Welfare Summary Plan Description

9.7 EXCLUSIONS AND LIMITATIONS

In addition to non-covered services outlined under the Exclusions and General Limitations section of this Booklet, this Plan will not extend any Dental Care Benefit for:

  1. Services that are eligible under any other Benefit provided by this Trust;
  2. Services for which no charge would have been made in the absence of this coverage;
  3. Any portion of charges that are determined by the Plan to exceed Usual, Customary and Reasonable charges;
  4. Services excluded under the General Exclusions, see Section 7.
  5. Services incurred prior to a Participant's date of eligibility; any Prosthetic devices or crowns (and the fitting thereof) which were ordered before the Participant became eligible;
  6. Services incurred after a Participant's eligibility for coverage terminates (including treatment for conditions arising prior to the termination of coverage);
  7. Any otherwise eligible expense that exceeds the annual maximum benefit for Dental Care Benefits or the lifetime maximum benefit for Orthodontic care;
  8. Replacement of a misplaced, lost or stolen Prosthodontic device (bridgework, complete or partial denture); duplicate or spare dentures;
  9. Repair or replacement of a lost or broken Orthodontic appliance; any Orthodontic services provided on or after the individual's 19th birthday;
  10. Services, appliances, or restorations necessary to alter vertical dimension or restore the occlusion; or ridge augmentation to maintain occlusion;
  11. Services (other than for replacement of structure loss from caries) to replace or stabilize tooth structure lost by attrition/erosion or abrasion;
  12. Services for the personalization or characterization of a Prosthetic device or restoration;
  13. Charges made for completion of forms, duplication of dental records, or charges made for cancelled, failed or broken appointments;
  14. Charges made for analgesia, sedation, hypnosis and/or related services provided for apprehension or anxiety, unless pre-approved by the Plan;
  15. Replacement of any existing Prosthodontic device (bridgework, complete or partial denture), crown, or inlay/onlay more often than once during any five-year period, and then only if the existing device, crown, or inlay/onlay is unserviceable. The five-year period is measured from the date that appliances were last installed;
  16. Special programs including oral hygiene and dietary instructions; or charges for infection control procedures;
  17. Services for the diagnosis or treatment of temporomandibular joint (TMJ) dysfunction, and any other craniomandibular disorder or other conditions of the joint linking the jawbone and skull, including ridge augmentation;
  18. Orthognathic surgical procedures or services in connection with orthognathic surgery;
  19. Charges made for sealants or topical application of fluoride, except as Class I – Diagnostic and Preventive Dental Services payable for Dependent children.

These exclusions shall not be interpreted to violate 26 U.S. Code Section 9802, 29 U.S. Code Section 1182, or 42 U.S. Code Section 300gg-2, but only if those Sections apply.