health
benefits

Dental

• Plan Summary
• Basic Services
• Major Services
• Orthodontic Services
• Out of Province
• Exclusions
• Claims
  
   

Payment of Benefits

1. We pay benefits based on Dental services, financial limits and treatment frequencies in the Fee schedule.
2. We apply the reimbursement percentage shown above to the fees shown in the Fee schedule/Fee guide as follows:
   1. for services performed in British Columbia or outside Canada, if your province of residence is British Columbia: the fees in the Fee schedule 
   2. for services performed in Canada but outside British Columbia: the fees in the Fee guide in the province/territory of service
   3. for services performed outside Canada if your province of residence is not British Columbia: the fees in the Fee guide in your province/territory of residence.
3. Fees in excess of the amount shown in the applicable Fee schedule/Fee guide will be your responsibility.
   
   
    

1. Diagnostic services
   1. examinations:
      1. complete – provided we have not paid for any other exam by the same Dentist in the past 6 months –1 per 3-year period
      2. recall – 2 per calendar year
      3. specific – 2 per calendar year
      4. consultations (as a separate appointment).
   2. x-rays
      1. diagnostic
      2. panoramic – 1 per 2-year period
      3. complete mouth series – 1 per 3-year period
      All x-rays combined shall not exceed the dollar limit for a complete mouth series.
   3. diagnostic models – 1 set per calendar year.
2. Preventive services 
   
   1. scaling
   2. polishing – 2 per calendar year
   3. topical application of fluoride – 2 per calendar year
   4. fixed space maintainers
   5. preventive restorative resins and pit and fissure sealants – combined limit of 1 per tooth in a 2-year period. No age limit. 
3. Restorative services
   
   1. fillings to restore tooth surfaces broken down as a result of decay – limited to a dollar amount equal to a 5 surface filling per tooth in a 2-year period:
      1. amalgam (silver coloured) fillings
      2. composite (tooth coloured) fillings on permanent front (anterior and bicuspid) teeth only
      On permanent posterior (molar) teeth and all primary teeth, we pay the bonded amalgam rate for composite fillings.
   2. stainless steel crowns on primary and permanent teeth – once per tooth in a 2-year period.
   3. inlays or onlays – only 1 inlay or onlay on the same tooth will be covered in a 5-year period. Where other material would suffice, you will be responsible for the difference between the cost of the chosen material and the cost of alternative material.
4. Endodontics – for the treatment of diseases of the pulp chamber and pulp canal including, but not limited to root canals – 1 per tooth in a 5-year period.
5. Periodontics – for the treatment of diseases of the soft tissue (gum) and bone surrounding and supporting the teeth, excluding bone and tissue grafts, but including the following: 
   1. occlusal adjustment and recontouring – a combined yearly limit shown in our Fee schedule
   2. root planing
   3. gingival curettage – 1 per sextant in a 5-year period
   4. osseous surgery – 1 per sextant in a 5-year period
6. Prosthetic repairs 
   1. removal, repairs, and recementation of fixed appliances
   2. rebase and reline of removable appliances – a combined limit of 1 per upper and 1 per lower prosthesis in a 2-year period
   3. tissue conditioning – 2 per upper and 2 per lower prosthesis in a 5-year period
   4. gold foil – only when used to repair existing gold restorations.
7. Surgical services 
   1. extractions
   2. other routine oral surgical procedures 
   3. anesthesia in conjunction with surgery shall not exceed the dollar limit shown in our Fee schedule.
      
      
       

1. Prosthodontic Services 
   1. removable 
      1. complete upper and lower dentures
      2. partial upper and lower dentures
   2. fixed bridges (does not apply to Group 903119).
2. Restorative Services (does not apply to Group 903119)
   1. inlays or onlays involved in bridgework
   2. veneers
   3. crowns and related services.
3. Periodontal Appliances bruxing guards – 2 appliances in a 5-year period (no benefit is payable for the replacement of lost, broken, or stolen bruxing guards).

1. Only 1 major restorative service involving the same tooth will be covered in a 5-year period.
2. Crowns and fixed bridges on permanent posterior (molar) teeth are limited to the cost of the gold restoration.
3. Only 1 upper and 1 lower denture (complete or partial) is eligible in a 5-year period.
4. No benefit is payable for the replacement of lost, broken, or stolen dentures. Broken dentures may be repaired under Basic Services.
5. Veneers, crowns, bridges, inlays, and onlays are subject to the conditions outlined in our Fee schedule. Where other material would suffice, you will be responsible for the difference between  the cost of the chosen material and the cost of alternative material.
   
   
    

1. The lifetime benefit maximum under Orthodontic Services is $3,000.00 per Member or Dependent.
2. No benefit is payable for the replacement of appliances which are lost or stolen.
3. Services done for the correction of temporomandibular joint (TMJ) dysfunction are not covered.
4. Treatment performed solely for splinting is not covered.
   
   
    

1. items not listed in our Fee schedule and fees in excess of those listed in the Fee schedule
2. any item not specifically included as a benefit
3. charges for broken appointments, oral hygiene or nutritional instruction, completion of forms, written reports, communication costs, or charges for translating documents into English
4. procedures performed for congenital malformations or for purely cosmetic reasons
5. charges for drugs, pantographic tracings, and grafts
6. charges for implants and/or services performed in conjunction with implants, except as indicated in our Fee schedule 
7. anesthesia not done in conjunction with surgery, and charges for facilities, equipment and supplies
8. charges for services related to the functioning or structure of the jaw, jaw muscles, or temporomandibular joint
9. incomplete or temporary procedures
10. recent duplication of services by the same or different Dentist
11. any extra procedure which would normally be included in the basic service performed
12. services or items which would not normally be provided, or for which no charge would be made, in the absence of dental benefits
13. travel expenses incurred to obtain Dental treatment.

1. Present your ID card to your Dentist’s office. It is important to ask if your Dental benefits will cover the entire cost of your treatment. To avoid any misunderstanding, we suggest that your Dentist submit an outline of the proposed services to us before you start treatment. This is important especially when your Dentist is recommending extensive Dental work. This will help you understand what portion of the Dentist’s bill must be paid by you in the event that you wish to proceed with the treatment recommended by your Dentist.
2. We suggest that you submit claims within 90 days of the completed date of services (earlier if possible). Failure to submit a claim within the 90-day limit will not invalidate the claim if it is submitted as soon as reasonably possible. However, in no event will we pay any claim or adjustment submitted later than 1 year from the date the service is performed.
3. We require a separate claim form for each member of your family who has received Dental services. Be sure to include the following information on the claim form: 
   1. name of the Dentist
   2. name and birthdate of the person receiving the Dental care
   3. your group and Social Insurance Numbers (this information is on your ID card)
   4. your home mailing address 
   5. whether you have coverage through another plan. Claims information regarding the other carrier is not retained on our files. If you or your Dependents are covered by two plans, your Dentist must complete two separate Dental claim forms (one for each plan). Incomplete claims will be returned for clarification.
4. Before your Dentist starts treatment, please ask them how billing is made. We may pay in either of two ways:
   1. We will pay the Dentist directly for services provided under this Dental plan when we receive a claim form signed by the Dentist, certifying these services were performed and the fee charged.
   2. If you have paid your Dentist directly, we will reimburse you the benefit amount when we receive a claim form or receipts signed by your Dentist. We will send you a cheque when the claim is processed.
5. Orthodontic Claims Procedures (Groups 903118, 903211 and 903120 only)
   1. Receipts 
      Because we do not return original receipts, we will accept photocopies. Do not hold receipts until the completion of treatment.
   2. Claiming deadlines
      1. We suggest that you submit Orthodontic claims within 90 days of the date the payment was due to your Orthodontist (the due date).
      2. Reimbursement is made if the complete and correct claims information is received within 1 year of the due date. However, no benefit is payable for claims not received within 1 year of the due date.
   3. Treatment plan
      1. Have your Orthodontist complete the “Certified Specialist in Orthodontics Standard Information Form” (the treatment plan) before treatment starts.
      2. If the payment schedule or treatment changes, we require a revised treatment plan for review.
      3. We will retain your treatment plan on file. If we do not have your treatment plan on file we are unable to pay:
         • your initial fee/down payment 
         • your monthly/quarterly fees
         • one time appliance fees
         • Claims for consultations, exams and records (x-rays, study models, etc.) will be reimbursed without a treatment plan on file.
   4. Monthly or quarterly fees
      1. Submit receipts for the monthly or quarterly fees on a regular basis – as treatment progresses.
      2. The amount paid will be pro-rated over the estimated months of active treatment. For example, when braces are on the teeth, the estimated length of treatment will be on the treatment plan.
      3. As long as your coverage is effective, monthly or quarterly reimbursements will be made to you until the dollar maximum is reached or the treatment is complete, whichever occurs first.