Dental Care

Routine Treatments

 
Covered Routine Services:

• oral examinations including scaling, polishing and cleaning of teeth
• topical application of sodium or stannous fluoride
• dental x-rays: single diagnostic x-rays; complete series or equivalent
• oral hygiene instruction
• consultations
• extractions
• routine oral surgery including excision of impacted teeth
• amalgam, acrylic, silicate or composite fillings, however molar teeth are limited to amalgam filling in accordance with the plan's policy to cover the least expensive suitable service.
• retentive pins
• anaesthesia where reasonably and customarily required in connection with other covered procedures
• treatment of periodontal and other diseases of gums and tissues of the mouth, (special periodontal appliances)
• emergency endodontic procedures and root canal therapy, limited to one course of treatment per tooth per lifetime
• prefabricated full coverage restorations for primary teeth
• passive space maintainers, those that do not move the teeth, and pit and fissure sealants for Dependent Children under the age of 18 only, for molar and bicuspid teeth
• caries, trauma and pain control
• study casts, once every twelve (12) months
• repairing, relining and rebasing of dentures to the frequency of once every 36 months
• initial installation of partial or full removable dentures to replace teeth lost, extracted or fractured after the effective date of this insurance

Dental Care Benefits

You may choose any licensed Dentist or licensed Denturist practicing within the scope of his or her profession.

What the Insurance Covers

The dental benefits described in this section apply to both the member and their eligible dependents. The insurance covers work included in a comprehensive list of dental expenses, which appears later. Many dental conditions can properly be treated in more than one way. This Trust Fund is designed to help pay your dental expenses but not on the basis of treatment that is more expensive than necessary for good dental care. Thus, if a condition is being treated for which two or more services included in the list are suitable under customary dental practices, the benefit under the Trust Fund will be based on the least expensive of the services.

Dental Care Benefits

Reimbursement: Provincial Fee Guide of member’s home province for the year determined from time to time by the Trustees.

If a dental service is performed that isn't in the list, but the list contains one or more other services that under customary dental practices are suitable for the condition being treated, then for the purpose of the Trust Fund, the least expensive of the suitable services listed will be considered to have been performed. Please refer to the list of Exclusions for additional items that are not covered.

The final choice of treatment is always between the patient and the dentist. You are financially responsible to your dentist for the cost of the dental work performed. This Trust Fund will reimburse you to the limits described herein.

Percentage Payable

The Percentage Payable is the maximum percentage of your costs that the Trust Fund will reimburse you, for you and your dependents’ Covered Expenses.

Calendar Year Maximum

The Calendar Year Maximum is the maximum amount the Trust Fund will allow any one individual for Dental Care Benefits in a single calendar year.

Pre-Determination of Benefits

Pre-determination of benefits permits the review of the proposed treatment in advance and allows for a solution of any questions before, rather than after, the work has been done. Additionally, both you and the dentist will know in advance what the Trust Fund will allow assuming you, or the dependent, remain covered.

A “Treatment Plan” is strongly recommended when dental work is expected to exceed $500.

A "Treatment Plan" is the dentist's report that

1. itemizes the dentist's recommended services
2. shows the dentist's charge for each service, and
3. is accompanied by supporting X-rays, or a letter of expertise.

The "Treatment Plan" will be returned to the dentist showing the estimated benefits.

What An "Eligible Charge" Is

An "eligible charge" is one the dentist makes to you for a covered dental service furnished to you or a covered dependent, provided the service is included in the list of Covered Dental Expenses and not listed under Exclusions.

All expenses are assessed on a Reasonable and Customary basis. Meaning the amount usually charged for treatment, services or supplies to provide an appropriate level of care given the severity of the condition being treated, in the geographical location where the treatment, services or supplies are being provided. Lab fees may be cut back accordingly.

A charge is considered incurred on the date the service is received, rather than on the date the charge is made. In the case of root canal therapy, crowns, dentures or bridgework, which may require multiple appointments, the date the expense is incurred will be the date the service is finally completed. For dentures or bridgework, this date will be the date the prosthetic device is installed. For crowns, this will be the date the permanent crown is installed and for root canal therapy, this will be the date the canal is closed.

Covered Dental Expenses

Charges for Reasonable and Customary services and specified supplies shall be considered covered expenses when incurred by you or a covered Dependent. Eligible expenses include Basic and Preventive Treatment, Endodontics, Periodontics, Oral Surgery, Major Restorative and Prosthodontics. An expense is eligible to the extent that coverage is not prohibited by provincial health insurance plans or because of other limitations described below.

Termination of Benefits

No benefits for Covered Dental Expenses will be paid for expenses incurred after the policy terminates, or after the individual’s coverage terminates.

The following exceptions apply only if the treatments specified are covered under this policy and there is no replacement dental insurance coverage after such termination:

• Where an impression for a denture, bridge or crown was taken or root canal therapy was started prior to the termination of insurance, dental expense in connection with these procedures and incurred within 30 days of termination will be considered as incurred prior to termination.
• Where Orthodontic Treatment has commenced and a treatment plan has been submitted in advance to the Insurer, dental expenses in connection with such treatment and incurred within 90 days of termination will be considered as incurred prior to termination.

Extension of Dental Care Benefit in the Event of Your Death

If you die while your dependents are insured for Dental Care Benefits under this Trust Fund, their Dental Care benefits will continue to the earlier of:

1. The date they cease to qualify as insurable dependents; or
2. 2 years after your death.

If your child is born after your death, the child is considered an insurable dependent.

Any extended benefits payable are subject to the provisions and limitations of the Trust Fund.