Dental Care

Payment will not be made for any dental procedure required due to an injury or dental disease for which you, or your dependent, were advised to receive treatment or for which treatment first began before the effective date for that dental procedure.

The following items are not considered as covered expenses:

• replacement of a lost or stolen prosthetic device
• root canal therapy for primary teeth
• isolation of teeth
• enlargement of pulp chambers
• services and supplies that are partially or wholly cosmetic in nature
• supplies or services which are not furnished by a legally qualified dentist or denturist acting within the scope of his license
• charges for completion of claim forms, broken appointments, counselling, travel, communication costs or for advice by telephone
• charges for protective athletic appliances
• expenses incurred as a result of intentionally self-inflicted injuries (while sane or insane) or as a result of committing or attempting to commit a criminal offence
• expenses for treatment required as a result of war, (declared or not) or participation in a riot, insurrection or civil commotion
• expenses for services or treatment that are payable by Workplace Safety & Insurance Law (or Similar legislation) or any government plan, or which are received without charge or which a government health plan prohibits being paid
• services or supplies for implantology, including tooth implantation, transplantation and surgical insertion of fabricated implants
• services or supplies in connection with any procedures excluded as an eligible expense
• any hospital charges for board and room and related services and supplies
• any dental examinations required by a third party
• services or supplies which are not medically necessary to the care and treatment of any existing or suspected injury or disease
• any charges which would not normally have been made but for the presence of this insurance or for which you or your dependent are not obligated to pay
• dental treatment which is primarily experimental or for dietary planning, congenital or developmental malformation
• any dental procedure required due to teeth extracted, missing or fractured before the effective date of your coverage for that procedure except as specifically stated for appliance replacement above
• any charges which were considered an insured service of any provincial government plan at the time this benefit was issued and subsequently were modified, suspended or discontinued
• any services covered in whole or in part by any government plan, services for which no charge is made, or services which the insurer is not permitted by law to cover.

This Trust Fund has been designed to help you meet the cost of disease or injury. Since it is not intended that you receive benefits greater than the actual expenses incurred, any dental care coverage you have under other “plans” will be taken into account in determining the amount of benefit payable under this Trust Fund, that is, the benefits under this Trust Fund will be coordinated with the benefits of the other plans.

Plan means any contract of group insurance or other arrangement for members of a group (whether on an insured basis or not), prepaid dental care coverage, or student accident insurance.

Specifically, this Trust Fund will pay either its regular benefits in full, or a reduced amount which, when added to the benefits available under the other plan, or plans, will equal 100% of “allowable expenses”.

Allowable expense means any necessary, Reasonable and Customary expense, incurred while eligible for benefits under this Trust Fund, part or all of which would be payable under any of the plans, but not any expenses contained in the list of Exclusions.

The manner in which this is done determines which plan pays first (and thus where to submit the claim first) and which plan(s) pays next. The plan that does not have a co-ordination of benefits provision pays before the plan that does (most, if not all, insurance company plans have such a provision).

For any person who is covered under more than one plan, benefits will be payable first under the plan where he is the insured member and secondarily where he is covered as a dependent.

Dependent children are covered first by the parent whose birthday comes first in the year, and any unpaid balance can then be submitted to the other parent’s plan.

If priority cannot be established in the above manner, the benefits shall be pro-rated between or amongst the plans in proportion to the amounts that would have been paid under each plan had there been coverage by just that plan.

To implement this provision, the Trust Fund and the insurer may:

• Subject to the consent of the covered person, if required by law, obtain from or release to any other person, corporation or organization any information deemed to be needed; or
• Pay to or recover from any person, corporation or organization any excess payment; any payment so made will be deemed to be benefits paid and, to the extent of such payments, will fully discharge the Trust Fund and the insurer from all liability under this benefit.

Orthodontic treatment includes the diagnosis or correction of teeth irregularities and malocculsion of jaws, by wire appliances, braces or other mechanical aids, commonly known as “straightening of the teeth”. These include active space maintainers, or orthodontic appliances for the purpose of repositioning or moving the teeth.

A Pre-Treatment Plan is always required for this benefit. Treatment will generally extend over a two or three year time span. The Claims Office will respond to the Pre-Treatment Plan with an explanation of how the monthly reimbursement process will work for the duration of the Orthodontic treatment. Claim payment is on a reimbursement basis, subject to the submission of paid receipts.

If you chose to pay your dentist in advance, your payments will be amortized over the period of the Pre-Treatment Plan and reimbursed on a monthly basis as the treatment progresses. Monthly reimbursements will terminate when the claimant no longer qualifies as an eligible dependent, regardless of whether the treatment is completed.