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For Class III procedures in the first 12 months that the insured is covered under this plan except when replacing another plan with similar benefits which results in 12 months of continuous coverage for Class III procedures;
For Class IV procedures in the first 12 months that the insured is covered under this plan except when replacing another plan with similar benefits which results in 12 months of continuous coverage for Class IV procedures;
In the first 12 months that a person is insured if the person is a Late Entrant except for exams, cleanings and fluoride application. The benefits are limited to procedures numbered 0110, 0120, 0130, 0150, 1110, 1120 and 1201;
For any treatment which is for cosmetic purposes, or to correct congenital malformations, other than medically necessary treatment of congenital cleft in the lip or palate;
To replace any prosthetic appliance, crown, inlay, or onlay restoration, or fixed bridge within five years of the date of the last placement of these items. But if replacement is required because of an accidental bodily injury sustained while the insured is covered under this section, it will be a Covered Expense;
For the placement of any prosthetic appliance, fixed bridge unless the placement is needed because of the extraction of one or more natural teeth while the insured is covered under this Policy. But the extraction of a third molar will not qualify under the above. Any such appliances of fixed bridge must include the replacement of the extracted tooth or teeth;
For any procedure begun before the insured was covered under this Policy;
For any procedure begun after the insured's insurance under this Policy terminates; or for any prosthetic dental appliance installed or delivered more then 90 days after the insured's insurance under this Policy terminates;
To replace lost or stolen appliances;
For appliances restorations, or procedures to:
- a. alter vertical dimension;
- b. restore or maintain occlusion;
- c. splint or replace tooth structure lost as a result of abrasion, or
- d. treat disturbances of the temporomandibular joint;
For any procedure which is not shown on the List of Dental or Vision Procedures;
For the completion of claims forms;
For sealants which are:
- a. not applied to a permanent molar;
- b. applied after attaining age 17; or
- c. reapplied to a molar within 3 years from the date of a previous sealant application;
Subgingival curettage or root planning unless the presence of periodontal disease is confirmed by both x-ray and pocket depth summaries of each tooth involved;
Because of an injury arising out of, or in the course of, work for wage or profit;
By an Insured because of sickness, injury or condition for which he or she is eligible for benefits under any Workers' Compensation act or similar laws;
For procedures which are not recommended by a Dentist, Ophthalmologist or Optometrist, or which are not required for medically necessary care and treatment;
Because of an act of war or any war, declared or not;
To an Insured if payment is not legal where the Insured is living when expenses are incurred;
Any services related to equilibration; bite registration or bite analysis;
Crowns for the purpose of peridontal splinting;
Charges for; any implants; precision or semi-precision attachments, and any endodontic treatment associated with it other customized attachments;
Special procedures, such as orthoptics, vision training and subnormal vision aids;
Plain or prescription sunglasses or other special purpose vision aids;
Medical or surgical treatment of the eyes, including hospital expenses;
Replacement of lost or broken lenses and/or frames;
Duplicate glasses or lenses or frames; and
Services or material not listed as an Eligible Expense.
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