25C - AGMT GROUP INSURANCE - Laserfiche WebLink

Home Browse Search

from Your or Your dependent's Selected General Dentist, You or Your dependent will receive coverage for the treatment of the Emergency Dental Condition up to a maximum of fifty dollars ($50). To be reimbursed for treatment of an Emergency Dental Condition, You must notify Us after receiving such treatment. If You or Your dependent's physical condition does not permit such notification, You must make the notification as soon as it is reasonably possible to do so. Please include your name, ID number of the person who received treatment, address and telephone number on all requests for reimbursement. If You or Your dependent do not have an Emergency Dental Condition and a delay in receiving treatment would not be detrimental to Your or Your dependent's health, please contact Your or Your dependent's Selected General Dental Office or Our Customer Service Department at (800) 880-1800 to make reasonable arrangements for Your or Your dependent's care. TERMINATION OF BENEFITS Cancellation of Benefits Your coverage may be cancelled for any reason, after not less than sixty (60) days Written notice by either SafeGuard or Your Organization. Your coverage may be cancelled after not less than thirty (30) days Written notice for: • Non-payment of amounts due under the contract, except no Written notice will be required for failure to pay premium. • Failure to establish a satisfactory Dentist -patient relationship and if it is shown that SafeGuard has, in good faith, provided You with the opportunity to select an alternative Dentist, • Failure to reside, live or work in the Service Area. Your coverage may be cancelled for not less than fifteen (15) days Written notice for: • An intentional misrepresentation, except as limited by statute. • Fraud in the use of services or facilities, or on the part of Your Organization. • Such other good cause as agreed upon in the group contract. Your coverage may be cancelled Immediately: • Subject to any continuation of coverage and conversion privilege provisions, if applicable, if You do not meet eligibility requirements other than the requirements that You live, work or reside in the Service Area. • Upon termination of the group contract between SafeGuard and Your Organization, if expired and not renewed. If Your Organization fails to pay the Prepayment Fees through and including the final month of the group contract, all coverage may be terminated at the end of the group contract's grace period, and You may be responsible for the usual and customary fees for any services received from Your Selected General Dentist or Specialty Care Dentist during the period the Prepayment Fees went unpaid, Including the group contract's grace period. If You terminate from the plan while the contract between SafeGuard and Your Organization is in effect, Your coverage will extend to the end of the month following notice of termination. Your Selected General Dentist must complete any dental procedures started on You before Your termination, abiding by the terms and conditions of the plan. Your and Your dependents' enrollment will be cancelled as of the last day for which Prepayment Fees have been received, subject to compliance with notice requirements. In the event Your and Your dependents' enrollment is cancelled, SafeGuard will send such notification to Your Organization, which will, in turn, notify You. Your Organization will also send You notice when Your actual coverage is terminated. GCERT2011-DHMO-EOC 25C-25 11