Page 11 - Customer-Booklet_Texas
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r. an elective abortion;
s. dental Treatment of the teeth, gums, or structures directly supporting the teeth, including dental

X-rays, examinations, repairs, orthodontics, periodontics, casts, splints, and services for dental
malocclusion for any condition are not covered, except if provided for or in connection with an
injury to sound natural teeth and a continuous course of dental Treatment is started within six (6)
months of the injury. Sound natural teeth are defined as natural teeth that are free of active
clinical decay, have at least fifty percent (50%) bony support, and are functional in the arch; or
t. cosmetic care, except when the Hospital Confinement is due to medically-necessary
reconstructive plastic surgery. Medically-necessary reconstructive surgery is defined as:
1. surgery as the result an injury; or
2. surgery to restore a normal bodily function; or
3. surgery to improve functional impairment by anatomic alteration made necessary as a result

of a congenital birth defect; or
4. breast reconstruction following mastectomy.

Also, no benefits will be payable under the Rider for:
a. loss that begins prior to the Rider Effective Date;
b. Treatment for which no charges are made by the provider of same;
c. services which are primarily for rest care, convalescent care, or for rehabilitation; or
d. any injury or Sickness paid for under any state or federal Workers’ Compensation, Employers’

Liability Law, or similar law.

PRE-EXISTING CONDITION(S) The benefits of the Rider will not be payable during the first twelve
(12) months that coverage is in force with respect to an Insured Person for any loss caused by Pre-
Existing Condition(s). This twelve (12) month period is measured from the Rider Effective Date for
each Insured Person.

In the event You die while this Rider is in force, a return of premium benefit may be payable to Your
named Beneficiary or estate. If this Rider is added to the policy after the policy was issued, only the
premium paid for the policy on or after the Rider Effective Date will be returned. The return of premium
benefit is Original Premium less Claims Paid.

The benefit provided by this Rider is payable only once during the entire time that the policy and this
Rider is in force.

If a payable claim is incurred on a date when the return of premium benefit would otherwise be
payable, regardless of whether it has been reported or adjudicated, We will:
a. Pay the claim, if it is payable upon the terms of the policy or Rider, and then reduce the return of

premium benefit by the sum of all Claims Paid; or
b. Pay the return of premium benefit, and then reduce the claim by the amount of the return of

premium benefit; or
c. Pay the return of premium benefit if the claim is not payable upon the terms of the Policy

or Rider.

LY-LSC-OC-B-FL 9 10/13
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