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25C - AGMT GROUP INSURANCE
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25C - AGMT GROUP INSURANCE
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Last modified
2/1/2018 7:02:12 PM
Creation date
2/1/2018 7:10:52 PM
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City Clerk
Doc Type
Agenda Packet
Agency
Personnel Services
Item #
25C
Date
2/6/2018
Destruction Year
2023
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(j) Delta Dental will pay the applicable percentage of the Dentist's Fee for a standard cast <br />chrome or acrylic partial denture or a standard complete denture, (A "standard" <br />complete or partial denture Is defined as a removable prosthetic appliance provided to <br />replace missing natural, permanent teeth and which is constructed using accepted and <br />conventional procedures and materials.) <br />(k) If an Enrollee selects a more expensive plan of treatment than Is customarily provided, <br />or specialized techniques, an allowance will be made for the least expensive, <br />professionally acceptable alternative treatment plan. Delta Dental will pay the <br />applicable percentage of the lesser fee and the Enrollee is responsible for the <br />remainder of the Dentist's fee. <br />For example: a crown, where an amalgam filling would restore the tooth, or a <br />precision denture, where a standard denture would suffice. <br />4.7 EXCLUSIONS - The following services are not BeneFlts: <br />(a) Services for Injuries or conditions that are covered under Workers' Compensation or <br />Employer's Liability Laws. <br />(b) Services which are provided to the Enrollee by any, Federal or State Government <br />Agency or are provided without cost to the Enrollee by any municipality, county or <br />other political subdivision, except as provided in California Health and Safety Code <br />Section 1373(a). <br />(c) Services with respect to congenital (hereditary) or developmental (following birth) <br />malformations or cosmetic surgery or dentistry for purely cosmetic reasons, Including <br />but not limited to: cleft palate, upper or lower jaw malformations, enamel hypoplasla <br />(lack of development), fluorosis (a type of discoloration of the teeth) and anodontia <br />(congenitally missing teeth). <br />(d) Services for restoring tooth structure lost from wear (abrasion, erosion, attrition, or <br />abfractlon), for rebuilding or maintaining chewing surfaces due to teeth out of <br />alignment or occlusion, or for stabilizing the teeth. Such services Include but are not <br />limited to equilibration and periodontal splinting. <br />(e) Prosthodontic services or any Single Procedure started prior to the date the person <br />became eligible for such services under this Contract. <br />(f) Prescribed or applied therapeutic drugs, premedication or analgesia. <br />(g) Experimental procedures. <br />(h) All hospital costs and any additional fees charged by the Dentist for hospital <br />treatment. <br />(1) Charges for anesthesia, other than general anesthesia or I.V. sedation administered by <br />a licensed Dentist In connection with covered Oral Surgery services and select <br />Endodontic and Periodontic procedures. <br />(j) Extra -oral grafts (grafting of tissues from outside the mouth to oral tissue). <br />(k) Diagnosis or treatment by any method of any condition related to the <br />temporomandibular (jaw) joint or associated musculature, nerves and other tissues. <br />(1) Replacements of existing restorations for any purpose other than active tooth decay. <br />25G-61 <br />
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