Pearl Dental - Gold Plan for Adults

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Adults Dental Insurance

For Ages 18 through 64

Adults Dental Insurance helps working individuals and families cover the costs of dental services for exams, cleanings, fillings and extractions, as well as crowns, bridges, dentures and orthodontia.

You choose your own dentist
For individuals ages 18 through 64 and their eligible dependents
There is one $50 deductible per insured person per calendar year
Maximum Benefit of $1,500 per insured person per calendar year
Major Services have a Maximum Benefit of $750 per insured person per calendar year
Eligible dependents include spouse and unmarried children from birth to age 19, or 23 if full-time students

Preventive, Basic, Major and Ortho Services

(after meeting the annual deductible, these plans will reimburse you according to the following schedule)

Preventive Dental Services - 100%

No waiting period

Exam, 2 per 12 months
Cleanings
Fluoride (up to age 16)

Basic Dental Services-50%

6 month waiting period

X-rays
Fillings
Simple extractions

Major Dental Services-50%

18 month waiting period

Crowns
Bridges
Dentures
Endodontics
Periodontics
Oral surgery (surgical extractions and impactions)

Major services are limited to a maximum benefit of $750 per calendar year per insured person on the adult plan and $500 per calendar year per insured person on the senior plan.

Orthodontic Services-50%

24 month waiting period

Straightening of teeth (limited to children under the age of 19)

Orthodontic services are available on the adult plan only and are limited to a maximum benefit of $350 per calendar year and $1000 lifetime per insured child.

Plan Information

Eligible Expenses: Expenses must be incurred while the Policy is in force and the person is covered by the Policy. To be an Eligible Expense, the dental services must be performed by: a licensed Dentist acting within the scope of his/her license; a licensed Physician performing dental services within the scope of his/her license; or a licensed dental hygienist acting under the supervision and direction of a dentist.

Expenses Incurred: An Eligible Expense is considered incurred on the following dates: for full and partial dentures - on the date the final impression is taken; for fixed bridges, crowns, inlays and onlays - on the date the teeth are first prepared; for root canal therapy - on the date the pulp chamber is opened; for periodontal surgery - on the date surgery is performed; for orthodontic services - on the date the appliance or bands are inserted or on the date a one-step orthodontic procedure is performed; for all other services-on the date the service is performed.

Expenses Not Covered: No benefits will be paid for expenses incurred: for any portion of a charge for any service in excess of the Scheduled Benefit; for any procedure not listed as a Scheduled Benefit; for overdentures and associated procedures; for cosmetic procedures, for the replacement of full and partial dentures, bridges, inlays, onlays or crowns that can be repaired or restored to normal function; for implants; and for (a) the replacement of lost or stolen appliances; (b) the replacement of orthodontic retainers; (c) athletic mouthguards; (d) precision or semi-precision attachments; (e) denture duplication; or for (f) sealants; for oral hygiene instructions; and for (a) plaque control; (b) the completion of claim form; (c) acid etch; (d) broken appointments; (e) prescription or take-home fluoride; or for (f) diagnostic photographs.

In addition, no benefits will be paid for expenses incurred: for services not completed by the end of the month in which coverage terminates; for procedures that are begun, but not completed; for those services for which there would be no charge in the absence of insurance or for any service or treatment provided without charge; for services in connection with war or any act of war, whether declared or undeclared, or condition contracted or accident occurring while on full- time active duty in the armed forces of any country or combination of countries; for care or treatment of a condition for which you are entitled to or eligible for benefits under any Workers' Compensation Act or similar law; that are applied toward satisfaction of a deductible, if any; that are generally considered by the dental profession as experimental or investigational; for the treatment of cleft palate and anodontia; for services or supplies payable under any medical expense plan; for orthodontia (unless specifically included); prior to the date the Insured is covered under the Policy; for the diagnosis or treatment of TMJ; for hospital services.

Alternate Benefit: If (1) We determine that a less expensive alternate procedure, service or Course of Treatment can be performed in place of the proposed treatment to correct a dental condition; and (2) the alternative treatment will produce a professionally satisfactory result; then the maximum we will allow will be the charge for the less expensive treatment.

General Information

Deductible Amount: The Deductible is shown in the Coverage Schedule. The Deductible is an amount of covered dental charges incurred by an insured person for which no benefits will be paid. Calendar Year Maximum: The maximum amount payable for all Eligible Dental Expenses in any calendar year is shown in the Coverage Schedule. The Calendar Year Maximum will apply to each insured person.

Coordination of Benefits: This plan will be coordinated with any other group, blanket or franchise plan under which an individual will receive benefits. This helps keep the cost of the Plan reasonable.

Termination of Coverage: Coverage terminates on the earliest of the following dates: the last day of the month in which you cease to be eligible for coverage; for dependents, the last day of the month for which they are no longer an eligible dependent as defined; subject to the Grace Period, the last day of the month for which a premium has been paid by you or on your behalf; or the date the Policy ends.

Pretreatment Review: If the course of treatment will exceed $300, we will require prior review. We must be given the Dentist's treatment plan consisting of a description of the planned treatment with estimated charges and diagnostic X-rays. We will determine Eligible Expenses and state how much we will pay for the treatment. Our determination may suggest an alternate, less expensive Course of Treatment, if it will produce professionally satisfactory results. If you do not request a pretreatment review, we will pay for the least expensive method of treatment regardless of the method actually used.

Effective Date: Plan effective dates are always the first of the month following receipt of the application. Incomplete enrollment cards or failure to submit the required initial premium amount may cause an initial delay in issuance of insurance. Do not cancel any other insurance or assume you are insured under the Plan until you receive written confirmation from Pearl & Associates, Ltd.

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Fraud Warnings

Arkansas: Any person who knowingly presents a false or fraudu- lent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policy holder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies.

District of Columbia: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.

Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.

Louisiana: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

New Mexico: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.

Ohio: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

Virginia: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.