Complete Indemnity Individual Dental Insurance

Transcription

1 PrimeStar Complete Indemnity Individual Dental Insurance Washington Protecting your smile starts with that semi-annual trek to the dentist. Research shows that good dental health is essential to your overall health. Keeping your smile sparkling with PrimeStar Complete Indemnity is as easy as Get started today with no enrollment fees! Here s what s covered: PREVENTIVE SERVICES Includes exams and cleanings (2 per year) and fluoride treatments (under age 16) Policy Pays % Calendar Year Deductible.. $50/year* FREEDOM TO USE ANY DENTIST PrimeStar Complete Indemnity gives you the freedom to use any dentist. Your dentist does not need to participate in a preferred provider organization or network. Waiting Period... None coverage begins day one BASIC SERVICES Includes fillings, x-rays and simple extractions Proudly brought to you by: Policy Pays... 80% Calendar Year Deductible.. $50/year* Waiting Period... 6 months MAJOR SERVICES Includes oral surgery, endodontics, periodontics, crowns, bridges and dentures Policy Pays... 50% Calendar Year Deductible.. $50/year* Waiting Period months MAXIMUM BENEFIT AMOUNT Policy Pays... $1,000/year per person * Preventive, Basic and Major calendar year deductible is combined per person, with a maximum of 3 deductibles per family. S Underwritten by Security Life Insurance Company of America Red Circle Drive, Minnetonka MN 55343

2 what s not included... DENTAL LIMITATIONS & EXCLUSIONS The Policy covers services and procedures as described in the Coverage Schedule. Your coverage, under the policy, does not cover any miscellaneous or separate expense not considered a covered service or procedure. No benefits will be paid for expenses incurred: For overdentures and associated procedures; For charges in excess of those considered Reasonable and Customary; For cosmetic procedures; For the replacement of dentures, bridges, inlays, onlays or crowns that can be repaired or restored to normal function; For implants; and for: replacement of lost or stolen appliances; replacement of retainers; athletic mouthguards; precision or semi-precision attachments; denture duplication; space maintainers; or sealants; For oral hygiene instructions; and for: plaque control; completion of a claim form; acid etch; broken appointments; prescription or take-home fluoride; or diagnostic photographs; For initial placement of dentures or fixed bridgework (including acid etch metal bridges), when denture or bridgework includes replacement of a natural tooth extracted or lost; For addition of teeth to existing partial denture; For services not completed by the end of the month in which coverage ends; For procedures that are begun, but not completed; For services and treatment provided without charge, or for which there would be no charge in the absence of insurance; For services in connection with war or any act of war, whether declared or undeclared, or condition contracted or accident occurring while on full-time active duty in the armed forces of any country or combination of countries; For a condition covered under any Worker s Compensation Act or similar law; For the treatment of cleft palate and anodontia; For orthodontia; Prior to the date the Insured is covered under the Policy; For the diagnosis or treatment of TMJ; For hospital services; If You voluntarily end Your insurance, You will not be eligible to re-enroll for a period of 2 years after the date Your coverage first ended. GENERAL INFORMATION Eligibility: Individuals 18+, plus their eligible dependents. This is subject to individual state regulations. Predetermination of Benefits: It is recommended that a treatment plan/ course of treatment be submitted when the total cost of eligible expenses for any insured is expected to exceed the amount shown on the coverage schedule. This should be submitted to us before the work is started. If actual services submitted do not agree with the treatment plan, or if a treatment plan is not sent in, we will base our payment on treatment consistent with reasonable and customary charges. Predetermination of benefits is not a guarantee of what we will pay. The estimated benefit payment is based on your current eligibility and benefits in effect at the time of the completed service. Submission of other claims or changes in eligibility or this policy may alter final payment. Alternate Benefit: If we determine that a less expensive procedure, service, or treatment plan/course of treatment that is customarily used to treat the dental problem and recognized by the dental profession to be appropriate according to broadly accepted standards of dental practice, then the maximum we will allow will be the charge for the less expensive treatment. Reasonable & Customary: The usual, customary and regular charges for the area where such expenses are incurred. The following are not covered or available as an alternative benefit: Telephone consultations, charges for failure to keep a scheduled appointment, x-ray copy fees, or charges for completion of a claim form. Ancillary charges, including but not limited to, hospital, ambulatory surgical center or similar facility; or use of provider office space. Charges for sterilization of equipment; disposal of medical waste or other requirements mandated by OSHA or other regulatory agencies. Cost for Dental Services: Your cost for covered dental services is dependent on multiple factors: what the dentist charges, the policy coinsurance amount, the Reasonable and Customary charge, any required deductible and the amount remaining on your Maximum Benefit Amount for the year. This provides a very brief description of some of the important features of the insurance policy. It is not the insurance policy and does not represent it. A full explanation of benefits, exceptions and limitations is contained in Individual Dental Policy Form IP1001-WA2. Premium rates may change upon renewal. This policy is renewable at the option of the insured. This product is subject to individual state regulations. SecurityLife.com

3 Washington rates effective April 1, 2014 Follow the steps below to find your PrimeStar Complete Indemnity monthly policy rate: Find your Area by locating the first 3 digits of your zip code State Zip Area MY AREA # 980, Washington , All Others 4 Find your dental rate by your Age and Area Under Age 65 Area: Area 3 Area 4 Area 5 Area 7 Applicant $44.34 $48.73 $53.60 $64.81 Applicant + Spouse* $88.68 $97.45 $ $ Applicant + Child(ren) $92.06 $ $ $ DENTAL RATE Applicant + Family $ $ $ $ Age 65 and above Area: Area 3 Area 4 Area 5 Area 7 Applicant $48.78 $53.60 $58.96 $71.29 Applicant + Spouse* $97.55 $ $ $ Applicant + Child(ren) $ $ $ $ Applicant + Family $ $ $ $ The monthly premium is guaranteed for the initial 12 months of coverage. After 12 months, premiums may increase. *Or state registered Domestic Partner.

4 Security Life Insurance Company of America Red Circle Drive Minnetonka, Minnesota PrimeStar Individual Application Plan Selection: Complete Complete Plus Essential I apply for coverage on: Applicant Only Applicant + Spouse/State Registered Domestic Partner Applicant + Child(ren) Applicant + Family I choose to pay my premium: Monthly Quarterly Semi-Annually Annually Applicant Information (please print clearly) Last Name First Name Middle Initial Date of Birth (MM/DD/YYYY) Address Telephone Number Sex: M F City State Zip Marital Status Married Single Billing Address (If Different) City State Zip State Registered Domestic Partner List All Your Eligible Dependents and Covered Children Under Age 26 Below Last Name (If Different) First Name Initial Sex M/F Age Birth Date Spouse/State Registered Domestic Partner Dependent/Child under age 26 Dependent/Child under age 26 Dependent/Child under age 26 Dependent/Child under age 26 Does Spouse/State Registered Domestic Partner have a dental plan: Yes No With whom? If answer is Yes, are dependents enrolled under Spouse s/state Registered Domestic Partner s plan? Yes No Important Fraud Notice It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits. Important Information Effective Date: The effective date is the first of the month following the day in which the application is received in Our Office. Identification Card and Policy: Upon receipt of your completed application you will receive a copy of your Insurance Policy and Identification Card(s). Do not cancel any other dental coverage you may have until you receive written confirmation from Security Life. Please allow 3-4 weeks for processing. By my signature below, I hereby apply for the above indicated coverage insured by Security Life Insurance Company of America. I also certify I have read the applicable Fraud Notice above. Applicant Signature Date APP-01-WA

5 PREMIUM RATE CALCULATION AND AUTHORIZATION AGREEMENT The following sections must be completed and signed by the applicant and agent CALCULATE YOUR RATES: 1. Locate the first three digits of your zip code on the Zip Code Area Chart found on the Premium Rate Table. Using the corresponding area number, determine the applicable monthly premium, based upon your eligibility age, plan selection and coverage type. 2. Select your mode of payment Monthly Bank Account Debit (ACH) (Checking or Savings) Complete Authorization Agreement below and submit two (2) months premium Checking Acct. - Attach voided check - DO NOT SUBMIT DEPOSIT SLIP. Savings Acct. - Attach savings deposit slip with account number including the bank routing number. Monthly Credit Card - Complete Authorization Agreement below. Visa Master Card Discover Card # CVC(back of card) Expiration Date / / Quarterly Direct Bill submit three (3) months premium Semi-Annual Bill submit six (6) months premium Authorization To Convert Your Check To An Electronic Funds Transfer Debit By sending your check to us, you authorize Security Life Insurance Company of America to convert the check into an electronic funds transfer. Please be aware that your bank account may be debited as soon as the same day we receive your payment. Multiply by 2,3 Fill in the Monthly Rate (found Vision Add-on or 6 depending applicable on the Premium Rate (found on the Sub Total: upon mode of Total information to Table) Premium Rate payment Remittance the left Table) selected above $ $ $ X $ For Initial payment, make check payable to Security Life Insurance Company of America AUTHORIZATION AGREEMENT: (When paying by ACH or Credit Card please complete the section below) I authorize Security Life Insurance Company of America to initiate electronic debit entries to my account chosen above for payment of my insurance premium. My account will be debited by the third business day of the month in which premium is due. I understand I will receive a notice if the amount changes. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of the US law. I understand that in order to make changes to this authorization (such as a change in bank account, method of payment, or termination of payment) I need to give Security Life written notification at least 10 days prior to the next scheduled payment. I understand that the insurance plan may be cancelled by Security Life if any payment is dishonored by my bank for any reason. In the case of an NSF, I am liable for any fees my bank may charge me and may also be responsible for an NSF fee of up to $25 which may be automatically debited for each NSF. Account Holder s Name Date Account Holder s Signature FOR AGENT USE ONLY Please Print Clearly Producer Name Producer Phone # Street Address City St Zip Producer Producer SS#/TIN# Appointed with Security Life? Yes No Producer Signature For your convenience, see below for enrollment options. FAX - the application to MAIL - the application long with initial payment to: (You must choose Credit Card or ACH Security Life payment options) P.O. Box Lancaster, PA FOR COMPANY USE ONLY Effective Date: / / Plan Code: WA ACH

6 Security Life Insurance Company of America Red Circle Drive Minnetonka, Minnesota IF THIS IS A REPLACEMENT leave the top half of this form with the Applicant and send the signed bottom half of this form with the Application NOTICE TO APPLICANT REGARDING REPLACEMENT OF DENTAL INSURANCE According to information you have furnished, you intend to lapse or otherwise terminate existing dental insurance and replace it with a policy to be issued by Security Life Insurance Company of America. For your own information and protection, you should be aware of and seriously consider certain factors that may affect the insurance protection available to you under the new policy. Even though some of your present health conditions may be covered under the new policy, these conditions may be subject to certain waiting periods under the new policy before coverage is effective. You may wish to secure the advice of your present insurer or its agent regarding the proposed replacement of your present policy. This is not only your right, but it is also in your best interests to make sure you understand all the relevant factors involved in replacing your present coverage. If, after due consideration, you still wish to terminate your present policy and replace it with new coverage, be certain to truthfully and completely answer all questions on the application. After the application has been completed and before you sign it, reread it carefully to be certain that all information has been properly recorded. Do not cancel your present policy until you have actually received your new policy and are sure you want to keep it. NOTICE TO APPLICANT REGARDING REPLACEMENT OF DENTAL INSURANCE According to information you have furnished, you intend to lapse or otherwise terminate existing dental insurance and replace it with a policy to be issued by Security Life Insurance Company of America. For your own information and protection, you should be aware of and seriously consider certain factors that may affect the insurance protection available to you under the new policy. Even though some of your present health conditions may be covered under the new policy, these conditions may be subject to certain waiting periods under the new policy before coverage is effective. You may wish to secure the advice of your present insurer or its agent regarding the proposed replacement of your present policy. This is not only your right, but it is also in your best interests to make sure you understand all the relevant factors involved in replacing your present coverage. If, after due consideration, you still wish to terminate your present policy and replace it with new coverage, be certain to truthfully and completely answer all questions on the application. After the application has been completed and before you sign it, reread it carefully to be certain that all information has been properly recorded. Do not cancel your present policy until you have actually received your new policy and are sure you want to keep it. The above "Notice to Applicant" was delivered to me on: (Date) (Applicant's Signature) REP1000-APP

7 Security Life Insurance Company of America Red Circle Drive Minnetonka, MN OUTLINE OF COVERAGE (1) READ YOUR POLICY CAREFULLY This outline of coverage provides a very brief description of the important features of your policy. This is not the insurance policy and only the actual policy provisions will control. The policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is, therefore, important that you READ YOUR POLICY CAREFULLY! (2) DENTAL COVERAGE This policy is designed to provide coverage for certain dental services. Policies of this category are designed to provide, to persons insured, limited coverage. (3) BENEFITS We will provide benefits subject to the limitations and exclusions described here and more specifically in the policy. DENTAL Class A. Class B. Class C. Preventative Services two routine exams (including any initial exam) of the mouth and teeth per year; two prophylaxis per year; one topical fluoride per year, to age 16. Deductible, each calendar year $50* We pay, after Deductible 100% Waiting Period None Basic Services one series of bitewing per year; full mouth or panoramic x-rays once every three years, periapical x-rays as necessary; extractions, routine removal; fillings of amalgram, silicate, acrylic, synthetic porcelain and composite filling materials; pin retention of fillings; antibiotic injections by a Dentist/Denturist/Physician. Please see your Policy and Coverage Schedule for specific details on benefits. Deductible, each calendar year $50* We pay, after Deductible 80% Waiting Period 6 Months Major Services endodontic treatment of disease of the tooth, pulp, root and related tissue; periodontic services; one study model in a 3 year period; crown build-up for nonvital teeth; recementing inlays, onlays and crowns; recementing bridges; one repair of dentures or bridges in any 2 year period limited to 20% of cost of replacement; general anesthesia, including intravenous sedation; restoration services; prosthetic services; oral surgery. Please see your Policy and Coverage Schedule for specific details on benefits. Deductible, each calendar year $50* We pay, after Deductible 50% Waiting Period 12 Months *Class A, B, and C Deductible is a combined $50 each calendar year. A maximum of three (3) individual deductibles per family shall apply. Maximum Benefit Amount: Combined per calendar year for Classes A, B, and C $1,000 OC1000-WA2 Waiting Period Plan 2

8 (4) EXCEPTIONS, REDUCTIONS, AND LIMITATIONS OF THIS POLICY Your Policy contains specific details of procedures covered and any frequency of other limitations on specific procedures. Certain Covered Expenses may be subject to the Waiting Period (an Elimination Period). Please refer to your Policy for details. DENTAL: No benefits will be paid for expenses incurred: 1. For overdentures and associated procedures; 2. For charges in excess of those considered Reasonable and Customary; 3. For cosmetic procedures; 4. For the replacement of dentures, bridges, inlays, onlays or crowns that can be repaired or restored to normal function; 5. For implants; and for: a. replacement of lost or stolen appliances; b. replacement of retainers; c. athletic mouthguards; d. precision or semi-precision attachments; e. denture duplication; f. space maintainers; or f. sealants; 6. For oral hygiene instructions; and for: a. plaque control; b. completion of a claim form; c. acid etch; d. broken appointments; e. prescription or take-home fluoride; or f. diagnostic photographs; 7. For initial placement of dentures or fixed bridgework (including acid etch metal bridges), when denture or bridgework includes replacement of a natural tooth extracted or lost; 8. For addition of teeth to existing partial denture; 9. For services not completed by the end of the month in which coverage ends; 10. For procedures that are begun, but not completed; 11. For services and treatment provided without charge, or for which there would be no charge in the absence of insurance; 12. For services in connection with war or any act of war, whether declared or undeclared, or condition contracted or accident occurring while on full-time active duty in the armed forces of any country or combination of countries; 13. For a condition covered under any Worker's Compensation Act or similar law; 14. For the treatment of cleft palate and anodontia; 15. For orthodontia; 16. Prior to the date the Insured is covered under the Policy; 17. For the diagnosis or treatment of TMJ; 18. For hospital services; 19. If You voluntarily end Your insurance, You will not be eligible to re-enroll for a period of 2 years after the date Your coverage first ended. ALTERNATE BENEFIT: If: 1) We determine that a less expensive alternate procedure, service or Course of Treatment can be performed in place of the proposed treatment to correct a dental condition; and 2) the alternative treatment will produce a professionally satisfactory result; then the maximum We will allow will be the charge for the less expensive treatment. Certain expenses are not covered. For instance, this Policy does not provide benefits for lost or stolen appliances or cosmetic procedures. It also does not cover hospitalization or prescription drugs. This is not a complete list of exclusions. A full list is in your Policy. OC1000-WA2 Waiting Period Plan 2

9 REASONABLE AND CUSTOMARY FEES: A. A Reasonable fee is the amount which an individual dentist/physician/denturist regularly charges and receives for a given service or the fee actually charged, whichever is less. B. A Customary fee is within the range of reasonable fees charged and received for a particular service by dentists/physicians/denturists of similar training in the same geographic area based on your zip code. C. This Policy utilizes the 80 th percentile of Reasonable & Customary for all benefits. (5) RENEWABILITY This policy is renewable at Your option unless: 1. Your Premium is not received before the Grace Period ends; 2. We refuse to renew all Policies of this form in Your state of residence; or 3. Subject to the Coverage Ends provisions provided in this policy. No refusal of renewal will affect an existing claim. We will give written notice to the Policyholder at least 45 days in advance of any premium change. Subject to applicable laws and regulations, we reserve the right to increase premiums on renewal, in which case we will give written notice. RETAIN FOR YOUR RECORDS. THIS OUTLINE OF COVERAGE IS ONLY A BRIEF SUMMARY OF YOUR POLICY. THE POLICY ITSELF SHOULD BE CONSULTED TO DETERMINE GOVERNING CONTRACTUAL PROVISIONS. OC1000-WA2 Waiting Period Plan 2