Exclusions & Limitations

Exclusions

Encore Dental coverage is available if you are age 18 - 99, regardless of your current or past dental history.

Encore Dental does not pay any benefits for any of the following:

Dental Services that are not NECESSARY.

Hospitalization or other facility charges.

Any Dental Service or procedure performed solely for cosmetic/aesthetic reasons. (Cosmetic procedures are those procedures that improve physical appearance).

Reconstructive surgery regardless of whether or not the surgery is incidental to a dental disease, injury, or congenital anomaly when the primary purpose is to improve physiological functioning of the involved part of the body.

Any Dental Service not directly associated with dental disease or condition.

Any Dental Procedure not performed in a dental office, medical facility, or similar facility whose primary function is to perform dental procedures.

Procedures that are considered to be experimental, investigational or unproven. This includes pharmacological regimens not accepted by the American Dental Association (ADA) Council on Dental Therapeutics. This also includes any experimental, investigational or unproven procedure that is the only available treatment for a particular condition if the procedure is considered to be experimental, investigational or unproven in the treatment of that particular condition.

Dental Services for injuries or conditions covered by Worker’s Compensation or employer liability laws, or which are provided without cost to the Insured by any municipality, county, or other political subdivision. This exclusion does not apply to any Dental Services covered by Medicaid or Medicare.

Expenses for Dental Services begun prior to the date the Insured’s coverage under the Policy/Certificate starts.

Dental Services received after the date an Insured’s coverage under the Policy/Certificate stops, including Dental Services for dental conditions arising prior to the date the insured’s coverage stops. This does not apply to any Dental Services that are covered under the Extended Coverage provision.

Dental Services provided in a foreign country, unless required as an Emergency.

Replacement of crowns, bridges, and fixed or removable prosthetic appliances inserted prior to plan coverage unless the patient has been eligible under the plan for 12 continuous months. If loss of a tooth requires the addition of a clasp, pontic, and/or abutment(s) within this 12 month period, the plan is responsible only for the procedures associated with the addition.

Replacement of natural teeth lost prior to the date the Insured’s coverage starts may not occur until twelve months after coverage has been in force for 12 continuous months.

Full mouth radiograph series in excess of once every 36 months. Panoramic radiographs in excess of once every 36 months, except when taken for diagnosis of third molars, cysts, or neoplasms.

Hard tissue periodontal surgery and soft tissue periodontal surgery persurgical area in excess of once in any 36 month period. This includes gingivectomy, gingivoplasty, gingival curettage (with or without a flap procedure), osseous surgery, pedicle grafts, and free soft tissue grafts.

Osseous grafts, with or without resorbable or non-resorbable GTR membrane placement in excess of once every 36 months per quadrant or surgical site.

Root planing and scaling (ADA Code 4341) in excess of once every 24 months per quadrant.

Full mouth debridement (ADA Code 4355) in excess of once every 36 months.

Replacement of complete or partial dentures, fixed bridgework, or crowns previously submitted for payment under the Plan within sixty (60) months of initial or supplemental placement. This includes retainers, habit appliances, and any fixed or removable interceptive orthodontic appliances.

Replacement of complete or partial dentures, crowns, or fixed bridgework if damage or breakage was directly related to provider error. This type of replacement is the responsibility of the Dentist. If replacement is necessary because of patient non-compliance, the patient is liable for the cost of replacement.

Denture relines for complete or partial conventional dentures for the 6 month period following the insertion of a prosthesis. Tissue conditioning and soft and hard relines for immediate full and partial dentures for the first six months after the insertion of a prosthesis. After the six month waiting period, relines are covered not more than once every 12 months.

Fixed or removable prosthodontic restoration procedures for complete oral rehabilitation or reconstruction.

Attachments to conventional removable prostheses or fixed bridgework. This includes semi-precision or precision attachments associated with partial dentures, crown or bridge abutments, full or partial overdentures, any internal attachment associated with an implant prosthesis, and any elective endodontic procedure related to a tooth or root involved in the construction of a prosthesis of this nature.

Procedures related to the reconstruction of a patient’s correct vertical dimension of occlusion (VDO).

Placement of dental implants, implant-supported abutments and prostheses. This includes pharmacological regimens and restorative materials not accepted by the American Dental Association (ADA) Council on Dental Therapeutics.

Placement of fixed bridgework solely for the purpose of achieving periodontal stability.

Billing for incision and drainage (ADA Code 7510) if the involved abscessed tooth is removed on the same date of service.

Treatment of malignant or benign neoplasms, cysts, or other pathology, unless removed through an excision. Treatment of congenital malformations of hard or soft tissue, including excision.

Setting of facial bony fractures and any treatment associated with the dislocation of facial skeletal hard tissue.

Services related to the temporomandibular joint (TMJ), either bilateral or unilateral. Upper and lower jaw bone surgery (including that related to the temporomandibular joint). No Coverage is provided for orthognathic surgery, jaw alignment, or treatment for the temporomandibular joint.

Acupuncture; acupressure and other forms of alternative treatment.

General Anesthesia, except if required for insureds under six years of age or patients with behavioral problems or physical disabilities.

Drugs/medications, obtainable with or without a prescription, unless they are dispensed and utilized in the dental office during the patient visit.

Occlusal guards except if prescribed to control of habitual grinding, including those specifically used as safety items or to affect performance primarily in sports-related activities.

Charges for failure to keep a scheduled appointment without giving the dental office 24 hours notice.

Limitations

Coverage can stop for any of the following reasons:

1. The Group Policy stops.
2. Coverage is cancelled for everyone in your class.
3. The insured performs an act of fraud or makes a material misrepresentation regarding this coverage.
4. If you fail to pay the premium when due after the 31 day Grace Period ends.
5. We receive your written request to cancel.

If coverage is to be discontinued due to reasons 1 or 2, we will notify you 60 days in advance.