Kentucky disclosures

OUR RIGHT TO CHANGE PREMIUMS

We have the right to change the premium we charge. However, we cannot single anyone out for a rate change. If we make a change, it will be made on all policies of this kind in force in the state where the policy was issued. If we plan to make a change, we will send a notice at least 31 days before we make it. We will not change premiums more than once in a 12-month period.

GUARANTEED RENEWABLE TO AGE 75

This policy is guaranteed renewable to policy anniversary date on or next following the name insured’s 75th birthday as long as you pay the premiums when they are due or within the grace period, except that we may discontinue or terminate the policy if you have performed an ad or practice that constitutes fraud or have made an intentional misrepresentation of material fact relating in any way to the policy, including claims for benefits under this policy. Your premium can be changed only if we change it on all policies of this kind in force in the state where the policy was issued.

REFUND UPON CANCELLATION

You may cancel this policy at any time by written notice delivered or mailed to us or our agent. The cancellation will become effective upon receipt by us or our agent or on the date you specify in your notice. If you cancel, we will promptly return any unearned portion of the premium within 30 days. The unearned premium will be computed on a pro-rata basis. Cancellation will be without prejudice to any claim originating prior to the effective date of the cancellation.

TERMINATION

Your coverage will terminate on the earliest of the following dates:

• the date we receive a request in writing to terminate this policy;
• the last day through which premium was paid;
• the policy anniversary date on or next following the named insured’s 75th birthday; or
• the date this policy lapses for nonpayment of premium per the grace period provision in the your premium payments section.

Coverage terminating at the policy anniversary date on or next following your 75th birthday will not affect any existing claim submitted while the coverage was in force.

EXCLUSIONS

• No benefits are payable under this policy for the procedures and services listed below unless such procedure or service is listed as covered in the Schedule of Covered Dental Procedures. In addition, the procedures listed below will not be recognized toward satisfaction of any policy year deductible.
• Any procedure or service not shown on the Schedule of Covered Dental Procedures.
• Amounts in excess of the policy year maximum benefit.
• Any procedure we determine which is not necessary, does not offer a favorable prognosis or does not have uniform professional endorsement or which is experimental in nature.
• Any injury or illness when covered under worker’s compensation or similar law.
• Any procedure or appliance installed before a covered person’s effective date, including started but not completed services.
• Any procedure begun after an covered person’s insurance under the policy terminates, or for any prosthetic dental appliance finally installed or delivered after an covered person’s insurance under the policy terminates.
• Charges for dental services performed by anyone other than a licensed dentist or dental hygienist.
• Services that are not recommended by a dentist or that are not required for the preservation or restoration of oral health.
• Repairs or adjustments to dental work within six months of the initial work.
• Replacement of full or partial dentures unless the prosthetic appliance is older than the age allowed in the Schedule of Covered Dental Procedures and cannot be made serviceable.
• Replacement of implants, crowns, inlays or onlays unless the prior restoration is older than the age allowed in the Schedule of Covered Dental Procedures and cannot be made serviceable.
• Any treatment which is elective or primarily cosmetic in nature and not generally recognized as a generally accepted dental practice by the American Dental Association, as well as any replacement of prior cosmetic restorations.
• Service or appliance rendered by someone who is related to a covered person by blood or by law (e.g., sibling, parent, grandparent, child), marriage (e.g., spouse or in-law) or adoption or is normally a member of the covered person’s household.
• The correction of congenital malformations or congenital missing teeth.
• The replacement of lost or discarded or stolen appliances.
• Replacement of bridges unless the bridge is older than the age allowed in the Schedule of Covered Dental Procedures and cannot be made serviceable.
• Appliances, services or procedures relating to: (a) the change or maintenance of vertical dimension; (b) restoration of occlusion (unless otherwise noted in the Schedule of Covered Dental Procedures-only for occlusal guards); (c) splinting; (d) correction of attrition, abrasion, erosion or abfraction; (e) bite registration; (f) bite analysis or (g) bruxism.
• Services provided for any type of temporomandibular joint (TMJ) dysfunctions, muscular, skeletal deficiencies involving TMJ or related structures, myofascial pain.
• Orthognathic surgery.
• Prescribed medications, premedication or analgesia.
• Any instruction for diet, plaque control and oral hygiene.
• Charges for: implants of any type (except those implants specified in the Schedule of Covered Dental Procedures), and all related procedures, removal of implants, precision or semi-precision attachments, denture duplication, overdentures and any associated surgery, or other customized services or attachments.
• Cast restorations, inlays, onlays and crowns for teeth that are not broken down by extensive decay or accidental injury or for teeth that can be restored by other means (such as an amalgam or composite filling).
• For treatment of malignancies, cysts and neoplasms.
• For orthodontic treatment except those services or treatments provided in the Schedule of Covered Dental Procedures.
• Charges for failure to keep a scheduled visit or for the completion of any claim forms.
• Expenses provided or paid for by any governmental program or law, except as to charges which the person is legally obligated to pay or as addressed later under the “Payment of Claims” provision.
• Procedures started but not completed.
• Any duplicate device or appliance.
• General anesthesia and intravenous sedation except in conjunction with covered complex oral surgery procedures as defined by us, plus the services of anesthetists or anesthesiologists.
• The replacement of 3rd molars.
• Crowns, inlays and onlays used to restore teeth with micro fractures or fracture lines, undermined cusps or existing large restorations without overt pathology.

No benefits will be paid for replacement of teeth missing prior to the effective date of coverage.

No benefits will be paid for the initial placement of removable full or partial dentures, unless it includes the replacement of a functioning natural tooth extracted while the covered person is insured under this policy.

No benefits will be paid for the initial placement of a fixed partial denture including a Maryland Bridge, unless it includes the replacement of a functioning natural tooth extracted while the covered person is insured under this policy.

Other limitations: Multiple restorations on one surface are payable as one surface. Multiple surfaces on a single tooth will not be paid as separate restorations. Coverage is limited to two prophylaxis and/or two periodontal maintenance procedures, subject to a maximum total of no more than two (2) procedures per twelve (12) month period. Coverage is limited to one (1) full mouth radiograph or panoramic film per limitation period listed in the Schedule of Covered Dental Procedures. On any given day, more than seven (7) periapical x-rays or a panoramic film in conjunction with bitewings will be paid as a full mouth radiograph. Additional limitations are noted in the Schedule of Covered Dental Procedures.

Federal, state or local taxes are not included as part of a covered dental expense.

See the Schedule of Covered Dental Procedures for all specific procedure limitations.

ALTERNATE BENEFIT PROVISION

Many dental problems can be resolved in more than one way. If:

• we determine that a less expensive alternative benefit could be provided for the resolution of a dental problem; and
• that benefit would produce the same resolution of the diagnosed problem within professionally acceptable limits, we may use the less expensive alternative benefit to determine the amount payable under the policy.

For example: When an amalgam filling and a composite filling are both professionally acceptable methods for filling a molar, we may base our benefit on the amalgam filling which is the less expensive alternative benefit. This is the case whether a participating provider or non-participating provider performs the service.

OUR RIGHT TO CHANGE PREMIUMS

We have the right to change the premium we charge. However, we cannot single anyone out for a rate change. If we make a change, it will be made on all policies of this kind in force in the state where the policy was issued. If we plan to make a change, we will send a notice at least 31 days before we make it. We will not change premiums more than once in a 12-month period.

GUARANTEED RENEWABLE

This policy is guaranteed renewable as long as you pay the premiums when they are due or within the grace period. Your premium can be changed only if we change it on all policies of this kind in force in the state where the policy was issued.

REFUND UPON CANCELLATION

You may cancel this policy at any time by written notice delivered or mailed to us or our agent. The cancellation will become effective upon receipt by us or our agent or on the date you specify in your notice. If you cancel, we will promptly return any unearned portion of the premium within 30 days. The unearned premium will be computed on a pro-rata basis. Cancellation will be without prejudice to any claim originating prior to the effective date of the cancellation.

NOTICE OF CANCELLATION

If we cancel this policy for nonpayment of premium, we must give you at least 30 days written notice of cancellation.

WHAT IS NOT COVERED BY THIS POLICY

Coding convention errors, misrepresentations or upcoding
A dentist or dental practice’s failure to comply with the current American Dental Association coding convention, including but not limited to upcoding, the overutilization of certain codes, and/or the misrepresentation of services, such as unbundling.

Crown replacement
Services to treat crowns for a given tooth within five years of last placement, regardless of the type of crown.

Inlay or onlay replacement
Services to replace inlays or onlays for a given tooth within five years of last placement.

Procedures prior to the effective date
Procedures performed prior to the policy coverage effective date.

Procedures prior to the expiration of the waiting period
Procedures performed prior to expiration of the waiting period, if any, for the specified benefit.

Prosthetic replacement
Services to replace prosthetics within five years of last placement.

Repairs
Repairs to dental work within six months of the initial procedure.

Sealant limitation
Benefits for sealants are limited to secondary molars for dependent children under age 16 and will not be payable more often than every five years.

Teeth missing before the policy coverage effective date
No benefits will be paid for replacement of teeth that were missing before the policy coverage effective date.

Treatment outside of the United States
Treatment received outside of the United States or its territories.

Unlisted procedures
Procedures not listed on the Policy Schedule or Policy Schedule Addendum, unless the code has been revised or replaced by the American Dental Association.

Unrecommended or unrequired services
Services not recommended by a dentist, or services not required for the preservation or restoration of oral health