CarePlus DIAMOND EXCLUSIONS AND LIMITATIONS
Return to Dental Associates Dental Insurance Plan
EXCLUSIONS AND LIMITATIONS
- The Contract does not cover any services performed at offices other than Dental Associates’ in Wisconsin.
- The Contract provides only supplemental benefits. The Contract will not replace, reduce, eliminate or modify any other coverage, including Medicare.
- The Contract will not reimburse you for missed appointment charges.
- A member of your family will no longer be covered if that person no longer meets the definition of “family” under the CarePlus Contract.
- No credits shall apply under the Contract if your plan is a group dental Contract offered by CarePlus. Notwithstanding the preceding sentence, Credits shall apply under the Contract with respect to a dental service if (a) you have exhausted your benefits with respect to that dental service under your plan or (b) your plan does not provide any benefits for that dental service (i.e., it is a non-covered service). This exception is only with respect to the difference between the reasonable, usual and customary charge for such dental service and the amount actually covered by your plan for such dental service.
- No Credits shall apply under the Contract if your plan is a PPO Contract and makes payments to the Dentists at reduced amounts. Notwithstanding the preceding sentence, Credits shall apply under this Contract with respect to a dental service if your plan does not provide any benefits for that dental service (i.e., it is a noncovered service). However, such Credits only apply to the extent listed in Exhibit A of the Contract.
- A routine orthodontic case is one in which the alignment of the teeth is accomplished using a single phase of treatment with complete braces and a single set of retainers. Additional costs are incurred when treatment requires appliance therapy, headgear, treatment of impacted tooth/teeth, cleft palate, orthognathic surgical procedures or orthodontic brackets other than stainless steel (i.e. gold, ceramic, invisible, etc.).
NOTICE OF 10-DAY RIGHT TO RETURN CONTRACT
You may return the Contract within ten (10) days after receipt to CarePlus Dental Plans, Inc. at 11711 W Burleigh Street Wauwatosa, WI 53222. If you do so, the Contract is void and all payments made under it shall be refunded.
If you fail to make any premium payment when due and such failure continues for more than thirty-one (31) days following the Renewal Date, the Contract and all rights you and members of your family have to receive benefits shall terminate.
- The Contract is issued for a term of 12 months. It is renewable at the option of CarePlus.
- When the Contract terminates, the right of you and your family to benefits hereunder shall terminate immediately.
- Coverage will end for your children when they reach age 26. Please refer to dental Contract for
fulldescription of dependent coverage.
- Coverage will end for any grandchildren when your child (their parent) reaches age 18.
- CarePlus may disenroll you, resulting in termination of coverage, for any one of the following reasons:
- You do not pay a required premium within thirty-one (31) days after the Renewal Date.
- You permit someone else to use the enrollment identification or knowingly provide fraudulent information in applying for coverage or receiving services.
- You pose a threat to providers, staff or other policyholders because of physical or verbal abuse.
- You are unable to establish or maintain a satisfactory provider-patient relationship with a Dentist. Disenrollment only will occur after we provide you the opportunity to select an alternate provider, have made reasonable efforts to assist you in establishing a satisfactory provider-patient relationship and have provided you with notice of the right to file a Grievance.