Dental Plan

Exclusions and Limitations 

Your Dental Plan will not pay for: 

  • A service that is not necessary and appropriate, as determined by Delta Dental Plan.
  • A service or procedure that is not generally accepted, as determined by Delta Dental Plan.
  • A service or procedure that is not described as a benefit in the plan contract.
  • Services that are rendered due to the requirements of a third party, such as an employer or school.
  • Travel time and related expenses.
  • An illness or injury that Delta Dental determines arose out of and in the course of your employment.
  • A service for which you are not required to pay, or for which you would not be required to pay if you did not have this contract.
  • An illness, injury or dental condition for which benefits in one form or another are available, in whole or in part, through a government program or would have been available if you did not have this contract. A government program includes a local, state or national law or regulation that provides or pays for dental services. It does not include Medicaid or Medicare. Delta Dental will not provide benefits if you could have received government benefits by applying for them within the appropriate agency’s time limitation.
  • A method of treatment more costly than is customarily provided. Benefits will be based on the least costly method of treatment.
  • A separate fee for services rendered by interns, residents, fellows or dentists who are salaried employees of a hospital or other facility.
  • Appointments with your dentist that you fail to keep.
  • Dietary advice and instructions in dental hygiene including proper methods of tooth brushing, the use of dental floss, plaque control programs and caries susceptibility tests.
  • A service rendered by someone other than a licensed dentist or a hygienist who is employed by a licensed dentist.
  • Consultations.
  • A service to treat disorders of the joints of the jaw (temporomandibular joints).
  • A service, supply or procedure to increase the height of teeth (increase vertical dimension) or restore occlusion.
  • Restorations for reasons other than decay or fracture, such as erosion, abrasion, or attrition.
  • Services that are meant primarily to change or to improve your appearance.
  • Occlusal guards for the treatment of disorders of the joints of the jaw or for bruxism (grinding).
  • Implants and transplants.
  • Replacement of dentures, bridges, space maintainers or periodontic appliances due to theft or loss.
  • Services, supplies or appliances to stabilize teeth when required due to periodontal disease such as:
    • Periodontal splinting.
    • Lab exams.
    • Photographs.
    • Laminate veneers.
    • Duplicate dentures and bridges.
    • Temporary complete dentures and temporary fixed bridges or crowns.
    • Stainless steel crowns on permanent teeth.
    • Cast restorations, copings and attachments for installing overdentures.
    • Services related to congenital anomalies. However, this exclusion does not apply to orthodontic services that may be covered by your group’s orthodontic rider.
    • Tooth desensitization.
    • Occlusal adjustment. 

SURGICAL SERVICES
No benefits are provided for the following services when the covered individual’s condition requires that he or she be admitted as an inpatient in a hospital or surgical day care center. However, Delta Dental will review and consider the following in-hospital surgical procedures for coverage if they are not covered under your medical plan: 

  • surgical removal of unerupted teeth or impacted teeth when imbedded in bone
  • extraction of seven or more permanent teeth
  • the excision of a benign or cancerous growth other than a radicular cyst
  • radicular cysts involving the roots of three or more teeth
  • gingivectomies involving two or more gum quadrants
  • gingival flap
  • mucogingival surgery
  • osseous surgery
  • osseous graft
  • soft tissue graft 
The Administrative Information section of this Summary Plan Description (SPD) is incorporated into this summary by reference. The Administrative Information section contains additional important information about your Dental Plan benefits, including your rights as a plan participant under the Employee Retirement Income Security Act of 1974 (ERISA).