Texas Delta Dental Insurance
For Individual, Family, Self Employed, and Group

By a Broker of Delta Dental and other Companies

Exclusions & Limitations

Limitations on all Benefits - Optional Services:

Services that are more expensive than the form of treatment customarily provided under accepted dental practice standards are called "Optional Services." Optional Services also include the use of specialized techniques instead of standard procedures. For example: a crown where a filling would restore the tooth, a precision denture where a standard denture could be used, or an inlay instead of a restoration. If you receive Optional Services, your Benefits will be based on the lower cost of the customary service or standard practice instead of the higher cost of the Optional Service. You will be responsible for the difference between the higher cost of the Optional Service and the loser cost of the customary service or standard practice.

Exclusions
Delta Dental does not pay Benefits for:

1. Services for injuries or conditions which are compsenable under workers' compensation or employers' liability laws; services which are provided to the Enrollee by any federal or state government agency or are provided without cost to the Enrollee by any municipality, county or other political subdivision except as such exclusion may be prohibited by law.

2. Services with respect to congenital (hereditary) or developmental (following birth) malformations or cosmetic surgery or dentistry for purely cosmetic reasons, including but not limited to cleft palate, maxillary and mandibular (upper and lower jaw) malformations, enamel hypoplasia (lack of development), fluorosis (a type of discoloration) of the teeth, and andontia (congenitally missing teeth), except those services provided to newborn children for congenital defect or birth abnormalities or services that may be provided under Orthodontic Benefits.

3. Services for restoring tooth structure lost from wear, erosion, or abrasion, for rebuilding or maintaining chewing surfaces due to teeth out of alignment or occlusion, or for stabilizing the teeth. Such services include, but are not limited to: equilibration, periodontal splinting, occlusal adjustment.

4. Any single procedure started prior to the date the person became covered for such services under this program.

5. Prescribed drugs, medication or analgesia

6. Experimental procedures

7. Charges by any hospital or other surgical or treatment facility and any additional fees charged by the Dentist for treatment in any such facility.

8. Charges for anesthesia, other than by a licensed Dentist for administering general anesthesia in connection with covered oral surgery services.

9. Extra oral grafts (grafting of tissues from outside the mouth to oral tissues).

10. Services with respect to any disturbance of the temporomandibular joint (jaw joint).

11. Services performed by any person other than a Dentist or auxiliary personnel legally authorized to perform services under the direct supervision of a Dentist.

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