(Subject to 6/9/06 binding arbitration award)
This dental plan provides benefits for most types of dental services. Your level of dental benefits is known as the GHI Preferred Dental Plan. This document is your Certificate of Insurance.
Payment will not be made for:
- Treatment Not Conforming to Accepted Dental Standards. You are
not covered for services that do not conform with accepted standards of
dental practice. You are also not covered for services which are considered
experimental in terms of generally accepted dental standards.
- Care Furnished Without Charge. You are not covered for services
for which no charge is incurred.
- Cosmetic Surgery or Treatment. You are not covered for cosmetic surgery, or cosmetic treatment unless it is otherwise medically necessary. Cosmetic surgery is covered only when the cosmetic surgery or treatment involves reconstructive surgery incidental to or following surgery resulting from trauma, infection or other diseases of the involved part, and reconstructive surgery arising out of congenital disease or anomaly of a covered dependent child which has resulted in a functional defect.
- Services Covered by Government. You are not covered for services
to the extent that your service is covered under any law of any State
or the United States. An example of this would be when your service is
covered by Workers' Compensation. Services provided under Medicaid do
not apply, and GHI coverage would remain primary.
- Services Through Your Employer or Welfare Fund. You are not covered
for services rendered in a hospital, department or clinic run by your
employer, labor union or welfare fund.
- No Fault Automobile Insurance. You are not covered for any service
for which automobile no fault insurance benefits are recovered or recoverable.
- Prescription Drugs and Medications. Prescription drugs and medications
are not covered.
- Substitution of Material and Services. When a more costly material
or service is substituted for a less costly material or service having
the same function, the allowance for the less costly material or service
will be paid.
- Injuries Due to War or an Act of War. Services rendered for
any injury or condition due to war or any act of war, whether declared
or undeclared, are not covered.
- Services Not Listed as Covered. GHI, in its sole discretion,
may cover unlisted dental procedures that are of the type listed in the
Reimbursement Schedule. In such cases, GHI will determine payment in a
manner consistent with the Reimbursement Schedule.
- Items and Services to Comply with Federal, State or Local Laws. Charges for items and services used or provided by Dentists and Providers
to comply with federal, state and local laws and regulations are not covered
unless specifically listed as covered in this Certificate.
- Services Rendered by Member of Immediate Family. You are not
covered for services rendered by the Enrollee, the Enrollee's spouse,
domestic partner or a child, brother, sister or parent of the Enrollee
or of the Enrollee's spouse or domestic partner.
- Workers' Compensation. You are not covered for care for
any injury, condition or disease if payment is available to you under
a Workers' Compensation Law or similar legislation. GHI will not
make payment even if you do not claim benefits you are entitled to receive
under the Workers' Compensation Law. Payment will not be made even
if you bring a lawsuit against the person who caused the injury or condition.
Payment will not be made even if you receive money from that lawsuit and
you have repaid the provider of services.
- Prohibited Referrals. You are not covered for clinical laboratory
services, x-ray or imaging services or other services provided pursuant
to a referral prohibited by Section 238-a(1) of the New York State Public
Health Law. This law prohibits your dentist or physician from making referrals
for such services to providers in which your dentist or physician, or
a member of their immediate family, has a financial interest.
- TMJ Disorders. Services and appliances for the treatment of temporomandibular
joint (TMJ) dysfunction syndrome are not covered.
- Behavioral Management. Costs incurred for behavioral management are not covered. These costs would include services necessary to treat the deeply dental phobic.