DENTAL CARE

This is an optional benefit for firms that have chosen the term life and long term disability insurance.

Coverage Available

There are three levels of service available, depending on the size of your firm.

  • A. Basic Preventive Services covers diagnostic and preventive services associated with regular dental care: examinations (maximum of four per patient per calendar year), X-rays, fillings, extractions, anesthetics, oral surgery, and space maintainers for dependent children under age 15. Services for root canal and gum disease, denture lining and rebasing are also covered. Fluoride treatment is covered only to age 19.

    Reimbursement options are 80% or 100%, with an annual (calendar year) maximum of $1,500 per insured individual/dependent. Basic services are available to firms of five persons or more.

  • B. Major Restorative Services covers dentures, crowns, inlays, onlays and bridgework. Replacements are covered only if the existing ones are at least five years old and no longer serviceable.
    Reimbursement is at 50%, with an annual maximum of $1,500 per insured individual/ dependent.
    Major services are available to firms of ten persons or more.

  • C. Orthodontics Services (for dependent children only) provide coverage for orthodontics and all necessary dental treatment which has as its objective the correction of malocclusion of the teeth.
    Reimbursement is at 50% with a lifetime maximum of $2,500 per dependent child.
    Orthodontic services are available to firms of fifteen persons or more.

Pre-Authorization for Treatment Over $500

If dental expenses are likely to be more than $500, you should submit a “Pre-determination” to Great-West Life. A Pre-determination is simply an outline of the proposed treatment prepared by your dentist prior to any work being performed. Great-West Life will advise your dentist of the portion that is covered by your dental plan, enabling you to determine your costs.

Claims

Claims can be either filed electronically or with a standard claim form. Please ensure the correct policy, and certificate number are on the claim form.

A claim can be filed when the expense is incurred, or at the end of the year. Claims for expenses in a calendar year must be submitted by March 31 of the following year.

Co-Ordination of Medical/Dental Benefits

If your spouse also has a benefit plan, you may submit claims to both plans to receive the maximum coverage on your expenses. For this to work, you must follow some insurance industry guidelines:

  1. Submit your personal expenses to the CAIPW plan first, and then to your spouse’s plan for any remaining expenses.
  2. Your spouse must submit his/her personal expenses to their employer’s plan first, and then to CAIPW for any remaining expenses.
  3. Submit claims for children to the plan of the spouse whose birthday is first in the calendar year, then to the other plan for any remaining expenses.
  4. ependents are as defined in the Extended Health Care Benefit (see page 9).

Exclusions

  • Any claim resulting from self-inflicted injury, insurrection or war, or active participation in a criminal offence;
  • Any cause for which you or your dependent may apply for and receive indemnity or compensation under the Workers’ Compensation Act, or any dental care or treatment for which you are not legally obligated to pay;
  • Any dental care or treatment which is mainly for cosmetic reasons;
  • Any charges for appointments not kept or for the completion of claim forms;
  • Any dental treatment that has a purpose of correcting tempomandibular joint dysfunction(TMJ);
  • Any endodontic treatment (root canal) started before you or your dependent became insured under this plan;
  • Replacement of mislaid, lost or stolen appliances;
  • Any crowns placed on teeth that are not functionally impaired by incisal or cuspal damage;
  • Any crowns, bridges or dentures for which tooth preparations were made before you or your dependent became insured under this benefit;
  • Any charge for a Full Mouth Series of X-rays for your dependent under age twelve or whose policy does not provide for orthodontic benefits;
  • Any charge for other than “metal” crowns or pontics, posterior to the second bicuspid tooth;
  • Any procedures, appliances or restorations used to increase vertical dimensions, or to repair or restore teeth damaged or worn due to attrition or vertical wear or to restore occlusion;
  • Any services or supplies for implantology, including tooth implantation and surgical insertion of fabricated implants;
  • Any orthodontic expenses which were incurred prior to the date on which you became insured;
  • Any treatment must be the least expensive that will produce a professionally adequate result.

Participation Requirements

To be eligible for the dental plan, certain requirements must be met:

  • The employer must pay at least 50% of the dental premiums.
  • The firm must have life and long term disability benefits.
  • All employees must join the firm’s dental plan, unless they have a spousal exemption. In addition, certain participation requirements apply to the firm over all.
  • If the firm has both extended health care and dental benefits, you must have the same status (single or family) for both benefits.

Termination Provision

Dental care benefits will automatically terminate on the employee’s 65th birthday, and in the case of a CA, their 69th birthday. If you leave your employer, the insurance terminates immediately.

Premiums

Rates vary by province. Please contact CAIPW for current rates.
Dental Care Benefits are underwritten by Great-West Life, Policy Number 56579.