Exclusions and Limitations
No coverage is available under this Policy for the following:
A. Cosmetic Services — We do not Cover cosmetic services or surgery unless otherwise specified, except that cosmetic surgery shall not include reconstructive surgery when such service is incidental to or follows surgery resulting from trauma, infection or diseases of the involved part, and reconstructive surgery because of congenital disease or anomaly of a covered Child which has resulted in a functional defect. Cosmetic surgery does not include surgery determined to be Medically Necessary. If a claim for a procedure listed in 11 NYCRR 56 (e.g., certain plastic surgery and dermatology procedures) is submitted retrospectively and without medical information, any denial will not be subject to the Utilization Review process in the Utilization Review and External Appeal sections of this Policy unless medical information is submitted.

B. Experimental or Investigational Treatment — We do not Cover any health care service, procedure, treatment, or device that is experimental or investigational. However, We will Cover experimental or investigational treatments, including treatment for Your rare disease or patient costs for Your participation in a clinical trial, when Our denial of services is overturned by an External Appeal Agent certified by the State. However, for clinical trials, We will not Cover the costs of any investigational drugs or devices, non-health services required for You to receive the treatment, the costs of managing the research, or costs that would not be Covered under this Policy for non-investigational treatments. See the Utilization Review and External Appeal sections of this Policy for a further explanation of Your Appeal rights.

C. Felony Participation — We do not Cover any illness, treatment or medical condition due to Your participation in a felony, riot or insurrection.

D. Government Facility — We do not Cover care or treatment provided in a Hospital that is owned or operated by any federal, state or other governmental entity, except as otherwise required by law.:

E. Medical Services — We do not Cover medical services or dental services that are medical in nature, including any Hospital charges or prescription drug charges

F. Medically Necessary — — In general, We will not Cover any dental service, procedure, treatment, test or device that We determine is not Medically Necessary. If an External Appeal Agent certified by the State overturns Our denial, however, We will Cover the service, procedure, treatment, test or device for which coverage has been denied, to the extent that such service, procedure, treatment, test or device is otherwise Covered under the terms of this Policy.

G. Medicare or Other Governmental Program — We do not Cover services if benefits are provided for such services under the federal Medicare program or other governmental program (except Medicaid).

H. Military Service — We do not Cover an illness, treatment or medical condition due to service in the Armed Forces or auxiliary units.

J. Services Not Listed — We do not Cover services that are not listed in this Policy as being Covered.

K. Services Provided by a Family Member — We do not Cover services performed by a covered person’s immediate family member. “Immediate family member” means a child, stepchild, spouse, parent, stepparent, sibling, stepsibling, parent-in-law, child-in-law, sibling-in-law, grandparent, grandparent’s spouse, grandchild, or grandchild’s spouse.

L. Services with No Charge — We do not Cover services for which no charge is normally made.

M. Waiting Periods — A Waiting Period means a period of time after the Policy Effective Date during which expenses incurred by Covered Persons for certain types of dental procedures are not covered. Any Waiting Periods applicable to Your coverage are shown in the Schedule. If a Covered Person is added to the Policy’s coverage after the Policy Effective Date, any applicable Waiting Periods shall begin with respect to that Covered Person on the date such Covered Person’s coverage takes effect.

Waiting Periods:

Type I – Preventive None
Type II – Basic None
Type III – Major 12 months

N. War — We do not Cover an illness, treatment or medical condition due to war, declared or undeclared.

O. Workers’ Compensation — We do not Cover services if benefits for such services are provided under any state or federal Workers’ Compensation, employers’ liability or occupational disease law.
Hospital is short term acute, general hospital which is not, other than incidentally, a place of rest, a place primarily for the treatment of tuberculosis, a place for the aged, a place for drug addicts, alcoholics, or a place for convalescent, custodial, educational, or rehabilitory care. Hospital does not mean health resorts, spas, or infirmaries at school or camps.
Coinsurance — Your share of the costs of a Covered Service, calculated as a percent of the Allowed Amount for the service that You are required to pay to a Provider. The amount can vary by the type of Covered Service.

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. Eye examinations must be performed by an optometrist or ophthalmologist.
The optional Vision Benefit Rider is available for an additional cost.

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. These discounted goods and services are not insurance. Access to these discounted goods and services will discontinue upon terminations of this rider or the termination of our arrangement with such third party.

Temporary Suspension Rights for Armed Forces’ Members — If You, the Subscriber, are a member of a reserve component of the armed forces of the United States, including the National Guard, You have the right to temporary suspension of coverage during active duty and reinstatement of coverage at the end of active duty if: 1.Your active duty is extended during a period when the president is authorized to order units of the reserve to active duty, provided that such additional active duty is at the request and for the convenience of the federal government, and 2. You serve no more than five (5) years of active duty.

Termination by Us — We may terminate this Policy with 30 days’ written notice as follows: 1. For Non-Payment of Premiums — Premiums are to be paid by the Subscriber to Us on each Premium due date. While each Premium is due by the due date, there is a grace period for each Premium payment. If the Premium payment is not received by the end of the grace period, coverage will terminate as follows: If the Subscriber fails to pay the required Premium within a 30-day grace period, this Policy will terminate retroactively back to the last day Premiums were paid. The Subscriber will be responsible for paying any claims submitted during the grace period if this Policy terminates. 2. Fraud or Misrepresentation of Material Fact — If the Subscriber has performed an act that constitutes fraud or made a misrepresentation of material fact in writing on his or her enrollment application, or in order to obtain coverage for a service, this Policy will terminate immediately upon a written notice to the Subscriber from Us. If termination is a result of the Subscriber’s action, coverage will terminate for the Subscriber and any Dependents. If termination is a result of the Dependent’s action, coverage will terminate for the Dependent. 3. If the Subscriber no longer lives or resides in Our Service Area. 4. The date the Policy is terminated because We stop offering the class of policies to which this Policy belongs, without regard to claims experience or health related status of this Policy. We will provide the Subscriber with at least 30 days’ prior written notice. No termination shall prejudice the right to a claim for benefits which arose prior to such termination.

Pre-Determination/Pre-Treatment Estimates — We allow You to request and obtain an estimate of coverage. You or Your Provider may contact Us and request a pre-determination of benefits, also known as a pre-treatment estimate. If We determine that an alternative procedure or treatment is more appropriate than the requested service, You may appeal Our decision through an internal Appeal or external appeal. See the Utilization Review and External Appeal sections of this Policy for Your right to an internal Appeal and external appeal.

Rate protection — Your rates will not go up, because of how many claims you file. We may change your renewal premium for this insurance policy, but only if the same change is made by us on all insurance policies of this form and class in the state where you live. In addition, we can change your renewal premium if you request a change in your insurance policy benefits or how you pay, or your dependent status. Your renewal premium will change with the first modal payment due on or after the premium change is effective.

Renewability — This Policy will automatically renew each year on the renewal date unless otherwise terminated by Us as permitted by this Policy or by the Subscriber upon 30 days prior written notice to us.

Additional information — 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. This material is not a contract and does not provide a complete description of the coverage provided by Individual Insurance Policy P154NY. We will send you an insurance policy with additional information upon your enrollment. Or, you may call Customer Service at 1-800-557-6545 to request a copy of the covered services.

Glossary