Common use of Alternate Benefits Clause in Contracts

Alternate Benefits. If Claims Administrator determines that a less costly covered service other than the covered service the Dentist performed could have been performed to treat a dental condition, we will pay benefits based upon the less costly service if such service would produce a professionally acceptable result under generally accepted dental standards. If the Member and the Dentist choose the more expensive treatment, the Member will be responsible for the additional charges, beyond those allowed under this clause. This limitation does not apply to covered implantology services. Alternate benefits applicable to your treatment plan will be determined during Authorization. However, should the services billed differ from those Authorized, Claims Administrator reserves the right to determine if an Alternate Benefit is applicable to the actual services rendered. If a Member has other coverage for dental benefits, and this Benefit Plan is offered in conjunction with or as a supplement to that other dental coverage, the dental benefits under this stand-alone coverage will be determined first. We reserve the right to make any coordination of benefits necessary so that no more than the full amount of the Allowable Charge for the same claim or service is ever paid under all the dental benefits the Member may have. A Covered Benefit for such service was incurred while coverage was in effect; and Such Covered Benefit is completed within thirty-one (31) days after coverage terminates. For appliances or changes to appliances – on the date the appliance or prosthesis is permanently placed; For Crowns, dentures or bridgework – on the date the impression is taken; For Root Canal therapy -- on the date the pulp chamber is opened; or If eligibility for Group coverage ceases upon the death of the Subscriber, a surviving Spouse covered as a Dependent who is fifty (50) years of age or older, has ninety (90) days from the date of the Subscriber's death to notify Company of his election to continue the same coverage for himself, and if already covered, for his Dependent children. • Coverage is automatic during the ninety (90) day election period. Premium is owed for this coverage. If continuation is not chosen, or if premium is not received for the ninety 90 days of automatic coverage, the ninety (90) days of automatic coverage is terminated retroactive to the end of the billing cycle in which the death occurred. • If the continuation coverage is chosen within the ninety (90) day period, coverage will continue without interruption. Premium is owed from the last date for which premium has been paid. No physical exams are required. Premium for continuing coverage will not exceed the premium assessed for each Subscriber by class of coverage under the Group Benefit Plan. The Group will be responsible for notifying the Spouse of the right to continue and for billing and collection of premium. However, if We have been furnished with the home address of the surviving Spouse at the time of death and have been notified by the Group in a manner acceptable to Us of the death of the Subscriber, We will notify the surviving Spouse of the right to continue. Coverage continues on a premium-paying basis until the earliest of: • the date premium is due and is not paid on a timely basis; or • the date the surviving Spouse or a Dependent child becomes eligible for Medicare; or • the date the surviving Spouse or a Dependent child becomes eligible to participate in another Group health plan; or • the date the surviving Spouse remarries or dies; or • the date this Group Benefit Plan ends; or • the date a Dependent child is no longer eligible. This section (State Continuation) is available only if the Group is not subject to Continuation of Coverage under the Consolidated Omnibus Budget Reconciliation Act of 1985 and any amendments thereto. A Subscriber or covered Dependent whose coverage under this Benefit Plan ends because of: 1) Subscriber’s death; or 2) Subscriber’s termination of active employment; or 3) because of the divorce of the Subscriber or a covered Member, may be entitled to continue the coverage under this Benefit Plan. The Subscriber or Dependent requesting continuation must have been continuously covered under this Benefit Plan (or another group policy that this Benefit Plan replaced) for the three (3) consecutive months immediately preceding the date this coverage would otherwise have ended. Continuation of coverage for a Subscriber or his Dependents is not available if:‌ • the Covered Person, within thirty-one (31) days of termination of coverage, is or could have been covered by other Group coverage or a government sponsored health plan such as Medicare or Medicaid, or Group; or • the Subscriber’s or Member’s coverage under this Benefit Plan terminated due to fraud or failure to pay his required contribution to premium; or • the Covered Person is eligible for continuation of coverage under COBRA. To elect continuation of coverage under this section, the Subscriber or Member must notify the Group in writing of his election to continue this Group health coverage and must pay any required contribution to the Group in advance. The initial contribution must be paid no later than the end of the month following the month in which the event occurred which made the Subscriber or Member eligible. (If the Dependent is eligible due to divorce, the event shall be deemed to have occurred on the date of the judgment of divorce.) A form to continue coverage is available from the Group. Continuation of insurance under the Group policy for any Covered Person shall terminate on the earliest of the following dates: • twelve (12) calendar months from the date coverage would have otherwise ended; or • the date ending the period for which the Subscriber or Dependent makes his last required premium contribution for the coverage; or • the date the Subscriber or Member becomes or is eligible to become covered for similar benefits under any arrangement of coverage for individuals in a Group, whether insured or uninsured, including Medicare or Medicaid; or • the date on which the Group policy is terminated; or • the date on which an enrolled Member of a health maintenance organization legally resides outside the service area of the Company.

Alternate Benefits. If Claims Administrator determines that a less costly covered service other than the covered service the Dentist performed could have been performed to treat a dental condition, we will pay benefits based upon the less costly service if such service would produce a professionally acceptable result under generally accepted dental standards. If the Member and the Dentist choose the more expensive treatment, the Member will be responsible for the additional charges, beyond those allowed under this clause. This limitation does not apply to covered implantology services. Alternate benefits applicable to your treatment plan will be determined during Authorization. However, should the services billed differ from those Authorized, Claims Administrator reserves the right to determine if an Alternate Benefit is applicable to the actual services rendered. If a Member has other coverage for dental benefits, and this Benefit Plan is offered in conjunction with or as a supplement to that other dental coverage, the dental benefits under this stand-alone coverage will be determined first. We reserve the right to make any coordination of benefits necessary so that no more than the full amount of the Allowable Charge for the same claim or service is ever paid under all the dental benefits the Member may have. A Covered Benefit for such service was incurred while coverage was in effect; and Such Covered Benefit is completed within thirty-one (31) days after coverage terminates. For appliances or changes to appliances – on the date the appliance or prosthesis is permanently placed; For Crowns, dentures or bridgework – on the date the impression is taken; For Root Canal therapy -- on the date the pulp chamber is opened; or If eligibility for Group coverage ceases upon the death of the Subscriber, a surviving Spouse covered as a Dependent who is fifty (50) years of age or older, has ninety (90) days from the date of the Subscriber's death to notify Company of his election to continue the same coverage for himself, and if already covered, for his Dependent children. • Coverage is automatic during the ninety (90) day election period. Premium is owed for this coverage. If continuation is not chosen, or if premium is not received for the ninety 90 days of automatic coverage, the ninety (90) days of automatic coverage is terminated retroactive to the end of the billing cycle in which the death occurred. • If the continuation coverage is chosen within the ninety (90) day period, coverage will continue without interruption. Premium is owed from the last date for which premium has been paid. No physical exams are required. Premium for continuing coverage will not exceed the premium assessed for each Subscriber by class of coverage under the Group Benefit Plan. The Group will be responsible for notifying the Spouse of the right to continue and for billing and collection of premium. However, if We have been furnished with the home address of the surviving Spouse at the time of death and have been notified by the Group in a manner acceptable to Us of the death of the Subscriber, We will notify the surviving Spouse of the right to continue. Coverage continues For all other dental expenses -- on a premium-paying basis until the earliest of: • the date premium is due and is not paid on a timely basis; or • the date the surviving Spouse service is rendered or a Dependent child becomes eligible for Medicare; or • the date the surviving Spouse or a Dependent child becomes eligible to participate in another Group health plan; or • the date the surviving Spouse remarries or dies; or • the date this Group Benefit Plan ends; or • the date a Dependent child supply is no longer eligible. This section (State Continuation) is available only if the Group is not subject to Continuation of Coverage under the Consolidated Omnibus Budget Reconciliation Act of 1985 and any amendments thereto. A Subscriber or covered Dependent whose coverage under this Benefit Plan ends because of: 1) Subscriber’s death; or 2) Subscriber’s termination of active employment; or 3) because of the divorce of the Subscriber or a covered Member, may be entitled to continue the coverage under this Benefit Plan. The Subscriber or Dependent requesting continuation must have been continuously covered under this Benefit Plan (or another group policy that this Benefit Plan replaced) for the three (3) consecutive months immediately preceding the date this coverage would otherwise have ended. Continuation of coverage for a Subscriber or his Dependents is not available if:‌ • the Covered Person, within thirty-one (31) days of termination of coverage, is or could have been covered by other Group coverage or a government sponsored health plan such as Medicare or Medicaid, or Group; or • the Subscriber’s or Member’s coverage under this Benefit Plan terminated due to fraud or failure to pay his required contribution to premium; or • the Covered Person is eligible for continuation of coverage under COBRA. To elect continuation of coverage under this section, the Subscriber or Member must notify the Group in writing of his election to continue this Group health coverage and must pay any required contribution to the Group in advance. The initial contribution must be paid no later than the end of the month following the month in which the event occurred which made the Subscriber or Member eligible. (If the Dependent is eligible due to divorce, the event shall be deemed to have occurred on the date of the judgment of divorcefurnished.) A form to continue coverage is available from the Group. Continuation of insurance under the Group policy for any Covered Person shall terminate on the earliest of the following dates: • twelve (12) calendar months from the date coverage would have otherwise ended; or • the date ending the period for which the Subscriber or Dependent makes his last required premium contribution for the coverage; or • the date the Subscriber or Member becomes or is eligible to become covered for similar benefits under any arrangement of coverage for individuals in a Group, whether insured or uninsured, including Medicare or Medicaid; or • the date on which the Group policy is terminated; or • the date on which an enrolled Member of a health maintenance organization legally resides outside the service area of the Company.

Alternate Benefits. If Claims Administrator determines that a less costly covered service other than the covered service the Dentist performed could have been performed to treat a dental condition, we will pay benefits based upon the less costly service if such service would produce a professionally acceptable result under generally accepted dental standards. If the Member and the Dentist choose the more expensive treatment, the Member will be responsible for the additional charges, beyond those allowed under this clause. This limitation does not apply to covered implantology services. Alternate benefits applicable to your treatment plan will be determined during Authorization. However, should the services billed differ from those Authorized, Claims Administrator reserves the right to determine if an Alternate Benefit is applicable to the actual services rendered. If a Member has other coverage for dental benefits, and this Benefit Plan is offered in conjunction with or as a supplement to that other dental coverage, the dental benefits under this stand-alone coverage will be determined first. We reserve the right to make any coordination of benefits necessary so that no more than the full amount of the Allowable Charge for the same claim or service is ever paid under all the dental benefits the Member may have. The dental coverage under this Benefit Plan will be extended after the date the coverage for the Member terminates only if: A Covered Benefit for such service was incurred while coverage was in effect; and Such Covered Benefit is completed within thirty-one (31) days after coverage terminates. A Covered Benefit expense will be deemed incurred as follows: For appliances or changes to appliances – on the date the appliance or prosthesis is permanently placed; For Crowns, dentures or bridgework – on the date the impression is taken; For Root Canal therapy -- on the date the pulp chamber is opened; or If eligibility for Group coverage ceases upon the death of the Subscriber, a surviving Spouse covered as a Dependent who is fifty (50) years of age or older, has ninety (90) days from the date of the Subscriber's death to notify Company of his election to continue the same coverage for himself, and if already covered, for his Dependent children. • Coverage is automatic during the ninety (90) day election period. Premium is owed for this coverage. If continuation is not chosen, or if premium is not received for the ninety 90 days of automatic coverage, the ninety (90) days of automatic coverage is terminated retroactive to the end of the billing cycle in which the death occurred. • If the continuation coverage is chosen within the ninety (90) day period, coverage will continue without interruption. Premium is owed from the last date for which premium has been paid. No physical exams are required. Premium for continuing coverage will not exceed the premium assessed for each Subscriber by class of coverage under the Group Benefit Plan. The Group will be responsible for notifying the Spouse of the right to continue and for billing and collection of premium. However, if We have been furnished with the home address of the surviving Spouse at the time of death and have been notified by the Group in a manner acceptable to Us of the death of the Subscriber, We will notify the surviving Spouse of the right to continue. Coverage continues For all other dental expenses -- on a premium-paying basis until the earliest of: • the date premium is due and is not paid on a timely basis; or • the date the surviving Spouse service is rendered or a Dependent child becomes eligible for Medicare; or • the date the surviving Spouse or a Dependent child becomes eligible to participate in another Group health plan; or • the date the surviving Spouse remarries or dies; or • the date this Group Benefit Plan ends; or • the date a Dependent child supply is no longer eligible. This section (State Continuation) is available only if the Group is not subject to Continuation of Coverage under the Consolidated Omnibus Budget Reconciliation Act of 1985 and any amendments thereto. A Subscriber or covered Dependent whose coverage under this Benefit Plan ends because of: 1) Subscriber’s death; or 2) Subscriber’s termination of active employment; or 3) because of the divorce of the Subscriber or a covered Member, may be entitled to continue the coverage under this Benefit Plan. The Subscriber or Dependent requesting continuation must have been continuously covered under this Benefit Plan (or another group policy that this Benefit Plan replaced) for the three (3) consecutive months immediately preceding the date this coverage would otherwise have ended. Continuation of coverage for a Subscriber or his Dependents is not available if:‌ • the Covered Person, within thirty-one (31) days of termination of coverage, is or could have been covered by other Group coverage or a government sponsored health plan such as Medicare or Medicaid, or Group; or • the Subscriber’s or Member’s coverage under this Benefit Plan terminated due to fraud or failure to pay his required contribution to premium; or • the Covered Person is eligible for continuation of coverage under COBRA. To elect continuation of coverage under this section, the Subscriber or Member must notify the Group in writing of his election to continue this Group health coverage and must pay any required contribution to the Group in advance. The initial contribution must be paid no later than the end of the month following the month in which the event occurred which made the Subscriber or Member eligible. (If the Dependent is eligible due to divorce, the event shall be deemed to have occurred on the date of the judgment of divorcefurnished.) A form to continue coverage is available from the Group. Continuation of insurance under the Group policy for any Covered Person shall terminate on the earliest of the following dates: • twelve (12) calendar months from the date coverage would have otherwise ended; or • the date ending the period for which the Subscriber or Dependent makes his last required premium contribution for the coverage; or • the date the Subscriber or Member becomes or is eligible to become covered for similar benefits under any arrangement of coverage for individuals in a Group, whether insured or uninsured, including Medicare or Medicaid; or • the date on which the Group policy is terminated; or • the date on which an enrolled Member of a health maintenance organization legally resides outside the service area of the Company.

Alternate Benefits. If Claims Administrator determines that a less costly covered service other than the covered service the Dentist performed could have been performed to treat a dental condition, we will pay benefits Benefits based upon the less costly service if such service would produce a professionally acceptable result under generally accepted dental standards. If the Member and the Dentist choose the more expensive treatment, the Member will be responsible for the additional charges, beyond those allowed under this clause. This limitation does not apply to covered implantology services. Alternate benefits Benefits applicable to your treatment plan will be determined during Authorization. However, should the services billed differ from those Authorized, Claims Administrator reserves the right to determine if an Alternate Benefit is applicable to the actual services rendered. If a Member has other coverage for dental benefitsBenefits, and this Benefit Plan Contract is offered in conjunction with or as a supplement to that other dental coverage, the dental benefits Benefits under this stand-alone coverage will be determined first. We reserve the right to make any coordination of benefits Benefits necessary so that no more than the full amount of the Allowable Charge for the same claim or service is ever paid under all the dental benefits Benefits the Member may have. A Covered Benefit The dental coverage under this Section will be extended after the date the coverage for such service was incurred while coverage was in effect; and Such Covered Benefit is completed within thirty-one (31) days after coverage terminates. the Member terminates only if: For appliances or changes to appliances – on the date the appliance or prosthesis is permanently placed; For Crowns, dentures or bridgework – on the date the impression is taken; For Root Canal therapy -- on the date the pulp chamber is opened; or If eligibility for Group coverage ceases upon the death of the Subscriber, a surviving Spouse covered as a Dependent who is fifty (50) years of age or older, has ninety (90) days from For all other dental expenses -- on the date of the Subscriber's death to notify Company of his election to continue service is rendered or the same coverage for himselfsupply is furnished. For orthodontic treatment, and if already covered, for his Dependent children. • Coverage is automatic during covered under the ninety (90) day election period. Premium is owed for this coverage. If continuation is not chosen, or if premium is not received for the ninety 90 days of automatic coverage, the ninety (90) days of automatic coverage is terminated retroactive to the end of the billing cycle in which the death occurred. • If the continuation coverage is chosen within the ninety (90) day periodPlan, coverage will continue without interruption. Premium is owed from the last date for which premium has been paid. No physical exams are required. Premium for continuing coverage will not exceed the premium assessed for each Subscriber by class of coverage under the Group Benefit Plan. The Group will be responsible for notifying the Spouse of the right to continue and for billing and collection of premium. However, if We have been furnished with the home address of the surviving Spouse at the time of death and have been notified by the Group in a manner acceptable to Us of the death of the Subscriber, We will notify the surviving Spouse of the right to continue. Coverage continues on a premium-paying basis until the earliest of: • the date premium is due and is not paid on a timely basis; or • the date the surviving Spouse or a Dependent child becomes eligible for Medicare; or • the date the surviving Spouse or a Dependent child becomes eligible to participate in another Group health plan; or • the date the surviving Spouse remarries or dies; or • the date this Group Benefit Plan ends; or • the date a Dependent child is no longer eligible. This section (State Continuation) is available only if the Group is not subject to Continuation of Coverage under the Consolidated Omnibus Budget Reconciliation Act of 1985 and any amendments thereto. A Subscriber or covered Dependent whose coverage under this Benefit Plan ends because of: 1) Subscriber’s death; or 2) Subscriber’s termination of active employment; or 3) because of the divorce of the Subscriber or a covered Member, may be entitled to continue the coverage under this Benefit Plan. The Subscriber or Dependent requesting continuation must have been continuously covered under this Benefit Plan (or another group policy that this Benefit Plan replaced) for the three (3) consecutive months immediately preceding the date this coverage would otherwise have ended. Continuation of coverage for a Subscriber or his Dependents is not available if:‌ • the Covered Person, within thirty-one (31) days of termination of coverage, is or could have been covered by other Group coverage or a government sponsored health plan such as Medicare or Medicaid, or Group; or • the Subscriber’s or Member’s coverage under this Benefit Plan terminated due to fraud or failure to pay his required contribution to premium; or • the Covered Person is eligible for continuation of coverage under COBRA. To elect continuation of coverage under this section, the Subscriber or Member must notify the Group in writing of his election to continue this Group health coverage and must pay any required contribution to the Group in advance. The initial contribution must be paid no later than extended through the end of the month following the month in which the event occurred which made the Subscriber or Member eligible. (If the Dependent is eligible due to divorce, the event shall be deemed to have occurred on the date of the judgment of divorceMember’s Termination Date.) A form to continue coverage is available from the Group. Continuation of insurance under the Group policy for any Covered Person shall terminate on the earliest of the following dates: • twelve (12) calendar months from the date coverage would have otherwise ended; or • the date ending the period for which the Subscriber or Dependent makes his last required premium contribution for the coverage; or • the date the Subscriber or Member becomes or is eligible to become covered for similar benefits under any arrangement of coverage for individuals in a Group, whether insured or uninsured, including Medicare or Medicaid; or • the date on which the Group policy is terminated; or • the date on which an enrolled Member of a health maintenance organization legally resides outside the service area of the Company.