Common use of Predetermination of Benefits Clause in Contracts

Predetermination of Benefits. If charges for a planned course of treatment by a licensed dentist would exceed $300, proposed details and x-rays should be submitted to the Plan Administrator for approval. Failure to do so may result in payment of a lesser benefit amount because of the difficulty in determining the need for such treatment after it has been provided. Dental x-rays will be promptly returned to the dentist. Course of Treatment means one or more services rendered by one or more dentists for the correction of a dental condition diagnosed as a result of an oral exam starting on the date the first service to correct such condition is rendered. Limitations No amount will be paid for charges for: - Dental care which is cosmetic; - Completion of claim forms; - Broken appointments; - Dental care covered under a medical plan provided by an employer or government; - Which, in the absence of coverage, there would be no charge; - Stainless steel crowns on permanent teeth; - Oral hygiene instruction or nutritional counselling; - Protective athletic appliances; - Prostheses, including crowns and bridgework, and the fitting thereof which were ordered while the person was not covered, or which were ordered while the person was covered but which were finally installed or delivered after this benefit is discontinued; - A full mouth reconstruction, for a vertical dimension correction, or for diagnosis or correction of a temporomandibular joint dysfunction; or - Replacement of lost or stolen appliances.

Predetermination of Benefits. If charges for a planned course of treatment by a licensed dentist practitioner would exceed $300., proposed details and x-rays should be submitted to the Plan Administrator Maritime Life for approval. Failure to do so may result in payment of a lesser benefit amount because of the difficulty in determining the need for such treatment after it has been provided. Dental x-rays will be promptly returned to the dentist. Course of Treatment treatment means one or more services rendered by one or more dentists for the correction of a dental condition diagnosed as a result of an oral exam starting on the date the first service to correct such condition is rendered. Limitations No amount will be paid for charges for: - Dental . dental care which is cosmetic; - Completion . completion of claim forms; - Broken . broken appointments; - Dental . dental care covered under a medical plan provided by an employer or government; - Whichgovernment which, in the absence of coverageinsurance, there would be no charge; - Stainless . stainless steel crowns on permanent teeth; - Oral . oral hygiene instruction or nutritional counselling; - Protective . protective athletic appliances; - Prostheses. prostheses, including crowns and bridgework, and the fitting thereof which were ordered while the person was not coveredinsured, or which were ordered while the person was covered insured but which were finally installed or delivered after this benefit is discontinueddiscontinued or more than 31 days after termination of insurance for any other reasons; - A . a full mouth reconstruction, for a vertical dimension correction, or for diagnosis or correction of a temporomandibular joint dysfunction; or - Replacement . replacement of a lost or stolen appliances.prosthesis; or . orthodontic treatment or correction of malocclusion APPENDIX "G"

Predetermination of Benefits. If charges for a planned course of treatment by a licensed dentist practitioner would exceed $300., proposed details and x-rays should be submitted to the Plan Administrator benefit provider for approval. Failure to do so may result in payment of a lesser benefit amount because of the difficulty in determining the need for such treatment after it has been provided. Dental x-rays will be promptly returned to the dentist. Course of Treatment treatment means one or more services rendered by one or more dentists for the correction of a dental condition diagnosed as a result of an oral exam starting on the date the first service to correct such condition is rendered. Limitations No amount will be paid for charges for: - Dental  dental care which is cosmetic; - Completion  completion of claim forms; - Broken  broken appointments; - Dental  dental care covered under a medical plan provided by an employer or government; - Whichgovernment which, in the absence of coverageinsurance, there would be no charge; - Stainless  stainless steel crowns on permanent teeth; - Oral  oral hygiene instruction or nutritional counselling; - Protective  protective athletic appliances; - Prostheses prostheses, including crowns and bridgework, and the fitting thereof which were ordered while the person was not coveredinsured, or which were ordered while the person was covered insured but which were finally installed or delivered after this benefit is discontinueddiscontinued or more than 31 days after termination of insurance for any other reasons; - A  a full mouth reconstruction, for a vertical dimension correction, or for diagnosis or correction of a temporomandibular joint dysfunction; or - Replacement  replacement of a lost or stolen appliances.prosthesis; or

Predetermination of Benefits. If charges for a planned course of treatment by a licensed dentist practitioner would exceed $300300.00, proposed details and x-rays should be submitted to the Plan Administrator Maritime Life for approval. Failure to do so may result in payment of a lesser benefit amount because of the difficulty in determining the need for such treatment after it has been provided. Dental x-rays will be promptly returned to the dentist. Course of Treatment treatment means one or more services rendered by one or more dentists for the correction of a dental condition diagnosed as a result of an oral exam starting on the date the first service to correct such condition is rendered. Limitations No amount will be paid for charges for: - Dental . dental care which is cosmetic; - Completion . completion of claim forms; - Broken . broken appointments; - Dental . dental care covered under a medical plan provided by an employer or government; - Whichgovernment which, in the absence of coverageinsurance, there would be no charge; - Stainless . stainless steel crowns on permanent teeth; - Oral . oral hygiene instruction or nutritional counselling; - Protective . protective athletic appliances; - Prostheses. prostheses, including crowns and bridgework, and the fitting thereof which were ordered while the person was not coveredinsured, or which were ordered while the person was covered insured but which were finally installed or delivered after this benefit is discontinueddiscontinued or more than 31 days after termination of insurance for any other reasons; - A . a full mouth reconstruction, for a vertical dimension correction, or for diagnosis or correction of a temporomandibular joint dysfunction; or - Replacement . replacement of a lost or stolen appliances.prosthesis; or APPENDIX "G"

Predetermination of Benefits. If charges for a planned course of treatment by a licensed dentist practitioner would exceed $300., proposed details and x-rays should be submitted to the Plan Administrator Maritime Life for approval. Failure to do so may result in payment of a lesser benefit amount because of the difficulty in determining the need for such treatment after it has been provided. Dental x-rays will be promptly returned to the dentist. Course of Treatment treatment means one or more services rendered by one or more dentists for the correction of a dental condition diagnosed as a result of an oral exam starting on the date the first service to correct such condition is rendered. Limitations No amount will be paid for charges for: - Dental · dental care which is cosmetic; - Completion · completion of claim forms; - Broken · broken appointments; - Dental · dental care covered under a medical plan provided by an employer or government; - Whichgovernment which, in the absence of coverageinsurance, there would be no charge; - Stainless · stainless steel crowns on permanent teeth; - Oral · oral hygiene instruction or nutritional counselling; - Protective · protective athletic appliances; - Prostheses· prostheses, including crowns and bridgework, and the fitting thereof which were ordered while the person was not coveredinsured, or which were ordered while the person was covered insured but which were finally installed or delivered after this benefit is discontinueddiscontinued or more than 31 days after termination of insurance for any other reasons; - A · a full mouth reconstruction, for a vertical dimension correction, or for diagnosis or correction of a temporomandibular joint dysfunction; or - Replacement · replacement of a lost or stolen appliances.prosthesis; or · orthodontic treatment or correction of malocclusion APPENDIX "G"

Predetermination of Benefits. If charges for a planned course of treatment by a licensed dentist practitioner would exceed $300., proposed details and x-rays should be submitted to the Plan Administrator Maritime Life for approval. Failure to do so may result in payment of a lesser benefit amount because of the difficulty in determining the need for such treatment after it has been provided. Dental x-rays will be promptly returned to the dentist. Course of Treatment treatment means one or more services rendered by one or more dentists for the correction of a dental condition diagnosed as a result of an oral exam starting on the date the first service to correct such condition is rendered. Limitations No amount will be paid for charges for: - Dental • dental care which is cosmetic; - Completion • completion of claim forms; - Broken • broken appointments; - Dental • dental care covered under a medical plan provided by an employer or government; - Whichgovernment which, in the absence of coverageinsurance, there would be no charge; - Stainless • stainless steel crowns on permanent teeth; - Oral • oral hygiene instruction or nutritional counselling; - Protective • protective athletic appliances; - Prostheses• prostheses, including crowns and bridgework, and the fitting thereof which were ordered while the person was not coveredinsured, or which were ordered while the person was covered insured but which were finally installed or delivered after this benefit is discontinueddiscontinued or more than 31 days after termination of insurance for any other reasons; - A • a full mouth reconstruction, for a vertical dimension correction, or for diagnosis or correction of a temporomandibular joint dysfunction; or - Replacement ▪ replacement of a lost or stolen appliances.prosthesis; or

Predetermination of Benefits. If charges for a planned course of treatment by a licensed dentist practitioner would exceed $300., proposed details and x-rays should be submitted to the Plan Administrator Maritime Life for approval. Failure to do so may result in payment of a lesser benefit amount because of the difficulty in determining the need for such treatment after it has been provided. Dental x-rays will be promptly returned to the dentist. Course of Treatment treatment means one or more services rendered by one or more dentists for the correction of a dental condition diagnosed as a result of an oral exam starting on the date the first service to correct such condition is rendered. Limitations No amount will be paid for charges for: - Dental ∙ dental care which is cosmetic; - Completion ∙ completion of claim forms; - Broken ∙ broken appointments; - Dental ∙ dental care covered under a medical plan provided by an employer or government; - Whichgovernment which, in the absence of coverageinsurance, there would be no charge; - Stainless ∙ stainless steel crowns on permanent teeth; - Oral ∙ oral hygiene instruction or nutritional counselling; - Protective ∙ protective athletic appliances; - Prostheses∙ prostheses, including crowns and bridgework, and the fitting thereof which were ordered while the person was not coveredinsured, or which were ordered while the person was covered insured but which were finally installed or delivered after this benefit is discontinueddiscontinued or more than 31 days after termination of insurance for any other reasons; - A ∙ a full mouth reconstruction, for a vertical dimension correction, or for diagnosis or correction of a temporomandibular joint dysfunction; or - Replacement ∙ replacement of a lost or stolen appliances.prosthesis; or ∙ orthodontic treatment or correction of malocclusion APPENDIX "G"

Predetermination of Benefits. If charges for a planned course of treatment by a licensed dentist practitioner would exceed $300, proposed details and x-rays should be submitted to the Plan Administrator Maritime Life for approval. Failure to do so may result in payment of a lesser benefit amount because of the difficulty in determining the need for such treatment after it has been provided. Dental x-rays will be promptly returned to the dentist. Course of Treatment treatment means one or more services rendered by one or more dentists for the correction of a dental condition diagnosed as a result of an oral exam starting on the date the first service to correct such condition is rendered. Limitations No amount will be paid for charges for: - Dental dental care which is cosmetic; - Completion completion of claim forms; - Broken broken appointments; - Dental dental care covered under a medical plan provided by an employer or government; - Whichgovernment which, in the absence of coverageinsurance, there would be no charge; - Stainless stainless steel crowns on permanent teeth; - Oral oral hygiene instruction or nutritional counselling; - Protective protective athletic appliances; - Prosthesesprostheses, including crowns and bridgework, and the fitting thereof which were ordered while the person was not coveredinsured, or which were ordered while the person was covered insured but which were finally installed or delivered after this benefit is discontinueddiscontinued or more than days after termination of insurance for any other reasons; - A a full mouth reconstruction, for a vertical dimension correctionCorrection, or for diagnosis or correction of a temporomandibular joint dysfunction; or - Replacement replacement of a lost or stolen appliances.prosthesis; or orthodontic treatment or correction of malocclusion APPENDIX

Predetermination of Benefits. If charges for a planned course of treatment by a licensed dentist practitioner would exceed $300., proposed details and x-rays should be submitted to the Plan Administrator Maritime Life for approval. Failure to do so may result in payment of a lesser benefit amount because of the difficulty in determining the need for such treatment after it has been provided. Dental x-rays will be promptly returned to the dentist. Course of Treatment treatment means one or more services rendered by one or more dentists for the correction of a dental condition diagnosed as a result of an oral exam starting on the date the first service to correct such condition is rendered. Limitations No amount will be paid for charges for: - Dental . dental care which is cosmetic; - Completion . completion of claim forms; - Broken . broken appointments; - Dental . dental care covered under a medical plan provided by an employer or government; - Whichgovernment which, in the absence of coverageinsurance, there would be no charge; - Stainless . stainless steel crowns on permanent teeth; - Oral . oral hygiene instruction or nutritional counselling; - Protective . protective athletic appliances; - Prostheses. prostheses, including crowns and bridgework, and the fitting thereof which were ordered while the person was not coveredinsured, or which were ordered while the person was covered insured but which were finally installed or delivered after this benefit is discontinueddiscontinued or more than 31 days after termination of insurance for any other reasons; - A . a full mouth reconstruction, for a vertical dimension correction, or for diagnosis or correction of a temporomandibular joint dysfunction; or - Replacement . replacement of a lost or stolen appliances.prosthesis; or APPENDIX "G"

Predetermination of Benefits. If charges for a planned course of treatment by a licensed dentist would exceed $300, proposed details and x-rays should be submitted to the Plan Administrator for approval. Failure to do so may result in payment of a lesser benefit amount because of the difficulty in determining the need for such treatment after it has been provided. Dental x-rays will be promptly returned to the dentist. Course of Treatment means one or more services rendered by one or more dentists for the correction of a dental condition diagnosed as a result of an oral exam starting on the date the first service to correct such condition is rendered. Limitations No amount will be paid for charges for: - • Dental care which is cosmetic; - • Completion of claim forms; - • Broken appointments; - • Dental care covered under a medical plan provided by an employer Company or government; - • Which, in the absence of coverage, there would be no charge; - • Stainless steel crowns on permanent teeth; - • Oral hygiene instruction or nutritional counselling; - • Protective athletic appliances; - • Prostheses, including crowns and bridgework, and the fitting thereof which were ordered while the person was not covered, or which were ordered while the person was covered but which were finally installed or delivered after this benefit is discontinued; - • A full mouth reconstruction, for a vertical dimension correction, or for diagnosis or correction of a temporomandibular joint dysfunction; or - • Replacement of lost or stolen appliances.

Predetermination of Benefits. If charges for a planned course of treatment by a licensed dentist practitioner would exceed $300., proposed details and x-rays should be submitted to the Plan Administrator benefit provider for approval. Failure to do so may result in payment of a lesser benefit amount because EBPSA - 18 of the difficulty in determining the need for such treatment after it has been provided. Dental x-rays will be promptly returned to the dentist. Course of Treatment treatment means one or more services rendered by one or more dentists for the correction of a dental condition diagnosed as a result of an oral exam starting on the date the first service to correct such condition is rendered. Limitations No amount will be paid for charges for: - Dental • dental care which is cosmetic; - Completion • completion of claim forms; - Broken • broken appointments; - Dental • dental care covered under a medical plan provided by an employer or government; - Whichgovernment which, in the absence of coverageinsurance, there would be no charge; - Stainless • stainless steel crowns on permanent teeth; - Oral • oral hygiene instruction or nutritional counselling; - Protective • protective athletic appliances; - Prostheses• prostheses, including crowns and bridgework, and the fitting thereof which were ordered while the person was not coveredinsured, or which were ordered while the person was covered insured but which were finally installed or delivered after this benefit is discontinueddiscontinued or more than 31 days after termination of insurance for any other reasons; - A • a full mouth reconstruction, for a vertical dimension correction, or for diagnosis or correction of a temporomandibular joint dysfunction; or - Replacement ▪ replacement of a lost or stolen appliances.prosthesis; or • orthodontic treatment or correction of malocclusion