Common use of Benefit Exclusions Clause in Contracts

Benefit Exclusions. The following shall be excluded from the benefits to be provided to Subscribers and eligible Dependents. 1. Benefits or services for injuries or conditions compensable under Worker’s Compensation or Employers’ Liability laws. 2. Benefits or services available from any federal or state government agency; or from any municipality, county, or other political subdivision or community agency; or from any foundation or similar entity. 3. Charges for services or supplies for which no charge is made that the patient is legally obligated to pay or for which no charge would be made in the absence of dental coverage. 4. Benefits for services or appliances started prior to the date the patient became eligible under this Plan may be excluded. 5. Charges for services when a claim is received for payment more than twelve (12) months after services are rendered. 6. Charges for any professional services performed by a relative of the patient. 7. Charges for treatment by other than a properly licensed dentist (unless allowed by state law), except radiographic images (x−rays) ordered by a dentist, cleaning and scaling of teeth, and topical application of fluoride may be performed by a properly licensed hygienist if treatment is rendered under the supervision and guidance of the dentist, in accordance with generally accepted dental standards. 8. Charges for completion of forms or submission of documentation required by DDPOK for a benefit determination. Such charges are not billable to the patient when services are provided by a Delta Dental Participating Dentist. Such charges are denied if submitted by a Nonparticipating Dentist. 9. Charges for house calls, hospital calls, or office visits. 10. Charges for missed or cancelled appointments, hospitalization or additional fees charged for hospital treatment, or management fees. 11. Charges for bleaching of teeth. 12. Prescription drugs, premedications, andƒor relative analgesia. 13. Experimental procedures. 14. Benefits or services for orthodontic treatment, unless specifically provided herein. 15. Charges for repair of an orthodontic appliance. 16. Charges for replacement of lost or missing crowns and appliances, or for stolen appliances. 17. Benefits or services to correct congenital or developmental malformations, for example, cleft palate, etc. 18. Services for the purpose of improving appearance when form and function are satisfactory and there is insufficient pathological condition evident to warrant the treatment (cosmetic dentistry). 19. Restorations for altering occlusion (bite), involving vertical dimensions, replacing tooth structure lost by attrition (grinding of teeth), erosion, abrasion (wear), or for periodontal, orthodontic, or other splinting. 20. Services with respect to diagnosis and treatment of disturbances of the temporomandibular joint (TMJ), unless specifically provided herein (refer to section B., “Other Miscellaneous Services”, above). 21. Charges for general anesthesiaƒIV sedation except when administered by a properly licensed dentist in a dental office in conjunction with covered oral surgery procedures or when necessary due to concurrent medical conditions. 22. Services and benefits excluded by the rules and regulations of Delta Dental, including the processing policies. 23. All other benefits and services not specified in this Appendix or any attachment andƒor addendum attached and forming a part of this Appendix.

Benefit Exclusions. The following shall be excluded from the benefits to be provided to Subscribers and eligible Dependents. 1. Benefits or services for injuries or conditions compensable under Worker’s Compensation or Employers’ Liability laws.. Form No. 1000.3 6 of 13 CONFIDENTIAL Appendix B Revised January 2022 2. Benefits or services available from any federal or state government agency; or from any municipality, county, or other political subdivision or community agency; or from any foundation or similar entity. 3. Charges for services or supplies for which no charge is made that the patient is legally obligated to pay or for which no charge would be made in the absence of dental coverage. 4. Benefits for services or appliances started prior to the date the patient became eligible under this Plan may be excluded. 5. Charges for services when a claim is received for payment more than twelve (12) months after services are rendered. 6. Charges for any professional services performed by a relative of the patient. 7. Charges for treatment by other than a properly licensed dentist (unless allowed by state law), except radiographic images (x−raysx-rays) ordered by a dentist, cleaning and scaling of teeth, and topical application of fluoride may be performed by a properly licensed hygienist if treatment is rendered under the supervision and guidance of the dentist, in accordance with generally accepted dental standards. 8. Charges for completion of forms or submission of documentation required by DDPOK for a benefit determination. Such charges are not billable to the patient when services are provided by a Delta Dental Participating Dentist. Such charges are denied if submitted by a Nonparticipating Dentist. 9. Charges for house calls, hospital calls, or office visits. 10. Charges for missed or cancelled appointments, hospitalization or additional fees charged for hospital treatment, or management fees. 11. Charges for bleaching of teeth. 12. Prescription drugs, premedications, andƒor and/or relative analgesia. 13. Experimental procedures. 14. Benefits or services for orthodontic treatment, unless specifically provided herein. 15. Charges for repair of an orthodontic appliance. 16. Charges for replacement of lost or missing crowns and appliances, or for stolen appliances. 17. Benefits or services to correct congenital or developmental malformations, for example, cleft palate, etc.. Form No. 1000.3 7 of 13 CONFIDENTIAL Appendix B Revised January 2022 18. Services for the purpose of improving appearance when form and function are satisfactory and there is insufficient pathological condition evident to warrant the treatment (cosmetic dentistry). 19. Restorations for altering occlusion (bite), involving vertical dimensions, replacing tooth structure lost by attrition (grinding of teeth), erosion, abrasion (wear), or for periodontal, orthodontic, or other splinting. 20. Services with respect to diagnosis and treatment of disturbances of the temporomandibular joint (TMJ), unless specifically provided herein (refer to section B., “Other Miscellaneous Services”, above). 21. Charges for general anesthesiaƒIV anesthesia/IV sedation except when administered by a properly licensed dentist in a dental office in conjunction with covered oral surgery procedures or when necessary due to concurrent medical conditions. 22. Services and benefits excluded by the rules and regulations of Delta Dental, including the processing policies. 23. All other benefits and services not specified in this Appendix or any attachment andƒor and/or addendum attached and forming a part of this Appendix.

Benefit Exclusions. The following shall be excluded from the benefits to be provided to Subscribers and eligible Dependents. 1. Benefits or services for injuries or conditions compensable under Worker’s Compensation or Employers’ Liability laws. 2. Benefits or services available from any federal or state government agency; or from any municipality, county, or other political subdivision or community agency; or from any foundation or similar entity. 3. Charges for services or supplies for which no charge is made that the patient is legally obligated to pay or for which no charge would be made in the absence of dental coverage. 4. Benefits for services or appliances started prior to the date the patient became eligible under this Plan may be excluded. 5. Charges for services when a claim is received for payment more than twelve (12) months after services are rendered. 6. Charges for any professional services performed by a relative of the patient. 7. Charges for treatment by other than a properly licensed dentist (unless allowed by state law), except radiographic images (x−rays) ordered by a dentist, cleaning and scaling of teeth, and topical application of fluoride may be performed by a properly licensed hygienist if treatment is rendered under the supervision and guidance of the dentist, in accordance with generally accepted dental standards. 8. Charges for completion of forms or submission of documentation required by DDPOK for a benefit determination. Such charges are not billable to the patient when services are provided by a Delta Dental Participating Dentist. Such charges are denied if submitted by a Nonparticipating Dentist. 9. Charges for house calls, hospital calls, or office visits. 10. Charges for missed or cancelled appointments, hospitalization or additional fees charged for hospital treatment, or management fees. 11. Charges for bleaching of teeth. 12. Prescription drugs, premedications, andƒor and/or relative analgesia. 13. Experimental procedures. 14. Benefits or services for orthodontic treatment, unless specifically provided herein. 15. Charges for repair of an orthodontic appliance. 16. Charges for replacement of lost or missing crowns and appliances, or for stolen appliances. 17. Benefits or services to correct congenital or developmental malformations, for example, cleft palate, etc. 18. Services for the purpose of improving appearance when form and function are satisfactory and there is insufficient pathological condition evident to warrant the treatment (cosmetic dentistry). 19. Restorations for altering occlusion (bite), involving vertical dimensions, replacing tooth structure lost by attrition (grinding of teeth), erosion, abrasion (wear), or for periodontal, orthodontic, or other splinting. 20. Services with respect to diagnosis and treatment of disturbances of the temporomandibular joint (TMJ), unless specifically provided herein (refer to section B., “Other Miscellaneous Services”, above). 21. Charges for general anesthesiaƒIV anesthesia/IV sedation except when administered by a properly licensed dentist in a dental office in conjunction with covered oral surgery procedures or when necessary due to concurrent medical conditions. 22. Services and benefits excluded by the rules and regulations of Delta Dental, including the processing policies. 23. All other benefits and services not specified in this Appendix or any attachment andƒor and/or addendum attached and forming a part of this Appendix.

Benefit Exclusions. The following shall be excluded from the benefits to be provided to Subscribers and eligible Dependents. 1. Benefits or services for injuries or conditions compensable under Worker’s Compensation or Employers’ Liability laws. 2. Benefits or services available from any federal or state government agency; or from any municipality, county, or other political subdivision or community agency; or from any foundation or similar entity. 3. Charges for services or supplies for which no charge is made that the patient is legally obligated to pay or for which no charge would be made in the absence of dental coverage. 4. Benefits for services or appliances started prior to the date the patient became eligible under this Plan may be excluded. 5. Charges for services when a claim is received for payment more than twelve (12) months after services are rendered. 6. Charges for any professional services performed by a relative of the patient. 7. Charges for treatment by other than a properly licensed dentist (unless allowed by state law), except radiographic images (x−raysx-rays) ordered by a dentist, cleaning and scaling of teeth, and topical application of fluoride may be performed by a properly licensed hygienist if treatment is rendered under the supervision and guidance of the dentist, in accordance with generally accepted dental standards. 8. Charges for completion of forms or submission of documentation required by DDPOK for a benefit determination. Such charges are not billable to the patient when services are provided by a Delta Dental Participating Dentist. Such charges are denied if submitted by a Nonparticipating Dentist. 9. Charges for house calls, hospital calls, or office visits. 10. Charges for missed or cancelled appointments, hospitalization or additional fees charged for hospital treatment, or management fees. 11. Charges for bleaching of teeth. 12. Prescription drugs, premedications, andƒor and/or relative analgesia. 13. Experimental procedures. 14. Benefits or services for orthodontic treatment, unless specifically provided herein. 15. Charges for repair of an orthodontic appliance. 16. Charges for replacement of lost or missing crowns and appliances, or for stolen appliances. 17. Benefits or services to correct congenital or developmental malformations, for example, cleft palate, etc. 18. Services for the purpose of improving appearance when form and function are satisfactory and there is insufficient pathological condition evident to warrant the treatment (cosmetic dentistry). 19. Restorations for altering occlusion (bite), involving vertical dimensions, replacing tooth structure lost by attrition (grinding of teeth), erosion, abrasion (wear), or for periodontal, orthodontic, or other splinting. 20. Services with respect to diagnosis and treatment of disturbances of the temporomandibular joint (TMJ), unless specifically provided herein (refer to section B., “Other Miscellaneous Services”, above). 21. Charges for general anesthesiaƒIV anesthesia/IV sedation except when administered by a properly licensed dentist in a dental office in conjunction with covered oral surgery procedures or when necessary due to concurrent medical conditions. 22. Services and benefits excluded by the rules and regulations of Delta Dental, including the processing policies. 23. All other benefits and services not specified in this Appendix or any attachment andƒor and/or addendum attached and forming a part of this Appendix.