Plan 3000 - Dental Alternatives Insurance Services Inc

2. You have Signed the application or enrollment form; and
3. a copy of the application or enrollment form has been given to You or Your Beneficiary.
Misstatement of Age
If Your or Your dependent’s age is misstated, the correct age will be used to determine eligibility for dental
benefits and, as appropriate, We will adjust the benefits and/or premiums.
Conformity with Law
If the terms and provisions of this evidence of coverage do not conform to any applicable law, this
evidence of coverage shall be interpreted to so conform.
Public Policy Committee
The Public Policy Committee (“Committee”) provides Our clients with the opportunity to participate in the
review of quality improvement activities. Representatives of group contractholders, Selected General
Dentists and Specialty Care Dentists, and Our employees, meet quarterly to discuss quality improvement
activities and policies. If You are interested in being a representative to the Committee meeting, please
contact Us at (800) 880-1800 and ask for the Director of Quality Management.
DEFINITIONS
As used in this evidence of coverage, the terms listed below will have the meanings set forth below.
When defined terms are used in this evidence of coverage, they will appear with initial capitalization. The
plural use of a term defined in the singular will share the same meaning.
Amalgam means a silver filling material usually used on posterior teeth.
Anterior means teeth located in the front of the mouth – upper and lower six (6) teeth with three in each
Quadrant of the mouth; twelve (12) teeth in total.
Asymptomatic means without symptoms, the absence of any indication of disease, surrounding
pathology or impaired function.
Bicuspid means teeth located immediately in front of the molar teeth – upper and lower with two in each
Quadrant of the mouth; eight (8) teeth in total.
Bridge or Bridgework means a fixed replacement for one or more missing teeth that is permanently
attached to the teeth adjacent to the empty space(s).
Cast Restoration means an inlay, onlay, or crown.
Co-Payment or Co-Pay means a fixed dollar amount or a fixed percentage of the Maximum Allowed
Charge of the Covered Services performed by Your Selected General Dentist, for which We are not
responsible, as shown in the Schedule of Benefits. You must pay Your Co-Payment at the time of delivery
of supplies or services.
Cosmetic means services performed solely for appearance. Treatment of decay, disease or injury to the
teeth or supporting tissues of the teeth that is not evident. Cosmetic means any procedure which is
directed at improving the patient’s appearance and does not meaningfully promote the proper function or
prevent or treat illness or disease.
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