2023 Archdiocese of Atlanta Meritain Group Plan Doc - Manual / Resource - Page 92
DENTAL AND VISION EXCLUSIONS AND LIMITATIONS
No payment will be eligible under any portion of this Dental/Vision Plan for Dental Expenses Incurred by a Covered
Person for the expenses or circumstances listed below. If an expense is paid that is found to be excluded or limited
as shown below, the Dental/Vision Plan has the right to collect that amount from the payee, the Covered Person,
or from future benefits, and any such payment does not waive the written exclusions, limitations or other terms of
the Dental/Vision Plan.
(1)
Administrative Costs: Expenses for administrative costs of completing claim forms or reports or for providing
dental records will not be considered eligible.
(2)
After Termination Date: Expenses which are Incurred after the termination date of your coverage under the
Plan will not be considered eligible.
(3)
Alternative Treatment: Expenses where there are alternate courses of treatment available carrying different
fees, the Dental/Vision Plan will provide benefits only for the treatment carrying the lesser fee.
(4)
American Dental Association: Expenses which do not meet the standards of dental practices accepted by
the American Dental Association.
(5)
Close Relative: Expenses for services, care or supplies provided by a person who normally resides in the
Covered Person’s home or by a Close Relative will not be considered eligible.
(6)
Cosmetic: Expenses for services or supplies partially or wholly cosmetic in nature will not be considered
eligible.
(7)
Crowns: Expenses for crowns that are restorable by other means or for the purpose of periodontal splinting
will not be considered eligible.
(8)
Department Maintained by an Employer: Expenses for services received from a Dentist or dental
department maintained by an employer, labor union, etc., where the individual is eligible under any group
insurance plan will not be considered eligible.
(9)
Duplicate Devices: Expenses for duplicate prosthetic devices or appliances; expenses for a lost or stolen
dental appliance will not be considered eligible.
(10) Hospital Expenses: Expenses for hospital expenses will not be considered eligible.
(11) Implants: Expenses for tooth implants will not be considered eligible.
(12) Medical Plan: Expenses which are covered or excluded under the Medical Plan or expenses which are
payable under any medical plan will not be considered eligible.
(13) Missed Appointments: Expenses for completion of claim forms, missed appointments or telephone
consultations will not be considered eligible.
(14) Not Listed as Eligible: Expenses for procedures or restorations other than those listed in the Eligible Dental
Expenses section will not be considered eligible.
(15) Not Performed by a Dentist: Expenses for treatment by other than a Dentist or physician, except charges
for treatment performed under the supervision and direction of a Dentist or physician, by any person duly
licensed or certified to perform such treatment under applicable professional statutes and regulations, will not
be considered eligible.
(16) Not Prescribed by a Dentist: Expenses for services not prescribed as necessary by a physician or Dentist
will not be considered eligible.
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