Accidental Dental
The plan will cover eligible services to a maximum of $5,000 per accident.
If healthy, natural teeth are damaged or lost due to a sudden impact, the plan will cover the cost of the dental services required to repair or replace the teeth if the impact that caused the damage or loss happened while you or your dependent are covered under this provision. This does not include damage or loss caused by objects or food placed in the mouth.
The amount payable will pay is based on the least expensive treatment that is adequate to correct the damage. No more than the fee stated in the current Dental Association General Practitioner’s Fee Guide will be covered. This treatment must be completed within 12 months of the impact. If treatment is scheduled to occur more than 90 days after the impact, NexgenRx must be given a treatment plan before the end of the 90-day period.
Orthodontic care must be for relocating teeth that are accidentally forced out of position or for splinting damaged teeth for stability. Dental procedures to correct existing cross bites, alignment of rotated teeth, the closing of spaces, and uprighting teeth are not covered. Implants and treatments related to implants are also not covered.
The plan will not pay for the cost of:
- health care services or supplies that you or your Dependents are eligible to claim under Workers’ Compensation legislation in your province of residence;
- health care services or supplies required due to intentionally self-inflicted injury;
- health care services or supplies required as the result of war, rebellion, or hostilities of any kind, whether or not you or your Dependent is a participant;
- health care services or supplies required as the result of participation in a riot or civil disturbance;
- health care services or supplies due to committing a criminal offense or provoking an assault;
- services required by a court, your employer, a school, or anyone other than your physician (for example, your employer requiring a doctor’s note or a court requiring that you receive psychological services);
- treatment on the temporomandibular joint (the hinge joint of the jaw);
- any service and supplies for which you or your Dependent would not normally be charged;
- cosmetic treatments; or
- any service that we are legally prohibited from paying.
Dental Benefit
The Benefit year is from January 1st to December 31st.
The Plan has no deductible.
The plan will cover the cost of eligible expenses that you incur for dental performed by a licensed dentist, denturist, and dental hygienist while you are covered under the Plan.
The Plan will not cover more than the fee stated in the Dental Association Fee Guide for General Practitioners in the province where the employee lives, regardless of where the treatment is performed.
The Plan will reimburse based on the prior year’s fee guide at the time the treatment is received.
Pre-Determination
If the cost of the dental treatment is more than $600, we suggest that you send an estimate, before the work is done. You should send a completed dental claim form that shows the treatment that the dentist is planning and the cost. Both you and the dentist will have to complete parts of the claim form.
NexgenRx will issue a written estimate outlining how much you are responsible for paying before the treatment begins. There may be a delay in processing your claim if you have the work done without submitting a predetermination because models or x-rays may be required to determine the amount that will be covered.
Alternate Benefit Clause
Coverage is based on the cost of the least expensive treatment that could be used to treat or prevent the dental problem. If the cost of the dental work given is more than the cost of the least expensive treatment, the plan will only cover the cost of the least expensive treatment. This rule does not apply to basic restorative fillings.
Benefit Percentages
- 85% for Basic Services
- 85% for Major Restorative Services
Maximum Benefit
The plan has an annual combined maximum of $1,250 per person per calendar year for eligible Basic and Major Restorative services.
The $1,250 per person combined maximum applies to the following:
- Diagnostic services;
- Preventative services;
- Basic Restorative services;
- Endodontic services;
- Periodontic services;
- Basic Surgical services;
- Major Restorative services; and
- Major Surgical services.
What you are covered for?
- Fluoride treatments are limited to once every 9 months;
- Recall exams, scaling, and polishing are limited to once every 9 months;
- Bitewing x-rays are limited to once every 9 months;
- Full Mouth Series X-rays or a Panoramic X-ray are limited to once every 36 months;
- Scaling (root planing) is payable up to 6 units every calendar year;
- White (composite) fillings are covered on all teeth;
- Periodontal appliances/mouthguards for bruxism, teeth grinding, snoring, or any other dental necessity only – 1 per person every 24 months
- Replacement of removable dentures and bridgework are eligible only:
- if a natural tooth is extracted and the existing appliance cannot be made serviceable,
- when it is 5 years old and cannot be made serviceable, or
- if the existing appliance is temporary and is replaced with the permanent denture within 12 months of its installation.
Exclusions
The plan will not pay for:
- Dental services or supplies that the insured person is eligible to claim under the Workers’ Compensation legislation;
- Any dental charges not included in the current Dental Association Suggested Schedule of Fees for General Practitioners, Dental Specialists, Denturists, or Hygienists;
- Cosmetic procedures;
- Charges for appointments that are not kept;
- Charges for completing claim forms;
- Treatment to correct temporomandibular joint dysfunction (the hinge joint of the jaw is called the temporomandibular joint);
- Any endodontic treatment which was started before the effective date of coverage;
- The replacement of dental appliances that are lost, misplaced, or stolen;
- Any treatment related to orthognathic surgery (remodeling or reconstruction of your jaw); or
- Orthodontic treatment.