Page 4 - FL_Independence Dental PPO
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Exclusions for Dental
The following exclusions list is an outline of the complete list available in the Independence Dental insurance Policy. Exclusions and
limitations may vary by state.
• Treatment, services or supplies which:
»» Are not medically/dentally necessary;
»» Are not prescribed by a dental provider;
»» Are determined to be experimental or investigational in nature by us;
»» Are received without charge or legal obligation to pay;
»» Would not routinely be paid in the absence of insurance;
»» Are received from any family member;
»» Are not rendered in accordance with generally accepted standards of dental practice; or
»» Are not covered services
• Expenses resulting from:
»» Suicide, attempted suicide or intentionally self-inflicted injury
»» War, or from voluntary participation in a riot or insurrection;
»» Engaging in an illegal act or occupation, the commission of a felony or assault;
»» Fixed or removable bridgework involving replacement of a natural tooth or teeth that were lost prior to the covered person’s effective
date of coverage;
»» Telephone consultations, failure to keep a scheduled appointment, completion of claim forms or attending dental provider
statements;
»» Use of materials, other than fluorides or sealants, to prevent tooth decay
»» Cast restorations, inlays, onlays and crowns for teeth that are not broken down by extensive decay or accidental injury, or for teeth
that can be restored by other means;
»» Replacement of third molars;
»» Crowns, inlays and onlays used to restore teeth with micro fractures or fracture lines, undermined cusps, or existing large restorations
without overt pathology; or
»» Any service not specifically listed in the Schedule of Benefits
• Expenses incurred by a covered person while on active duty in the armed forces
• Expenses for which benefits are paid or payable under Workers’ Compensation Act or similar laws
• Treatment that began before the covered person’s effective date of coverage or after the covered person’s termination of coverage
• Congenital or developmental malformations existing on the covered person’s effective date
• Periodontal splinting
• Replacement of partial or full dentures, fixed bridgework, crowns, gold restorations and jackets more often than once in any 60-month
period per tooth
• Relining of dentures more often than once in any 24-month period
• Expenses for lost, stolen or missing appliances of any type, or
for duplicates
• Prescription drugs and analgesia pre-medication
• Dental education or training programs, diet and nutrition counseling
• Expenses resulting from the following, unless stated on the Schedule of Benefits:
»» Prosthodontics;
»» Orthodontia;
»» Implants of any type and all related procedures, removal of implants, precision or semi-precision attachments, denture duplication,
overdentures and any associated surgery, or other customized services or attachments; or
»» Porcelain on crowns, or pontics posterior to the second bicuspid
• Cosmetic dentistry
• Charges that are payable under any other insurance, unless specifically available under the Coordination of Benefits provision in the
Policy
• Charges made by any government entity unless the covered person is required to pay, or by any public entity from which coverage could
have been obtained by application or enrollment even if application or enrollment was not actually made
• Bite registrations
• Bacteriologic cultures
• Temporomandibular joint syndrome (TMJ), unless coverage is required by state mandate
Brochure Independence Dental PPO 0918 4
The following exclusions list is an outline of the complete list available in the Independence Dental insurance Policy. Exclusions and
limitations may vary by state.
• Treatment, services or supplies which:
»» Are not medically/dentally necessary;
»» Are not prescribed by a dental provider;
»» Are determined to be experimental or investigational in nature by us;
»» Are received without charge or legal obligation to pay;
»» Would not routinely be paid in the absence of insurance;
»» Are received from any family member;
»» Are not rendered in accordance with generally accepted standards of dental practice; or
»» Are not covered services
• Expenses resulting from:
»» Suicide, attempted suicide or intentionally self-inflicted injury
»» War, or from voluntary participation in a riot or insurrection;
»» Engaging in an illegal act or occupation, the commission of a felony or assault;
»» Fixed or removable bridgework involving replacement of a natural tooth or teeth that were lost prior to the covered person’s effective
date of coverage;
»» Telephone consultations, failure to keep a scheduled appointment, completion of claim forms or attending dental provider
statements;
»» Use of materials, other than fluorides or sealants, to prevent tooth decay
»» Cast restorations, inlays, onlays and crowns for teeth that are not broken down by extensive decay or accidental injury, or for teeth
that can be restored by other means;
»» Replacement of third molars;
»» Crowns, inlays and onlays used to restore teeth with micro fractures or fracture lines, undermined cusps, or existing large restorations
without overt pathology; or
»» Any service not specifically listed in the Schedule of Benefits
• Expenses incurred by a covered person while on active duty in the armed forces
• Expenses for which benefits are paid or payable under Workers’ Compensation Act or similar laws
• Treatment that began before the covered person’s effective date of coverage or after the covered person’s termination of coverage
• Congenital or developmental malformations existing on the covered person’s effective date
• Periodontal splinting
• Replacement of partial or full dentures, fixed bridgework, crowns, gold restorations and jackets more often than once in any 60-month
period per tooth
• Relining of dentures more often than once in any 24-month period
• Expenses for lost, stolen or missing appliances of any type, or
for duplicates
• Prescription drugs and analgesia pre-medication
• Dental education or training programs, diet and nutrition counseling
• Expenses resulting from the following, unless stated on the Schedule of Benefits:
»» Prosthodontics;
»» Orthodontia;
»» Implants of any type and all related procedures, removal of implants, precision or semi-precision attachments, denture duplication,
overdentures and any associated surgery, or other customized services or attachments; or
»» Porcelain on crowns, or pontics posterior to the second bicuspid
• Cosmetic dentistry
• Charges that are payable under any other insurance, unless specifically available under the Coordination of Benefits provision in the
Policy
• Charges made by any government entity unless the covered person is required to pay, or by any public entity from which coverage could
have been obtained by application or enrollment even if application or enrollment was not actually made
• Bite registrations
• Bacteriologic cultures
• Temporomandibular joint syndrome (TMJ), unless coverage is required by state mandate
Brochure Independence Dental PPO 0918 4
