effective date provisions set forth in the Certificate evidencing coverage under the Policy; (c) is approved for coverage by Us; and (d) for whom all applicable premiums are paid, and therefore has coverage under the Policy.

Medically Necessary: A treatment, drug, device, procedure, supply or service that is necessary and appropriate for the diagnosis or treatment of a Covered Person’s condition in accordance with generally accepted standards of dental practice in the United States at the time it is provided. A treatment, drug, device, procedure, supply or service shall not be considered as Medically Necessary if it:

  • is Experimental/Investigational;
  • is provided solely for education purposes or the convenience of the Covered Person, a Family Member, Dentist, Hospital or any other provider;
  • exceeds in scope, duration, or intensity the level of care that is needed to provide safe, adequate and appropriate diagnosis or treatment.
  • is for maintenance or preventive care;
  • could have been omitted without adversely affecting the person’s condition or the quality of dental care; or
  • can be safely provided to the patient on a more cost effective basis or pursuant to a more conservative form of treatment.

The fact that a Dentist may prescribe, order, recommend, or approve a service, supply or level of care does not, of itself, make the treatment Medically Necessary or make the charge a Covered Charge under the Policy. We reserve the right to determine whether a service, supply or drug is Medically Necessary.

Out-of-Network Provider: A Dentist, located within the PPO Service Area, who is not under contract with Us or Our subcontracted vendor.

Policy: The contract providing the benefits described herein issued to the Policyholder.

Policyholder: Means the Group, in whose name the Policy is issued, as shown on the Schedule of Benefits.

PPO Service Area: The geographical area in which We have arranged to provide PPO services to Covered Persons.

Preferred Provider Organization (PPO): A designated entity within the PPO Service Area under contract with Us or Our subcontracted vendors to provider certain services at a reduced reimbursement rate within a PPO Service Area. We or Our subcontracted vendors will contract with In-Network Providers to provide services covered by the Policy.

Prescription Drugs: Drugs which may only be dispensed by written prescription under Federal law, and approved for general use by the Food and Drug Administration. Reasonable and Customary Charge: The most common charge for similar professional services, drugs, procedures, devices, supplies or treatment within the Geographic Area in which the charge is incurred. The most common charge means the lesser of:

  • the actual amount charged by the provider;
  • the negotiated rate;
  • the usual charge which would have been made by a provider (Dentist, Hospital, etc) for the same or a comparable professional services, drugs, procedures, devices, supplies or treatment within the same Geographic Area, as determined by Us.

Geographic Area: the three digit zip code in which the service, treatment, procedure, drugs or supplies are provided; or a greater area if necessary to obtain a representative cross-section of charge for a like treatment, service, procedure, device drug or supply.

We, Our, Us, The Company: Independence American Insurance Company.

You, Your: The person named on the Schedule of Benefits as the Insured Person.

What about preferred provider organizations?

Covered Charges incurred in the event of an Emergency, shall be payable under the Schedule of Benefits as an In-Network Provider or an Out-of-Network Provider.

We do not make any representation or warranty as to the medical competence or ability of an In-Network Provider or an Out-of-Network Provider or to their respective staff or Dentists. We shall not have any liability or responsibility, either direct, indirect, vicarious or otherwise, for any actions or inactions, whether negligent or otherwise, of the In-Network Provider or Out-of-Network Provider, their staff or Dentists.

What about coordination of benefits?

Applicability

The following provisions are applied to determine which insurance Plan pays benefits first when a Covered Person is covered by two or more plans. A Plan that pays first is called “primary”. All other plans are called “secondary”. 2. If these provisions apply, the order of benefit determination rules should be looked at first. Those rules determine whether the benefits of This Plan are determined before or after those of another plan. The benefits of This Plan:

  • Shall not be reduced when, under the order of benefit determination rules, This Plan determines its benefits before another plan; but
  • May be reduced when, under the order of benefits determination rules, another plan determines its benefits first. The above reduction is described under "Effect on the Benefits of This Plan."

Are there any exclusions or limitations?

Benefits will not be paid for dental expenses arising from or in connection with:

  1. Treatment, services or supplies which:
    A. Are not Medically Necessary;
    B. Are not prescribed by a Dentist;
    C. Are determined to be Experimental/Investigational in nature by Us;
    D. Are received without charge or legal obligation to pay;
    E. Would not routinely be paid in the absence of insurance;
    F. Are received from any Family Member;
    G. Are not Covered Procedures.
  2. Self-inflicted injuries.
  3. War or an act of war, whether or not declared.
  4. A Covered Person's commission of a felony or an assault on another person.
  5. Riot, nuclear accident, or a major disaster.
  6. Employment; whether caused by, related to, or as a condition of employment, including self-employment. This exclusion applies even if Workers' Compensation or any Occupational Disease or similar law does not cover the charges.
  7. Treatment which began, before the Covered Person's Effective Date of coverage or after the Covered Person's termination of coverage.
  8. Congenital or development malformations existing on the Covered Person's effective date as shown on the Schedule of Benefits.
  9. Cosmetic procedures, unless the coverage is elected by the Insured Person and the required premium is paid.
  10. Implants of any type, and all related procedures, removal of implants, precision or semi-precision attachments, denture duplication, overdentures and any associated surgery, or other customized services or attachments, unless the coverage is elected by the Insured Person and the required premium is paid.
  11. Periodontal splinting.
  12. Porcelain on crowns, or pontics posterior to the 2nd bicuspid.
  13. Replacement of partial or full dentures, fixed bridge work, crowns, gold restorations and jackets more often than once in any 5 year period.
  14. Relining of dentures more often than once in any 2 year period.
  15. Lost, stolen, or missing dentures or bridges or for duplicates.
  16. Fixed or removable bridgework involving replacement of a natural tooth or teeth which was lost prior to the Covered Person's Effective Date of coverage as shown on the Schedule of Benefits. Benefits may be payable for bridgework required for loss of teeth while covered under the Policy, if such bridgework is not an abutment for non-covered bridgework.
  17. Prescription Drugs and analgesia pre-medication.
  18. Telephone consultations, failure to keep a scheduled appointment, to complete claim forms or attending Dentist statements, and any other services or supplies which are not part of the direct treatment of the Covered Person.
  19. Dental education or training programs including oral hygiene or plaque control programs.
  20. Counseling on diet and nutrition.
  21. Military service, including service in a military reserve unit.
  22. Orthodontia, unless this coverage is elected by the Insured Person and the required premium is paid.
  23. Prosthodontics, unless this coverage is elected by the Insured Person and the required premium is paid.
  24. Charges payable under any medical insurance.
  25. Charges made by any government entity unless the Covered Person is required to pay; or by any public entity from which coverage could have been obtained by application or enrollment even if application or enrollment was not actually made.
  26. Use of materials, other than fluorides or sealants, to prevent tooth decay.
  27. Bite registrations.
  28. Bacteriologic cultures in connection with a covered dental service.
  29. Therapeutic injections administered by a Dentist.
  30. Cast restorations, inlays, onlays and crowns for teeth that are not broken down by extensive decay or accidental injury or for teeth that can be restored by other means (such as an amalgam or composite filling).
  31. Replacement of 3rd molars.
  32. Composites on teeth posterior to the 2nd bicuspid.
  33. Crowns, inlays and onlays used to restore teeth with micro fractures or fracture lines, undermined cusps, or existing large restorations without overt pathology.
  34. Temporomandibular joint syndrome.

Who is the Administrator?

IHC Health Solutions, Inc. specializes in providing dental plan services for the group and individual dental market nationwide. We are owned by Independence Holding Company (NYSE:IHC), and a member of The IHC Group.

This site provides a brief description of the benefits, exclusions and other provisions of the policy or certificate Form Master Policy IAIC-ADEN POL 0206, Form Master Policy MNL ADEN-CER.010 0905 and Master Policy# SSL ADEN-POL 0606 issued to Communicating for America. For a complete listing, see the policy or certificate. Benefits may vary in different states. This dental insurance plan may not be available in all states.



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