Individual Dental Care Coverage

GENERAL INFORMATION
1. Definitions
Spouse:
The man or the woman who, on the date of the event entitling
such person to benefits, is married to the participant and lives
with that person; or is of the opposite sex of the participant and
continuously has lived in a martial relationship with that person
for three years or one year if a child is born from this common
law couple. The status of spouse is forfeited through
dissolution of such marriage by divorce or annulment, or in the
case of a marriage not legally contracted by separation for
more than three months.
Dependent child:
A single child of the participant or his or her spouse, who
resides with him or her and whose needs are looked after
wholly or to a large degree and who is over 24 hours of age
and is under age 18, or is over 18 but less than age 25 and
attends on a full-time basis as a duly registered student, a
recognized educational institution, or whatever his or her age,
if the child has been the victim of total disability while he or she
satisfied any one of the preceding conditions and has
remained totally and continuously disabled since that date.
2. Membership
Membership is optional for any employee and for his or her
dependents, if applicable, provided they meet the eligibility
conditions. Any employee, who wishes to participle in this
contract, must complete a membership application within the
31 day period following the date on which he or she becomes
eligible. However, no other application will be accepted after
the expiry of this said period.
3. Eligibility
Dependent insurance terminates on the first of the following
two dates:
- The termination date of the participant’s insurance;
- the date on which said dependent ceases to be dependent.
INDIVIDUAL
DENTAL CARE COVERAGE
5. Procedure for filing claims
The insured presents his or her Service Card to the dentist.
The system validates the card and states if the dental care is
covered and includes the percentage of refund to which the
insured is entitled. There is no need to fill out a claims form
since the insured portion of the dental care is claimed directly
by the dentist from the Insurer. The insured only pays for the
uninsured portion of the dental care (including the deductible,
if applicable). If the dental clinique is not connected to this
service, the insured must pay the dental care expenses in full
and then send an application for benefits to the Insurer.
Annual rates per participant
Effective, January 1, 2014
Participant’s
age
Individual
plan ($)
Family
plan ($)
Under age 24
$785.48
$1,434.83
25 to 29
$746.68
$1,381.95
30 to 34
$746.68
$1,452.04
35 to 39
$669.07
$1,609.76
40 to 44
$669.07
$1,785.33
45 to 49
$591.46
$1,767.49
50 to 54
$591.46
$1,662.33
55 to 59
$514.16
$1,329.38
60 to 64
$514.16
$1,189.18
FOR COMPLETE INFORMATION
Quebec
625 Saint-Amable St.
P.O. Box 1500
Quebec QC G1K 8X9
418 644-4200
Insured by
Montreal
Suite 820
425 De Maisonneuve Blvd W
Montreal QC H3A 3G5
514 873-6506
No charge: 1 800 463-4856
No tax will be added to the amounts indicated in this document.
Any member under age 65 whose health insurance coverage
ceases to be in force under the previous contract for a reason
other than retirement, is eligible for the insurance within
31 days following the termination date of his or her duties. Any
member’s dependent is eligible for the insurance either on the
same date as the member if he or she is already a dependent
or on the date he or she becomes a dependent.
4. Termination of insurance
Dental care coverage for any participant terminates on the first
of the following dates:
-
-
The date of the end of the contract;
The due date on any premium that has not been paid;
The date of receipt by the Insurer of the written notice from
the member who wishes to terminate his or her insurance,
or the termination date mentioned in such notice,
whichever date is the furthest;
th
On the date of his or her 65 birthday.
Modification of premium rates
The Insurer may modify premium rates at the end of the first
contractual period or at any time thereafter. Nonetheless, in
the event of an increase, the Insurer must notify the
Policyholder in writing of the new rates at least 30 days in
advance and no increase may be applied less than 12
months after the preceding increase.
Change of government policy
If the federal or provincial governments pass or amend laws
or regulations which could influence the Insured’s rates, the
Insurer reserves the right to adjust premium rates for the
coverages, involved at the time such an act or amendment
comes into force.
Contract 3998
January 2015
This pamphlet is only for information purposes and in no way
modifies the terms and conditions of the contract.
February 2015
ELIGIBLE EXPENSES
When an insured person incurs expenses for dental treatments
as defined hereafter, dispensed and recommended by a
dentist, the Insurer reimbursed the preventive, the basic
restorative and the major restorative services according to a
coinsurance of 80%. The reimbursement for all these services
is limited to $1,000 per calendar year, per insured person. An
annual deductible of $75 for a participant covered under an
individual contract and $150 for a participant covered under a
family contract is applicable.
Eligible expenses are expenses that are reasonably incurred,
recommended by a dentist and justified by the current practice
of dental art, and whose cost does not exceed the rates for the
current year in the Fee Guide of the Quebec Dental Surgeons
Association.
PREVENTIVE SERVICES
1. Diagnostic
- Clinic oral examination (maximum 1 per 6-month
consecutive period); 01110 to 01700
2. Radiographs (maximum 1 sitting
consecutive period)
- Intra oral films; 02111 to 02152
- Extra oral films; 02201 to 02504
- Tomography; 02920, 02929
per
6-month
The complete series of periapical and bitewing films is
refundable one times per 36-month consecutive period.
3. Preventive
- Polishing of coronal portion of teeth (maximum 1
treatment per 6-month consecutive period); 11100 to
11300
- Periodontal scaling (maximum 1 treatment per 6-month
consecutive perioid); 43411 to 43414, 43417, 43419
- Topical application of fluoride (maximum 1 treatment per
6-month consecutive period); 12400
- Finishing restorations; 13300 to 13301
- Pits and fissure sealants; 13401 and 13404
- Antimicrobial agent; 13600
- Interproximal discing; 13700
- Eenameloplasty; 13715
BASIC RESORATIVE SERVICES
1. Restorative
Primary teeth
- Amalgam anteriors or posteriors; 21101 to 21105
- Composite anteriors; 23311 to 23315
- Composite posteriors; 23411 to 23415
- Amalgam, bonded anteriors or posteriors; 21121 to 21125
Permanent teeth
- Amalgam anteriors and bicuspids; 21211 to 21215
- Amalgam molars; 21221 to 21225
- Amalgam, bonded anteriors and bicuspids; 21231 to 21235
- Amalgam, bonded molars; 21241 to 21245
- Composite anteriors; 23111 to 23118, 23122
-
Composite bicuspids; 23210 to 23215
Composite molars; 23220 to 23225
Retentive pins; 21301 to 21304
Supplement for restoration; 21601
2. Oral surgery
- Removal of erupted tooth, per quadrant (uncomplicated);
71101 to 71121
- Surgical removal of erupted tooth (complicated); 72100
to 72450
- Alveolectomy; 73020
- Alveoloplasty; 73100 to 73110
- Stomatoplasty; 73123
- Osteoplasty; 73133 to 73140
- Tuberoplasty; 73150 and 73151
- Removal of hyperplastic tissue; 73171 to 73176
- Removal of excess mucosa; 73181 to 73186
- Alveolar ridge reconstruction; 73360, 73361
- Extension of mucous folds with secondary epithelization;
73381 to 73384
- Extension of mucous folds with mucous or skin graft;
73401 to 73404
- Removal and curettage of tumor and cyst; 74108 to
74410
- Incision and drainage; 75100 to 75110
- Removal of foreign body from bone tissue and soft
tissue; 75301, 75361
- Frenectomy; 77801 to 77803
- Hemorrhage control; 79400 and 79401
- Post-surgical treatment; 79601 and 79602
3. General basic services
- Local anaesthesia; 04470, 04471
- General anaesthesia (anaesthetic cost only); 92311 to
92319
- Professional visits; 94100, 94200, 94400
- Conscious sedation, intravenous; 92331 to 92339
- Oral conscious sedation; 92421 to 92429
MAJOR RESTORATIVE SERVICES
1. Endodontics
- Endodontic emergency
a) Pain control; 20111, 20121, 20131, 20161
b) Pulpotomy; 32201, 32202, 32210
c) Emergency pulpectomy; 39901 to 39904
- Endodontic traumatism; 39970, 39981 and 39985
- Open and drain; 39201, 39202
- General endodontic treatments; 39100 to 39120, 33100
to 33412 and 33475
- Apexification; 33521 to 33524, 33531 to 33534, 33541 to
33544
- Endodontic surgery
a) Apectomy; 34101 to 34104
b) Apectomy and root canal; 34111 to 34115
c) Apicoectomy and root canal retreatment; 34171 to
34175
d) Retrofilling; 34201 to 34212 and 34215
e) Root amputation; 34401 and 34402
f) Hemisection; 39230
g) Reimplantation; 34451 to 34453
h) Perforation repair; 34511
Other endodontic services
- Supplement for endodontic treatment through a crown;
32101
- Unsuccessful attempt to complete root canal treatment;
32102
General endodontic treatments
- Preparation of tooth for treatment; 39100, 39110, 39120
Restrictions: These dental services are refundable
provided they be performed more than 6 months after the
insertion of the said denture and that at least 36-month
consecutive period have lapsed since the last relining or
rebasing, whichever applies. Nonetheless, these services
are not refundable if they are done on a temporary
(transitional) denture.
EXCLUSIONS AND RESTRICTION OF COVERAGE
2. Bleaching
- Bleaching of tooth in office (maximum 10 sessions per
calendar year for all teeth); 39410
Bleaching in office; 97101 and 97102
The following dental procedures are excluded from this
coverage and the Insurer makes no refund for them:
-
3. Periodontics
- Management of acute infections and other oral lesions;
41200
- Desensitization (maximum 10 visits per calendar year,
per insured for all teeth); 41300
- Periodontal surgery
a) Root planing; 42000 and 42001
b) Gingivoplasty and/or gingivectomy; 42002, 42003
and 42010
c) Flap approach with osteoplasty/osteoectomy per
sextant; 42100
d) Paradontal irrigation; 49211
e) Application of slow release antimicrobialt; 49221,
49229
f) Gingival graft; 42570 and 42575
g) Autogenous grafts, soft tissue; 42200, 42300 and
42301
h) Graft, free connective tissue; 42560, 42561, 42565
i) Gingival fiber incision; 42330 and 42331
j) Proximal Wedge (mesial or distal); 42400
- Provisional splinting; 43200 to 43211, 43212, 43260,
43290, 43295
- Occlusal equilibration; 43300 and 43310
- Periodontal appliance; 43611, 43612, 43622, 43631
- Intra-oral appliance and adjustments; 43711, 43712,
43732, 43741
4. Denture adjustments
- Minor adjustements provided that these adjustements be
made more than 6 months after the initial insertion of the
denture; 54250 and 54251
- Remount and equilibration; 54300 to 54302
5. Rebasing and relining
- Reline removable complete or partial denture; 56200 to
56232
- Rabasing (jump); 56260 to 56263, 56280, 56290
- Tissue Conditioning; 56270 to 56273
- Resetting of teeth; 56602
-
-
-
-
-
-
-
-
Dental care that is free of charge or that the insured is not
required to pay, that he or she would not be required to
pay if he or she had invoked the provisions of any public or
private, individual or group plan, to which the insured
would be eligible or would not be required to pay in the
absence of this contract.
Dental treatments for which the insured is entitled to a
refund under the Act respecting industrial accidents and
occupational diseases, the Automobile Insurance Act or
any other Canadian or foreign act having the same effect;
dental treatments payable by a health insurance plan in
which the insured participates.
Dental treatments and supplies which, in accordance with
accepted dental art standards, are note required from a
dental viewpoint; or which are not recommended or
approved by the attending dentist, or which do not meet
accepted dental art standards.
Dental treatments performed mainly for esthetic
purposes, including the transformation or extraction and
replacement of healthy teeth in order to modify
appearance.
Dental treatments required following an injury that the
insured willfully inflicted upon him or herself, whether or
not of sound mind, at war, or actively participating in a
real or apprehended insurrection.
Fees invoiced by a dentist for an appointment missed by
an insured or for the filling out of claim forms required by
the insured, or for additional information required by the
Insurer; also for travel time, transportation costs and
counselling
provided
by
any
means
of
telecommunications.
Fees invoiced by a dentist for a treatment plan, either for
extra time spent for explanations due to the complexity of
the treatment, or when the insured requires this extra time
for explanations, or when the diagnostic material comes
from another source; for consultation with the insured; for
consultation with another dentist.
Fees invoiced by a dentist for the analysis of an
alimentary diet and recommendations for initial
instructions as well as reinstruction in oral hygiene, and
for a plaque control program; for any protective athletic
appliances.
Expenses incurred while this coverage is not in force.