Dental Accidents Sample Clauses
The Dental Accidents clause defines the terms under which dental injuries or emergencies are covered under an insurance policy or agreement. Typically, this clause outlines what constitutes a dental accident, such as injuries resulting from external, sudden events like falls or sports injuries, and specifies the types of treatments or expenses that are eligible for coverage. Its core practical function is to clarify the scope of protection for dental emergencies, ensuring that policyholders understand when and how dental accidents are covered, and to prevent disputes over coverage eligibility.
Dental Accidents. This plan covers accidental injuries to teeth, gums or jaw. Covered services include exams, consultations, dental treatment, and oral surgery when repair is performed within 12 months of the injury. To request an extension, please have your provider contact Customer Service. In order for us to review an extension request, we will ask the provider to send additional information that would show the necessity for the extension; such as, the severity of the accident or other circumstances. Services are covered when all of the following are true: Treatment is needed because of an accidental injury Treatment is done on the natural tooth structure and the teeth were free from decay and functionally sound when the injury happened. Functionally sound means that the teeth do not have: Extensive restoration, veneers, crowns or splints Periodontal (gum) disease or any other condition that would make them weak This plan does not cover damage from biting or chewing, even when caused by a foreign object in food. If necessary services can’t be completed within 12 months of an injury, coverage may be extended if your dental care meets our extension criteria. We must receive extension requests within 12 months of the injury date. To request an extension, please have your provider contact Customer Service. In order for us to review an extension request, we will ask the provider to send additional information that would show the necessity for the extension; such as, the severity of the accident or other circumstances. Emergency services are covered the same as any other emergency service. In some cases, this plan covers general anesthesia, professional services and facility charges for dental procedures. These services can be in a hospital or an ambulatory surgical facility. They are covered only when medically necessary for one of these reasons: The member is under age 9 years old, or has a disability and it would not be safe and effective to treat them in a dental office You have a medical condition (besides the dental condition) that makes it unsafe to do the dental treatment outside a hospital or ambulatory surgical center This plan covers routine foot care for the treatment of diabetes. Covered services include treatment for corns, calluses, toenail conditions other than infection and hypertrophy or hyperplasia of the skin of the feet. This benefit is provided for outpatient professional services, supplies, drugs and solutions required for infusion therapy. I...