PLAN EXCLUSIONS AND LIMITATIONS
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Services performed solely for cosmetic reasons;
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Replacement of a lost or stolen appliance;
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Replacement of a bridge, crown or denture within
5 years after the date it was originally installed
unless: (a) the replacement is made necessary by
the placement of an original opposing full denture
or the necessary extraction of natural teeth; or (b)
the bridge, crown or denture, while in the mouth,
has been damaged beyond repair as a result of an
injury received while a person is insured for these
benefits;
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Any replacement of a bridge, crown or denture
which is or can be made usable according to
common dental standards;
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Procedures, appliances or restorations
(except full dentures) whose main purpose
is to: (a) change vertical dimension; (b)
diagnose or treat conditions or dysfunction
of the temporomandibular joint; (c) stabilize
periodontally involved teeth; or (d) restore
occlusion;
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Porcelain or acrylic veneers of crowns or pontics
on, or replacing, the upper and lower first, second
and third molars;
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Bite registrations, precision or semiprecision
attachments, or splinting;
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Instruction for plaque control, oral hygiene and
diet;
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Dental services that do not meet common dental
standards;
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Services that are deemed to be medical services;
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Services and supplies received from a hospital;
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Orthodontic treatment;
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The surgical placement of an implant body or
framework of any type; surgical procedures in
anticipation of implant placement; any device,
index or surgical template guide used for implant
surgery; treatment or repair of an existing implant;
prefabricated or custom implant abutments;
removal of an existing implant;
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Services for which benefits are not payable
according to the “General Limitations” section.
General Limitations
No payment will be made for expenses incurred for
you or any one of your dependents:
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For services not specifically listed as covered
services in the policy.
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For services or supplies that are not
dentally necessary.
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For services received before the start date
of coverage.
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For services received after coverage under this
policy ends.
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For services for which you have no legal
obligation to pay or for which no charge
would be made if you did not have dental
insurance coverage.
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For professional services or supplies received or
purchased directly or on your behalf by anyone,
including a dentist, from any of the following.
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Yourself or your employer.
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A person who lives in the insured person’s
home or that person’s employer.
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A person who is related to the insured person
by blood, marriage or adoption or that
person’s employer.
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For or in connection with an injury arising out of,
or in the course of, any employment for wage
or profit.
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For or in connection with a sickness which is
covered under any workers’ compensation or
similar law.
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For charges made by a hospital owned or
operated by or which provides care or performs
services for the United States government, if such
charges are directly related to a military-service-
connected condition.
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Services or supplies received as a result of dental
disease, defect or injury due to an act of war,
declared or undeclared.
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To the extent that payment is unlawful where the
person resides when the expenses are incurred.
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For charges which the person is not legally
required to pay.
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For charges which would not have been made if
the person had no insurance.
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To the extent that billed charges exceed the rate of
reimbursement as described in the schedule.
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For charges for unnecessary care, treatment
or surgery.
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To the extent that you or any of your dependents
are in any way paid or entitled to payment for
those expenses by or through a public program,
other than Medicaid.
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For or in connection with experimental procedures
or treatment methods not approved by the
American Dental Association or the appropriate
dental specialty society.
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To the extent that benefits are paid or payable for
those expenses under the mandatory part of any
auto insurance policy written to comply with a
“no-fault” insurance law or an uninsured motorist
insurance law. Cigna will take into account any
adjustment option chosen under such part by you
or any one of your dependents.
What is not covered by this plan
Excluded services
Covered expenses do not include expenses incurred for
amily PlansIndividual and F
Insured by Cigna Health and Life Insurance Company