DENTAL CARE PLAN
(Refer to your Identification Card for maximum amounts and percentage paid.) Employees and registered dependents are entitled to the following Dental services when performed by a Dentist:
Plan “A” Basic Services
Those basic procedures necessary to assist the Dentist in evaluating the existing conditions to determine the required Dental treatment including:
(a) Oral examinations - once in any 6-month period. Complete oral examinations will be covered once in any 3-year period.
(b) X-rays - limited to the equivalent of one full-mouth series per year. Complete mouth X-rays will be covered once in any 3-year period.
(c) Consultations (as a separate appointment).
Those basic procedures necessary to prevent the occurrence of oral disease including:
(a) Cleaning and topical application of fluoride and other anticariogenic substances - once in any 6-month period.
(c) Initial provision and installation of space maintainors.
(d) Diagnostic casts or study models
Those basic procedures necessary for extractions and other basic surgical procedures normally performed by a Dentist.
Those basic procedures necessary for initially filling teeth with amalgam, silicate, acrylic or composite restorations and stainless steel crowns. Replacement of amalgam, silicate, acrylic or composite restorations, provided that, unless an additional tooth surface is involved, a continuous period of at least 12 consecutive months has elapsed since the last date on which the restoration was provided or replaced for the individual by any person.
Those basic procedures required to repair or reline fixed or removable appliances. Repairs to complete upper and/or lower dentures may be performed by either a licensed Dentist or a duly licensed Dental Mechanic.
Those basic procedures necessary for the treatment of tissues supporting the teeth, (deep scaling limited to three (3) units per year).
Plan “B” Prosthetic Appliances,
Crowns and Bridges
1. Initial provision of crowns, (other than stainless steel crowns) metal inlays or onlays, if the tooth is broken down by decay or traumatic injury so that the tooth structure cannot be restored with an amalgam, silicate, acrylic or composite restoration.
2. Replacement of crowns, other than stainless steel, if a 5-year period has elapsed since the last date on which the crown was provided.
3. Initial installation of full dentures, partial dentures, or fixed bridgework.
4. Replacement of or addition of teeth to existing full or partial dentures or fixed bridge work including implants provided the existing denture, fixed bridgework, or implants were installed at least 5 years prior to its replacement and cannot be made serviceable. The Plan does not pay for duplicate, incomplete or unsuccessful procedures. The Plan pays in accordance with the current General Practitioners Fee Guide. If the services are provided by a Specialist, the Plan will add a maximum of 10% to the General Practitioners Fee Guide in recognition of the higher charges. Any fees in excess of these amounts are your responsibility.
Plan “C” Orthodontics
Those services listed by the College of Dental Surgeons of British Columbia in their Fee Guide and described as Orthodontic Services. Appliances lost, broken or stolen will not be replaced. Any fees in excess of the Fee Guide are your responsibility.
Emergency Dental Care Anywhere in the World
In an EMERGENCY if you require Dental care while travelling or on vacation outside British Columbia, you are entitled to the services of a duly qualified Dentist and will be reimbursed up to the amount that would have been paid had the services been rendered in British Columbia.
Extension of Benefits
Dental Benefits for an employee who is Totally Disabled will remain in force while the employee is receiving Long Term Disability Benefits.
As used in this benefit, the term:
Dental procedure shall mean in a single Dental service, certified as necessary by a Dentist, to repair an injury to or to correct a deficiency in the teeth orassociated tissues of the mouth;
Dentist shall mean a licensed graduate of a recognized Dental faculty, having received a diploma as a D.D.S. or L.D.S. which entitles him to treat teeth and the associated tissues of the mouth;
Qualified Dental Hygienist shall mean a person who has taken and passed a course in Dental Hygiene under a recognized Dental faculty and has received a diploma as a Qualified Dental Hygienist.
Services Not Covered
No amount shall be payable under this benefit for charges:
1. in connection with general health examinations;
2. for which an individual is entitled under any government plan;
3. for which an individual is entitled to obtain benefits without charge;
4. resulting from any act related to war, insurrection or participation in a riot;
5. which are not medically necessary;
6. incurred as a result of any Dental disease, defect or injury arising out of or in the course of any employment of an Insured Individual;
7. for education or training in, and supplies used for dietary or nutritional counselling, personal oral hygiene or Dental plaque control;
8. for facings on pontics or crowns posterior to the first molar;
9. for replacement of dentures which are mislaid, lost or stolen;
10. for a Dental procedure which requires two or more appointments and which commenced prior to the effective date of an Insured Individual’s insurance under this benefit;
11. for Dental care which is cosmetic, except charges which are incurred as a result of Dental care rendered by a Dentist for injuries caused by an accidental bodily injury sustained while the individual is insured for this benefit, and which are incurred while his insurance under this benefit is in force and within the 180-day period immediately following the date the accidental injury is sustained, unless a detailed treatment plan is approved within 60 days of the date of the accident;
12. incurred by an Insured Individual after the date his insurance under this benefit terminates;
13. for procedures and appliances in connection with implants;
14. for anaesthesia charges, unless provided by a qualified Dentist; or
15. for occlusal equilibration charges in excess of 8 units of time during any 12-month period. Proviso: Where alternative procedures are available, benefit payments will be based on the least expensive procedure.
How to Submit a Dental Claim
On your next visit to your Dentist’s office, please indicate that you are a Member of the B.C. Marine Industry Employee Health Benefit Plan and present your Identification Card. Your Dentist may bill the Plan directly for the reimbursement portion or may choose to continue to bill you. Please ask at the beginning of treatment how billing will be made.
1. Should your Dentist choose to seek payment directly from the Plan, the Dentist will submit the claim. You must pay the difference between the bill and the reimbursable portion.
2. Should the Dentist choose to bill you, ask for a detailed claim form indicating the services rendered. Be sure that the claim form shows: that you belong to the B.C.Marine Industry Employee Health Benefit Plan, your name, your Identification Number, your home address, the name and date of birth of the person receiving the Dental care. You should then submit this form to the Administrator’s office so that the Plan can reimburse you.
NOTE: Claims should be submitted as soon as possible after the Dental treatment has been completed. No action may be brought against the Plan for any claim unless presented within 60 days of treatment completion date.