Dental Services - Accidental Injury (Emergency Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Dental Care (Pediatric) - for members under age 19 See Dental Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19. Oral evaluations 0% - After deductible 0% - After deductible X-rays 0% - After deductible 0% - After deductible Cleanings (prophylaxis) 0% - After deductible 0% - After deductible Fluoride treatments 0% - After deductible 0% - After deductible Sealants 0% - After deductible 0% - After deductible Space Maintainers 0% - After deductible 0% - After deductible Palliative treatment 50% - After deductible 50% - After deductible Fillings 50% - After deductible 50% - After deductible Simple extractions 50% - After deductible 50% - After deductible Denture repairs and relines/rebasing 50% - After deductible 50% - After deductible Crowns & onlays 50% - After deductible 50% - After deductible Therapeutic Pulpotomies 50% - After deductible 50% - After deductible Root canal therapy 50% - After deductible 50% - After deductible Non-surgical periodontal services 50% - After deductible 50% - After deductible Surgical periodontal services 50% - After deductible 50% - After deductible Periodontal maintenance 50% - After deductible 50% - After deductible Fixed bridges and dentures 50% - After deductible 50% - After deductible Implants 50% - After deductible 50% - After deductible Oral surgery services 50% - After deductible 50% - After deductible General anesthesia or IV sedation - dental office 50% - After deductible 50% - After deductible Biopsies 50% - After deductible 50% - After deductible Occlusal (night) guards 50% - After deductible 50% - After deductible Orthodontic services (braces) - when medically necessary. 50% - After deductible 50% - After deductible Dialysis Services Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider.
Illness or Injury If an employee or dependent of an employee shall, while the employee is insured, be confined in a hospital as a bed-patient for treatment and not primarily for medical investigation or diagnosis only, and if the employee shall incur expense in respect of such confinement, the Company will pay, subject to the proviso below, benefits equal to the actual charges made by the hospital for bed, board and routine nursing services as regularly provided by such hospital, but the Company will in no event make payment in respect of that part of any charge for bed, board and routine nursing services which exceeds
Work-related Injury/Disability An employee who receives an Employer Contribution and who is off the State payroll due to a work-related injury or a work-related disability remains eligible for an Employer Contribution as long as such an employee receives workers' compensation payments. If such employee ceases to receive workers' compensation payments for the injury or disability and is granted a medical leave under Article 10, he/she shall be eligible for an Employer contribution during that leave.
Bodily Injury Bodily injury means death, disease, illness, physical and mental injury of or to an individual.
Employees with a Work-related Injury/Disability An employee who was off the State payroll due to a work-related injury or a work-related disability may continue to participate in the Group Insurance Program as long as such an employee receives workers' compensation payments or while the workers' compensation claim is pending.
Compensable Work-Related Injury or Illness Leave An employee who sustains a work-related illness or injury that is compensable under the state workers’ compensation law may select time-loss compensation exclusively or leave payments in addition to time-loss compensation. Employees who take sick leave, vacation leave or compensatory time during a period in which they receive time-loss compensation will receive full sick leave, vacation leave or compensatory time pay in addition to any time-loss payments. Notwithstanding Section 18.1, of Article 18, Leave Without Pay, the Employer may separate an employee in accordance with Article 31, Reasonable Accommodation and Disability Separation.
ACCIDENTAL DAMAGE IN HANDLING ( “ADH”): If purchased, the Covered Product is protected against accidental damage in handling such as drops and liquid spills. Immersion of Your Covered Product is not covered under this Agreement. ADH only covers operational or mechanical failure caused by a single incident while handling and does not include protection against theft, mysterious disappearance, misplacement, viruses or reckless, abusive, willful or intentional misconduct associated with handling and/or use of the Covered Product, cosmetic damage and/or other damage that does not affect the unit’s functionality, damage caused during shipment between You and Our service providers and any other limitations listed in the “What is Not Covered” section of this Agreement. For the purpose of this Agreement, Accidental Damage is defined as a single, unexpected, sudden and unintentional event and does not include accumulated damage from continual or multiple events. The use of this coverage requires an explanation of where and when the Accidental Damage occurred as well as a detailed description of the actual event. If needed, the replacement value of the Covered Product will be solely determined by the Administrator of this Agreement.
OUR RESPONSIBILITY FOR LOSS OR DAMAGE SUFFERED BY YOU 14.1 We are responsible to you for foreseeable loss and damage caused by us. If we fail to comply with this Agreement, we are responsible for loss or damage you suffer that is a foreseeable result of our breaking this Agreement or our failure to use reasonable care and skill, but we are not responsible for any loss or damage that is not foreseeable. Loss or damage is foreseeable if either it is obvious that it will happen, or if, at the time the Agreement is made, both we and you knew it might happen. We are not responsible for any loss or damage you suffer which is a result of you breaking this Agreement or you acting fraudulently.
Accidental Damage The service contract provides protection against accidental damage to the covered product (for example: falling off Your hands, or a car, or water damage) resulting from the handling of such product and that is not intentionally caused by You. IF YOU NEED SERVICE: To locate or arrange for service, call the toll free number on the Schedule Page. We will select an Authorized Repair Center which will contact You to arrange for Your service. You should contact Us if the completion of Your repair is not satisfactory.
Work-Related Injury or Illness In the event of an eligible employee’s absence from work being due to work related injury or work related illness, contributions at the normal rate will continue for the period of the absence provided that:
