DENTAL EXCLUSIONS 

No coverage will be provided for services, supplies or charges: 

1. Not specifically listed as a Covered Service on the Schedule of Benefits and those listed as not covered on the Schedule of Benefits. 

2. Which are necessary due to patient neglect, lack of cooperation with the treating dentist or failure to comply with a professionally prescribed Treatment Plan.  This exclusion does not apply to Group Policies and Certificates issued and delivered in California. 

3. Stated prior to the Member's Effective Date or after the Termination Date of coverage with the Company, including, but not limited to multi-visit procedures such as endodontics, crowns, bridges, inlays, onlays and dentures.   

4. Services or supplies that are not deemed generally accepted standards of dental treatment. 

5. For hospitalization costs. 

6. That are the responsibility of Worker's Compensation or employer's liability insurance, or for treatment of any automobile related injury in which the Member is entitled to payment under an automobile insurance policy.  The Company's benefits would be in excess to the third party benefits and therefore, the Company would have right of recovery for any benefits paid in excess.  For Group Policies and Certificates issued and delivered in Georgia, Missouri, and Virginia, only services that are the responsibility of Workers Compensation or employer's liability insurance shall be excluded from this Plan.  For Group Policies and Certificates issued and delivered in Texas, only services that are the responsibility the employer's liability insurance, or for treatment of any automobile related injury shall be excluded from this Plan. 

7. For prescription or non-prescription drugs, vitamins, or dietary supplements. 

8. Administration of nitrous oxide, general anesthesia and i.v. sedation, unless specifically indicated on the Schedule of Benefits. 

9. Which are Cosmetic in nature as determined by the Company, including, but not limited to bleaching, veneer facings, personalization or characterization of crowns, bridges and/or dentures. 

This exclusion does not apply to Group Policies and Certificates issued and delivered in Pennsylvania for Cosmetic services required as the result of an accidental injury.  This exclusion does not apply to Group Policies issued and delivered in New Jersey for Cosmetic services for newlyborn children of Members as defined in the definition of Dependent. 

10. Elective procedures including but not limited to the prophylactic extraction of third molars. 

11. For the following which are not included as orthodontic benefits - retreatment of orthodontic cases, changes in orthodontic treatment necessitated by patient neglect, or repair of an orthodontic appliance. 

12. For congenital mouth malformations or skeletal imbalances, including, but not limited to treatment related to cleft lip or cleft palate, disharmony of facial bone, or required as the result of orthognathic surgery including orthodontic treatment. For Group Policies and Certificates issued and delivered in Arizona, Kentucky, and Pennsylvania this exclusion shall not apply to newly born children of Members as defined under the definition of Dependent including adoptive children, regardless of age.  For Group Policies issued and delivered in Colorado, this exclusion shall not apply to orthodontic or dental services for a newly born Dependent with cleft lip or cleft palate and shall be covered as listed on the Schedule of benefits.  For Group Policies and Certificates issued and delivered in Florida, this exclusion shall not apply for diagnostic or surgical dental (not medical) procedures rendered to a Member of any age. 

13. For dental implants including placement and restoration of implants unless specifically covered under a rider to the Certificate.  This exclusion does not apply if dental services are required for sound teeth as a result of accidental injury. 

14. For oral or maxillofacial services including but not limited to associated hospital, facility, anesthesia, and radiographic imaging even if the condition requiring these services involves part of the body other than the mouth or teeth.  This exclusion shall not apply to Group Policies issued and delivered in Georgia when such services are medically necessary. 

15. Diagnostic services and treatment of jaw joint problems by any method unless specifically covered under a Rider to the Certificate.  These jaw point problems include but are not limited to such conditions as temporomandibular joint disorder (TMD) and craniomandibular disorders or other conditions of the joint linking the jaw bone and the complex of muscles, nerves and other tissues related to the joint. For Group Policies and Certificates issued in Florida, this exclusion does not apply to diagnostic or surgical dental (not medical) procedures for Treatment of TMD rendered to a Member of any age as a result of congenital or developmental mouth malformation, disease or injury and such procedures are covered under a Rider to the Certificate or the Schedule of Benefits. 

16. For treatment of fractures and dislocations of the jaw.  This exclusion does not apply to Group Policies and Certificates issued in Pennsylvania if the dental condition is as a result of an accidental injury. 

17. For treatment of malignancies or neoplasms. 

18. Services and/or appliances that alter the vertical dimension, including but not limited to full mouth rehabilitation, splinting, fillings to restore tooth structure lost from attrition, erosion or abrasion, appliances or any other method.  This exclusion does not apply to Group Policies and Certificates issued in Pennsylvania if the dental condition is as a result of an accidental injury. 

19. Replacement of lost, stolen or damaged prosthetic or orthodontic appliances. 

20. For broken appointments. 

21. Arising from any intentionally self-inflicted injury or contusion when the injury is a consequence of the Member's commission of or attempt to commit a felony or engagement in an illegal occupation or of the Member's being intoxicated or under the influence of illicit narcotics.  This exclusion does not apply to Group Policies and Certificates issued and delivered in Maryland. 

22. For house or hospital calls for dental services. 

23. Replacement of existing crowns, onlays, bridges and dentures that are or can be made serviceable. 

24. Preventive restorations in the absence of dental disease. 

25. Periodontal splinting of teeth by any method. 

26. For duplicate dentures, prosthetic devices or any other duplicate device. 

27. For services determined to be furnished as a result of a referral to an entity in which the referring dentist, or the dentist's immediate family; (a) owns a beneficial interest; or (b) has a compensation arrangement.  The dentist's immediate family includes the spouse, child, child's souse, parent, spouse's parent, sibling or sibling's spouse of the dentist or that dentist in combination. 

28. For which in the absence of insurance the Member would incur no charge. 

29. For plaque control programs, oral hygiene, and dietary instructions. 

30. For any condition caused by or resulting from declared or undeclared war or act thereof, or resulting from service in the guard or in the armed forces of any country or international authority.  This exclusion does not apply to Group Policies and Certificates issued and delivered in Oklahoma.   

31. For training and/or appliance to correct or control harmful habits, but not limited to muscle training therapy (myofunctional therapy). 

32. For any claims submitted to the Company by the Member or on behalf of the Member in excess of twelve (12) months after the date of service. 

33. Which are not Dentally Necessary as determined by the Company.  This exclusion does not apply to Group Policies and Certificates in California and Maryland. 

Certificate Holders must be members of the Student Osteopathic Medical Association and meet the Policyholder's eligibility requirements and waiting periods for insurance.  Dependent children are eligible to age 19, extended to age 23 for dependent children who are full-time students. 

The Dental program is underwritten by United Concordia Life and Health Insurance Company.