Dental Cover Benefits and exclusions

Transcription

1 Dental Cover Benefits and exclusions This document contains all of the benefits and exclusions for Dental Cover from PruHealth. To help make it easier to understand, we ve also included the Definitions section. We have tried to make sure this document is as clear and straightforward as possible by writing the terms in plain English. There are however certain words that have special meaning that we d like to draw to your attention: We/us/our means PruHealth You/your means the insured member and insured dependants. Where the words you or your refer specifically to the insured member, we ll say you (the insured member) We have printed the remaining defined words in bold to help you identify them as you read through this document. You ll find a full explanation of each word in the Definitions section. PruHealth 1

2 Level 1 Level 2 Level 3 Dental Cover Level 1 In this section we ve set out the rules on paying benefits under Dental Cover Level 1 and the specific exclusions that apply to each benefit. Other exclusions applying to the dental cover are contained within the What s not covered section. All benefits are per insured person unless stated otherwise. Important notes To be eligible for this benefit, you must have undergone a check-up with your regular dental practitioner and have completed all dental treatment recommended in the 12 months before your cover start date. If you have not seen your dental practitioner in the 12 months before your cover start date, then eligibility for this benefit will only begin after you have undergone a check-up by a dental practitioner and completed all dental treatment recommended. This requirement does not apply for routine examinations and routine scaling and polishing. Treatment new and replacement crowns new and replacement bridges or implants root canal treatment apicectomy/excision of the root of a tooth extractions new, partial or repairs to dentures If the dental treatment required is as a result of an accident or injury this is covered under the Accidental dental section. up to 300 per up to 200 per up to 150 per up to 100 per up to 150 per up to 250 per for routine, precautionary or preventive examinations for dental check-ups 2 PruHealth

3 Accidental dental The charges made by a dental practitioner or specialist for an accidental dental injury damage to dentures whilst being worn prescription charges The accidental dental injury sustained must be immediately followed by an emergency dental appointment or the insured person must seek treatment via an A & E department. up to 2,500 per claim with a maximum of 4 claims per For dental treatment required for any injury caused while engaging in professional sports any injury, caused other than as a direct result of an accident repair or replacement of crowns, bridges or dentures unless damaged as a direct result of an accidental dental injury Additional exclusions apply to Accidental dental please see the section What s not covered. Emergency call-out fees the cost of an emergency call-out Dental treatment must be deemed necessary for the dental practitioner to re-open the practice between the hours of 2100 and 0800 on weekdays, weekends or bank holidays when the practice would otherwise be closed. up to 50 per call-out with a maximum of 2 claims per PruHealth 3

4 Level 1 Level 2 Level 3 Dental Cover Level 2 In this section we ve set out the rules on paying benefits under Dental Cover Level 2 and the specific exclusions that apply to each benefit. Other exclusions applying to the dental cover are contained within the What s not covered section. All benefits are per insured person unless stated otherwise. Important notes To be eligible for this benefit, you must have undergone a check-up with your regular dental practitioner and have completed all dental treatment recommended in the 12 months before your cover start date. If you have not seen your dental practitioner in the 12 months before your cover start date, then eligibility for this benefit will only begin after you have undergone a check-up by a dental practitioner and completed all dental treatment recommended. This requirement does not apply for routine examinations and routine scaling and polishing. Maintenance routine examinations up to 15 per claim with per for dental treatment which is classed as accidental or for emergency dental treatment routine scaling and polishing provided by a registered dental practitioner or hygienist up to 25 per claim with per radiograph of teeth or jaws which must be medically necessary up to 15 per claim with per Treatment fillings new and replacement crowns new and replacement inlays, onlays and overlays new and replacement bridges or implants root canal treatment apicectomy/excision of the root of a tooth extractions new, partial or repairs to dentures If the dental treatment required is as a result of an accident or injury this is covered under the Accidental dental section. up to 20 per claim with per up to 300 per up to 50 per up to 200 per up to 150 per up to 100 per up to 150 per up to 250 per 4 PruHealth

5 Accidental dental The charges made by a dental practitioner or specialist for an accidental dental injury damage to dentures whilst being worn prescription charges The accidental dental injury sustained must be immediately followed by an emergency dental appointment or the insured person must seek treatment via an A & E department. up to 2,500 per claim with a maximum of 4 claims per For dental treatment required for any injury caused while engaging in professional sports any injury, caused other than as a direct result of an accident repair or replacement of crowns, bridges or dentures unless damaged as a direct result of an accidental dental injury Additional exclusions apply to Accidental dental please see the section What s not covered. Emergency dental immediate relief of severe pain, haemorrhage and/or infection The insured member or insured dependant must have been treated in an emergency dental appointment with a dental practitioner. up to 200 per claim with a maximum of 2 claims per any subsequent dental treatment following the initial emergency appointment, except where this is included under another part of the dental cover Emergency call-out fees the cost of an emergency call-out Dental treatment must be deemed necessary for the dental practitioner to re-open the practice between the hours of 2100 and 0800 on weekdays, weekends or bank holidays when the practice would otherwise be closed. up to 50 per call-out with a maximum of 2 claims per PruHealth 5

6 Level 1 Level 2 Level 3 Dental Cover Level 3 In this section we ve set out the rules on paying benefits under Dental Cover Level 3 and the specific exclusions that apply to each benefit. Other exclusions applying to the dental cover are contained within the What s not covered section. All benefits are per insured person unless stated otherwise. Important notes To be eligible for this benefit, you must have undergone a check-up with your regular dental practitioner and have completed all dental treatment recommended in the 12 months before your cover start date. If you have not seen your dental practitioner in the 12 months before your cover start date, then eligibility for this benefit will only begin after you have undergone a check-up by a dental practitioner and completed all dental treatment recommended. This requirement does not apply for routine examinations and routine scaling and polishing. Maintenance routine examinations up to 30 per claim with per for dental treatment which is classed as accidental or for emergency dental treatment routine scaling and polishing provided by a registered dental practitioner or hygienist up to 40 per claim with per radiograph of teeth or jaws which must be medically necessary up to 40 per claim with per Treatment fillings new and replacement crowns new and replacement inlays, onlays and overlays new and replacement bridges or implants root canal treatment apicectomy/excision of the root of a tooth extractions new, partial or repairs to dentures If the dental treatment required is as a result of an accident or injury this is covered under the Accidental dental section. up to 40 per claim with per up to 400 per up to 100 per up to 300 per up to 250 per up to 150 per up to 250 per up to 350 per 6 PruHealth

7 Accidental dental The charges made by a dental practitioner or specialist for an accidental dental injury damage to dentures whilst being worn prescription charges The accidental dental injury sustained must be immediately followed by an emergency dental appointment or the insured person must seek treatment via an A & E department. up to 2,500 per claim with a maximum of 4 claims per For dental treatment required for any injury caused while engaging in professional sports any injury, caused other than as a direct result of an accident repair or replacement of crowns, bridges or dentures unless damaged as a direct result of an accidental dental injury Additional exclusions apply to Accidental dental please see the section What s not covered. Emergency dental immediate relief of severe pain, haemorrhage and/or infection The insured member or insured dependant must have been treated in an emergency dental appointment with a dental practitioner. up to 300 per claim with a maximum of 2 claims per any subsequent dental treatment following the initial emergency appointment, except where this is included under another part of the dental cover Emergency call-out fees the cost of an emergency call-out Dental treatment must be deemed necessary for the dental practitioner to re-open the practice between the hours of 2100 and 0800 on weekdays, weekends or bank holidays when the practice would otherwise be closed. up to 50 per call-out with a maximum of 2 claims per PruHealth 7

8 What s not covered These are the exclusions that apply to all levels of Dental Cover. We will not pay claims arising from: any dental treatment that s planned or already taking place at your cover start date or which has been recommended in the 12 months immediately before your cover start date. This does not include routine examinations or routine scaling and polishing cosmetic dental treatment such as bleaching, teeth whitening, orthodontic or periodontal treatment and procedures related to such treatment mouth guards, gum shields or dental appliances of any kind any injury caused while engaging in contact sports unless the appropriate mouth guard was worn wisdom teeth extraction other than those extracted by your dental surgery loss of, or damage to, dentures other than whilst being worn any treatment or care in relation to tooth jewellery any treatment charges related to non-invasive tumours any treatment charges related to oral cancer any prescription charges unless related to an accident and emergency any treatment under the care of a specialist unless the treatment is the result of an accidental dental injury Accidental dental We will not pay claims arising from: any damage to dentures when not being worn any injury caused by eating and drinking normal wear and tear any treatment relating to injury which is received more than 12 months after the incident giving rise to a claim General exclusions In addition to the specific exclusions detailed, the following general exclusions apply: treatment of alcoholism, drug abuse or any addiction including the treatment of any related condition resulting from these treatment of any self-inflicted illness or injury, or any treatment related to them, or treatment arising from attempted suicide treatment of any illness or injury which is medically considered to be linked directly or indirectly with Human Immunodeficiency Virus (HIV) and/or Acquired Immune Deficiency Syndrome (AIDS) and/or any form or variation of HIV or AIDS, however caused treatment arising from nuclear or chemical contamination, war, invasion, act of foreign enemy, hostilities (whether war is declared or not), civil war, riot, civil disturbance, rebellion, revolution, military force or coup, act of terrorism treatment received after the period covered by any premium or after the plan has been cancelled treatment received outside the UK except as described in the Travel Cover section if Travel Cover has been selected 8 PruHealth

9 Definitions These definitions are shown in bold print throughout this document and have the same meaning wherever they appear. Accidental dental injury A dental accident is a sudden unforeseen external blow to the face, teeth and jaws which occurs at an identifiable place and time and results in dental injury. Dental injury is an injury to your teeth and gums caused by direct extra-oral impact. Annual renewal date The date, 12 months after the plan start date and each anniversary after that date. Cancer A malignant tumour, tissues or cells, characterised by the uncontrolled growth and spread of malignant cells and invasion of tissue. Company The employer who has agreed with us to operate a scheme for employees, paid for by the employer. Cosmetic dental treatment Treatment which is not medically necessary to maintain dental health and is used solely for the purpose of improving your appearance. Cover start date The date on which each insured person s cover starts. Dental practitioner A registered licensed dental practitioner in general practice. Dental treatment Dental procedures undertaken by your dental practitioner which are clinically necessary for the maintenance and/or restoration of oral health and are provided in accordance with accepted standards of dental practice. Diagnostic tests Investigations, such as x-rays or blood tests, to find or to help find the cause of your symptoms. Drug abuse The taking of any drug, substance or solvent unless it was as prescribed by a GP or specialist. Emergency dental treatment Dental treatment required for the immediate relief of severe pain, haemorrhage or the control of an acute infection of a condition which causes severe threat to the insured person s general health. General practitioner (GP) A registered licensed medical practitioner in general practice. Hygienist A qualified dental hygienist registered with the General Dental Council. Implant An implant inserted in the jaw bone to support or retain dental appliances or prostheses. PruHealth 9

10 Insured dependant Your insured husband, wife or partner, who live at the same address as you. Your insured children, who must be under the age specified in your certificate of insurance at the cover start date and at each annual renewal date. Insured member Any qualifying employee or person in the company whom we accept for cover. Plan start date The date on which the plan began. Plan year A period of 12 months from the plan start date or from any annual renewal date. Specialist A medical practitioner who is fully registered with the General Medical Council, and who is recognised by us in writing. They must either: hold or have held a substantive consultant post with the NHS, or hold a Certificate of Completion of Training (CCT) and be registered on the Specialists Register, or fulfil the qualification criteria requirements set by the Postgraduate Medical and Educational Training Board (PMETB) and be registered on the Specialists Register. We reserve the right to withhold or remove recognition of any specialist, at our discretion, due to reasons such as fraud or unreasonable charges. Treatment Surgical or medical services (including diagnostic tests) that are needed to diagnose, relieve or cure a disease, illness or injury. UK Great Britain and Northern Ireland including the Channel Islands and the Isle of Man. PruHealth is a trading name of Prudential Health Insurance Limited (registered number ), and Prudential Health Services Limited (registered number ). Prudential Health Insurance Limited provides and manufactures benefits under the plan and Prudential Health Services Limited distributes and services the plan and issues the documentation. Companies are registered in England and Wales. Registered offices at Laurence Pountney Hill, London EC4R 0HH. Both companies authorised and regulated by the Financial Services Authority Calls may be recorded/monitored to help improve customer service. Call charges may vary PruHealth SLH/1770/1110