Group Benefits Plan Information

Dental Plan Benefit Schedule by Module

Dental Fee Guide

Current Fee Guide for General Practitioners approved by the Provincial Dental Association in the Province where the Employee resides.

Should your Dentist charge fees in excess of the Fee Guide, the additional costs will not be covered.

Manulife Financial will pay the Benefit Percentage of all Covered Expenses incurred for the dental care of an insured person.

Payment is subject to any maximum amounts shown in the Benefit Schedule and to any limit on benefits shown in the Covered Expenses described herein. Lifetime Maximums apply to all periods combined in which an insured person is covered by Manulife Financial

In determining if an expense is covered, Manulife Financial may require the following information:

a) x-rays and a complete dental chart showing any extractions, fillings, or other work performed prior to the date of the incurred expenses for which claim is being made;

b) itemized bills from the dentist or other sources, of services or treatments; and

c) laboratory or hospital reports, casts, mold or study models or other similar evidence of the condition or treatment of the teeth or mouth.

Claim Amounts Applied to the Maximum

Claim amounts that will be applied to the maximum are the amounts paid by Manulife Financial for Covered Expenses after applying the Deductible, Benefit Percentage and any other applicable Policy provisions.

Deductible is nil.

Expenses for the services outlined for this Benefit are covered if they:

a)are incurred for the necessary dental care of an insured person;

b) are incurred for the care of a person while he is insured under this Benefit;

c) are incurred for services provided by a Dentist, a dental hygienist working within the scope of the dental hygienist’s license, or a denturist working within the scope of the denturist’s license;

d) are reasonable as determined by the Manulife Financial, taking all factors into account; and

e) do not exceed

i) the fees recommended in the Dental Fee Guide, or

ii) Reasonable and Customary charges as determined by Manulife Financial, if such expenses are not included in the Dental Fee Guide.

Where any two or more courses of treatment covered under this benefit would produce professionally adequate results for a given condition, Manulife Financial will pay benefits as if the least expensive course of treatment were used. Manulife Financial will determine the adequacy of the various courses of treatment available, through a professional dental consultant.

When a proposed course of treatment is expected to cost more than $500, a treatment plan should be filed with Manulife Financial before treatment begins.

Manulife Financial will then advise the Employee of the amount, if any, that is payable.

Basic Services

Expenses covered under Level I include:

a) complete oral exam, one per 2 calendar years;

b) full-mouth x-rays, one per 2 calendar years;

c) recall examinations, one every 6 months

d) bitewing x-rays, once every 6 months

e) routine diagnostic and laboratory procedures;

f) one unit of light scaling and one unit of polishing once every 6 months, when the service is performed outside Quebec, or prophylaxis (light scaling and polishing) once every 6 months, when the service is performed in Quebec

g) fluoride treatments, once every 6 months;

h) oral hygiene instruction, initial plus one recall;

i) space maintainers (excluding appliances placed for orthodontic purposes);

j) fillings, (amalgam, silicate, acrylic and composite), retentive pins, and pit and fissure sealants. Replacement fillings are covered only if:

• • the existing filling is at least 12 months old and required due to significant breakdown of the existing filling or recurrent decay, or
  • the existing filling is amalgam and there is medical evidence indicating that the patient is allergic to amalgam;

k) pre-fabricated full coverage restorations (metal and plastic);

l) minor surgical procedures, simple extractions,  and post surgical care;

m) complicated extractions including impacted and residual roots;

n) consultations, anesthesia, and conscious sedation;

o) denture repairs, relines and rebases, only if the expense is incurred later than 3 months after the date of the initial placement of the denture;

p) injection of antibiotic Drugs when administered by a Dentist in conjunction with dental surgery.

Supplementary Basic Services

Expenses covered under Level II include:

a) surgical procedures not included in Level I (excluding implant surgery);

b) periodontal services for treatment of diseases of the gums and other supporting tissue of the teeth, including:

• • scaling not covered under Level I, and root planing, up to a combined maximum of 8 units per calendar year;
  • provisional splinting; and
  • occlusal equilibration, up to a maximum of 8 units per calendar year;

c) endodontic services (which include root canals and therapy, root amputation, apexifications and periapical services). Root canals and therapy are limited to one initial treatment plus one re-treatment per tooth per lifetime. Re-treatment is covered only if the expense is incurred more than 12 months after the initial treatment.

Work in Progress when Coverage under this Policy ends

If a person’s insurance terminates under this Policy for reasons other than termination of this Policy or this Dental Care Benefit, and endodontic treatment had begun exposing a tool, Manulife Financial will pay for expenses related to such treatment provided the expenses is incurred within 31 days after the insurance terminates

Dentures

Expenses covered under Level III include:

a) initial provision of full or partial removable dentures;

b) replacement of removable dentures, provided the dentures are required because:

i) a natural tooth is extracted and the existing appliance cannot be made serviceable;

ii) the existing appliance is at least 60 months old and cannot be made serviceable; or

iii) the existing appliance is temporary and is within 12 months of its installation it is replaced by a permanent dentures. The total amount payable for both the temporary and permanent dentures is the amount which would have been allowed for permanent dentures.

Work in Progress when Coverage under this Policy ends

If a person’s insurance terminates under this Policy for reasons other than termination of this Policy or this Dental Care Benefit, and an impression for a denture had been taken prior to the termination, Manulife Financial will pay for expenses related to the installation of the denture provided the expense is incurred within 31 days after the insurance terminates.

Expenses covered under Level IV include:

a) crowns, onlays and veneers (only when the function is impaired due to cuspal or incisal angle damage caused by trauma or decay);

b) inlays (covering at least 3 surfaces, provided the tooth cusp is missing);

c) initial provision of fixed bridgework;

d) replacement of fixed bridgework or the addition of teeth to bridgework,  provided the replacement or addition is due to one of the following::

i) a natural tooth is extracted and the existing appliance cannot be made serviceable;

ii) the existing appliance is at least 60 months old and cannot be made serviceable;

iii) the existing appliance is temporary and within 12 months of its installation it is replaced by a permanent bridge. The total amount payable for both the temporary and permanent bridge is the amount which would have been allowed for a permanent bridge.

Work In Progress when Coverage under this Policy ends

If a person’s insurance terminates under  this Policy for reasons other than termination of the Policy or this Dental Care Benefit, and an impression for a crown, onlay, inlay, veneer, or bridgework had been taken prior to the termination, Manulife Financial will pay for expenses related to the installation of the crown, onlay, inlay, veneer, or bridgework provided the expense is incurred within 31 days after the insurance terminates.

Coverage is included for Modules Green and Teal for Dependent children only, provided treatment commences prior to reaching age 19.

Expenses covered under Level V include:

a) correction of malocclusion of the teeth;

b) observation and adjustment;

c) appliances for tooth guidance or uncomplicated tooth movement;

d) appliances to control oral habits;

e) retention appliances;

f) fixed or cemented, unilateral and bilateral appliances.

No benefit is payable for any expense which is directly or indirectly related to:

a) a charge, or a portion of a charge, which is eligible for reimbursement under any other part of this Policy, or through a government plan or legally mandated program;

b) war, insurrection, the hostile actions of any armed forces or participation in a riot or civil commotion;

c) the committing of or the attempt to commit an assault or criminal offence;

d) injuries sustained while operating a motor vehicle, either while under the influence of any intoxicant or is the insured person’s blood contained more than 80 milligrams of alcohol per 100 millilitres of blood at the time of injury;

e) charges for broken appointments, third party examinations, travel to and from appointments, or completion of claim forms;

f) services or supplies:

i) when there would have been no charge at all in the absence of insurance;

ii) which are received from a medical or dental department maintained by an employer, association or trade union; or

iii) which are performed or provided by the insured person, an Immediate Family Member or a person who lives with the insured person;

iv) which are not specified as a Covered Expense under this Benefit;

g) treatment rendered for a full mouth reconstruction, for a vertical dimension or for a correction of temporomandibular joint dysfunction;

h) cosmetic treatment, unless this is needed because of an accidental injury which occurred while the person was insured under this Policy;

i) implants, or any services rendered in conjunction with implants. However, where an implant is the choice of treatment and a denture or bridge would produce professionally adequate results for the condition, Manulife Financial will consider benefits as if the least expensive of a denture or bridge were used;

j) anti-snoring or sleep apnea devices;

k) treatment which is not generally recognized by the dental profession as an effective, appropriate and essential form of treatment for the dental condition;

l) the replacement of removable appliances which have been lost, mislaid or stolen;

m) laboratory fees which exceed Reasonable and Customary charges, as determined by Manulife Financial.