Free Dental Information Kit

Your Acceptance Is Guaranteed

Your acceptance is guaranteed for one certificate/insurance policy of this type.

Satisfaction Guarantee

If for any reason you decide this coverage is not for you, just return your certificate/insurance policy within 31 days of receipt.

Coverage and Rate Guarantee

We can't refuse to renew your coverage on an individual basis unless you fail to pay the premium when due, your eligibility for coverage ends (C250A only), or you commit fraud or intentional misrepresentation. Changes in coverage or rates will apply to all certificates/insurance policies of this form and class in the state where you live. Your renewal premium will change at age 50, unless you're within the three-year rate guarantee. We will not increase your renewal premium for at least three years from the policy effective date shown in the schedule unless you request a change in your policy benefits or riders, change your premium mode or frequency, or there is a change in dependent status.

Waiting Periods

Your coverage will begin about four to five business days after we process and approve your enrollment form/application. The exact date your coverage starts will be listed in the Schedule of Benefits section of the dental insurance packet you'll receive in the mail.

After the effective date, the waiting periods include:

• Preventive care (Type I): no waiting period; benefits begin immediately
• Basic care (Type II): benefits begin after three months
• Major care (Type III): benefits begin after 12 months

Limitations: Dental Coverage

This is limited-benefit insurance. No benefits under the insurance are payable (or considered a covered expense) for any of the following:

1. Expense incurred during any waiting period (and while the insurance policy is not in force for P150 only).
2. Any treatment which is for cosmetic purposes. Facings on crowns or pontics beyond the second bicuspid are considered cosmetic.
3. Replacement of any prosthetic appliance, crown, inlay or onlay restoration, or fixed partial denture within five years of the date of the last placement of these items; unless a) replacement is required due to an accidental injury sustained while a covered person's coverage is in force; and b) replacement occurs while such covered person's coverage is in force.
4. Initial placement of any prosthetic appliance or fixed partial denture unless such placement is needed because of the extraction of one or more teeth while the covered person is insured under this coverage. But the extraction of a third molar (wisdom tooth) will not qualify under the above. Any such appliance or fixed partial denture must include the replacement of the extracted tooth or teeth.
5. Any procedure started before the covered person was insured under this coverage.
6. Any procedure started after the covered person's insurance under this coverage terminates; or for any prosthetic dental appliances installed or delivered more than ninety (90) days after the covered person's insurance under this coverage terminates.
7. The replacement of lost or stolen appliances.
8. Appliances, restorations, or procedures to a) alter vertical dimension; b) restore or maintain occlusion; or c) splint or replace tooth structure lost as a result of abrasion or attrition.
9. Any procedure not covered by the schedule in the issued certificate/insurance policy.
10. Orthodontic treatment.
11. Sealants which are a) not applied to a permanent molar; b) applied after attaining the age of 17; or c) reapplied to a molar within three years from the date of a previous sealant application.
12. Periodontal scaling and root planning unless the presence of periodontal disease is confirmed by both X-ray films and pocket-depth summaries of each tooth involved.
13. Injury or sickness arising out of, or in the course of, work for wage or profit, for which the covered person receives benefits under any Workers' Compensation Act or similar laws.
14. Charges for which the covered person is not liable or which would not have been made had no insurance been in force.
15. Services which are not recommended by a dentist/physician or which are not required for necessary care and treatment.
16. War or any act of war, declared or not.

Alternative Procedures: If two or more procedures are adequate and appropriate treatment to correct a certain condition, your benefit amount may be limited to that available for the least expensive procedure.

Optional Vision Rider Limitations: In addition to any Policy Limitations, We will not pay Vision Benefits for:

1. Eye examinations performed or correction materials ordered for a Covered Person while their coverage is not in force; or
2. Expenses incurred for missed appointments; or
3. Subnormal vision aids; orthoptic or vision training or any associated testing; or
4. Medical or surgical treatment of the eyes.

We arrange for a third party to give you access to discounted goods and services such as vision exams and material discounts. Access to these discounts will discontinue upon termination of this rider or our arrangement with such third party. Eye examinations must be performed by an optometrist or ophthalmologist. Covered vision correction materials do not include items available for purchase without a prescription. You may have only one vision benefit rider with us.

Additional Information: The optional Vision Rider is available for an additional cost. This is not a contract and does not provide a complete description of the coverage provided by Group Insurance Policy M250 (Individual Insurance Policy P150). We will send you a certificate/insurance policy with additional information upon your enrollment. Or, you may call Customer Service 1-800-557-6545 1-800-557-6545 to request a copy.

What is not covered: The Participating Providers and Preventive Benefits Rider will not pay benefits for: (a) procedures not payable under the certificate/insurance policy; (b) procedures not listed in this Rider Benefits provision; or (c) expenses incurred while this rider is not in force.

If the provider discounted fee at the Participating Provider or the actual charge at a Non-Participating Provider is greater than the benefits paid by us, you are responsible for the difference.

In addition to any Policy Limitations and Exclusions, we will not pay Vision Benefits for:

1. Expenses incurred for missed appointments; or
2. Subnormal vision aids; orthoptic or vision training or any associated testing; or
3. Medical or surgical treatment of the eyes.
4. Eye examinations performed or correction materials ordered for a Covered Person while their coverage is not in force; or

Eye examinations must be performed by an optometrist or ophthalmologist. Covered vision correction materials do not include items available for purchase without a prescription. Third Party Discount Details: We arrange for a third party to give you access to discounted goods and services such as vision exams and material discounts. Access to these discounts will discontinue upon termination of this rider or our arrangement with such third party. These discounted goods and services are not insurance. All covered persons are eligible to receive these discounted goods and services at no additional cost, provided they obtain the goods and services from a third-party provider participating in this arrangement.

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Your Acceptance is Guaranteed

Your acceptance is guaranteed for one insurance policy of this type.

Satisfaction Guarantee

If for any reason you decide this coverage is not for you, just return your insurance policy within 31 days of receipt.

Coverage and Rate Guarantee

We can terminate your coverage for non-payment of premiums, fraud or misrepresentation of material fact or if we stop offering policies of this form and class. Any change in coverage will apply to all policies of this form and class in your state of residence. Your renewal premium can change if the same change is made by us on all policies of this form and class issued in New York and subject to approval by the New York Department of Financial Services. We will not increase your renewal premium unless you request a change in your policy benefits or riders or there is a change in dependent status.

This policy provides dental insurance only. The expected benefit ratio for this policy is 55%. This ratio is the portion of future premiums that the company expects to return as benefits, when averaged over all people with this policy.

Waiting Periods

Your coverage will begin about four to five business days after we process and approved your application. The exact date your coverage starts will be listed in the Schedule of Benefits section of the dental insurance packet you'll receive in the mail.

After the effective date, the waiting periods include:

• Preventive care (Type I): no waiting period; benefits begin immediately
• Basic care (Type II): benefits begin after three months
• Major care (Type III): benefits begin after 12 months

Exclusions and Limitations: Dental Coverage

This is limited-benefit insurance. Services covered in this policy must be medically necessary. No benefits under the insurance are payable (or considered a covered expense) for any of the following:

Exclusions:

1. Cosmetic services or surgery, except that cosmetic surgery does not include reconstructive surgery when such service is incidental to or follows surgery resulting from trauma, infection or other diseases of the involved part, and reconstructive surgery because of congenital disease or anomaly of a covered dependent child which has resulted in a functional defect.
2. Services provided under any state or federal Workers' Compensation, employers' liability or occupational disease law.
3. Services for which no charge is normally made.
4. Illness, treatment or medical condition due to war, declared or undeclared.

Limitations:

1. Any procedure started before coverage takes effect.
2. Any procedure started after the Policy terminates; or for any prosthetic dental appliances installed or delivered more than 90 days after the Policy terminates.
3. Facings on crowns or pontics beyond the second bicuspid.
4. Replacement of any prosthetic appliance, crown, inlay or onlay restoration, or fixed partial denture within five years of the date of the last placement of these items; unless: replacement is required due to an accidental Injury sustained while coverage is in force; and replacement occurs while such coverage is in force.
5. Initial placement of any prosthetic appliance or fixed partial denture unless placement is needed due to tooth extraction. The extraction of a wisdom tooth will not qualify. The appliance or fixed partial denture includes the replacement of the extracted tooth or teeth.
6. Replacement of lost or stolen appliances.
7. Appliances, restorations, or procedures to: alter vertical dimension; restore or maintain occlusion; or splint or replace tooth structure lost as a result of abrasion or attrition.
8. Orthodontic treatment.
9. Sealants which are: not applied to a permanent molar; applied as of age 17; or applied to a molar within three years.
10. Periodontal scaling or root planing unless periodontal disease is confirmed by both x-ray films and pocket depth summaries of each tooth involved.

Alternative Procedures: If two or more procedures are adequate and appropriate treatment to correct a certain condition, your benefit amount may be limited to that available for the least expensive procedure.

Optional Vision Rider Limitations: In addition to any Policy Exclusions/Limitations, We will not pay Vision Benefits for:

1. Eye examinations performed or correction materials ordered for a Covered Person while their coverage is not in force; or
2. Expenses incurred for missed appointments; or
3. Subnormal vision aids; orthoptic or vision training or any associated testing; or
4. Medical or surgical treatment of the eyes.

We arrange for a third party to give you access to discounted goods and services such as vision exams and material discounts. These discounted goods and services are not insurance. All covered persons are eligible to receive these discounted goods and services at no additional cost, provided they obtain the goods or services from a third-party provider participating in this arrangement. Access to these discounts will discontinue upon termination of this rider or our arrangement with such third party. Eye examinations must be performed by an optometrist or ophthalmologist. Covered vision correction materials do not include items available for purchase without a prescription. You may have only one vision benefit rider with us.

Additional Information:The optional Vision Rider is available for an additional cost. This policy provides Dental Insurance and Vision Coverage only. The expected benefit ratio for this policy is 55%. This ratio is the portion of future premiums that the company expects to return as benefits, when averaged over all people with this policy. This is not a contract and does not provide a complete description of the coverage provided by Individual Insurance Policy P150. We will send you an insurance policy with additional information upon your enrollment. Or, you may call Customer Service 1-800-557-6545 to request a copy.

What is not covered: The Participating Providers and Preventive Benefits Rider will not pay benefits for: (a) procedures not payable under the certificate/insurance policy; (b) procedures not listed in this Rider Benefits provision; or (c) expenses incurred while this rider is not in force.

If the provider discounted fee at the Participating Provider or the actual charge at a Non-Participating Provider is greater than the benefits paid by us, you are responsible for the difference.

In addition to any Policy Limitations and Exclusions, we will not pay Vision Benefits for:

1. Expenses incurred for missed appointments; or
2. Subnormal vision aids; orthoptic or vision training or any associated testing; or
3. Medical or surgical treatment of the eyes.
4. Eye examinations performed or correction materials ordered for a Covered Person while their coverage is not in force; or

Eye examinations must be performed by an optometrist or ophthalmologist. Covered vision correction materials do not include items available for purchase without a prescription. Third Party Discount Details: We arrange for a third party to give you access to discounted goods and services such as vision exams and material discounts. Access to these discounts will discontinue upon termination of this rider or our arrangement with such third party. These discounted goods and services are not insurance. All covered persons are eligible to receive these discounted goods and services at no additional cost, provided they obtain the goods and services from a third-party provider participating in this arrangement.

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