Embed Size (px)
Citation preview
Premier Dental Care Plan
International Dental Cover
www.premierdentalplan.co.uk
2
Contents
Why choose a dental plan? Welcome to the Premier Dental Care Plan 3
Why choose a dental plan? 3
Why the Premier Dental Care Plan? 3
Dental Wellness Programme 4
Top 4 ways of maintaining your dental health 4
How to use the plans Plan benefits 5
How to claim – 4 easy steps 6
What to do in a dental emergency 7
About the plans Policy summary 8 to 10
Terms and conditions 11 to 20
How to contact us 21
3
Welcome to the Premier Dental Care Plan
Whether your teeth are in peak condition or not nearly as good, you are immediately covered for
both NHS and private dental treatment as a member of the Premier Dental Care Plan.
This booklet explains all you need to know about the range of plans available and allows you to
choose the plan which best suits your needs.
The plan levels are designed to suit your needs and lifestyle, whether you are looking to protect
yourself and your family against the cost of NHS treatment, or provide for comprehensive cover
against the increasing costs of routine private preventative and restorative dental fees.
Cover can be extended to your partner and dependant children can be covered up to the age of 25.
Why choose a dental plan?
Good oral health is integral to your general health and wellbeing.
Poor oral health can impact all areas of your life. Gum disease has proven links with strokes, heart
disease and pancreatic cancer. By ensuring that you have healthy teeth and gums, not only are you
reducing the chances of suffering the pain and discomfort of gum disease, you are also helping to
minimise the risk of contracting serious life threatening conditions.
Why the Premier Dental Care Plan?
Broad range of services
As a member of the Premier Dental Care Plan you have access to an extensive range of services,
specifically focused on helping keep your teeth in great shape.
Not registered with a dentist? No problem – simply contact us and we will help you find a dentist
in your area.
In dental pain? No problem – give our 24 hour worldwide emergency helpline a call and we’ll help
you find a dentist for emergency treatment – wherever you are in the world.
Easy to understand, easy to claim
Simple benefits and clear limits make it easy for you to know how to use your policy. You do not
need to change your dentist to use this plan which will provide cover for NHS and private treatments
up to comprehensive preventative and restorative treatments.
Our four step claim process makes it easy to claim following treatment.
4
Dental wellness programme
Informed consent to treatment is the right of every patient and not all treatment options necessarily
best suit a patient’s needs. With dental work you always have time to review the options and select
what suits you (and your pocket) best. As a member of the Premier Dental Care Plan you will have
free access to this dental wellness and education program to assist you with this process as well as
keep you informed about your general dental health.
Your dental plan is connected with this program and you are invited to visit www.denisglobal.com
for more information or to unsubscribe.
Top 4 ways of maintaining your dental
health
1 Brush teeth vigorously twice a day
Brushing physically removes the germs which cause tooth decay and gum disease.
But remember, they grow back within 24 hours – that’s why it’s essential to brush
twice a day. Good daily brushing is the most effective way to avoid dental problems
over the long term.
2 Brush your children’s teeth
Children less than 7 years old should have their teeth brushed twice daily by an adult.
3 Brush effectively and floss
Brush in a rotary action. Simply brushing from side to side will over time erode the thin
enamel-cementum coating on the neck of the teeth and is not an effective method to clean
between the teeth. Rotary-electric tooth brushes provide an ideal solution. Gentle daily
flossing will further provide an effective clean between the teeth.
4 Use a fluoride rich toothpaste
The use of a fluoride rich toothpaste is proved to be beneficial for the long term prevention
of tooth and gum decay. Always consult your dentist as to the suitability of these products
for your circumstances.
5
Premier Dental Care Plan benefits
Private Treatments
Normal Examination
Extensive Examination
Full case assessment
X-rays Small X-ray
Medium X-ray
Panoral X-ray
Scale & Polish
Scale & polish
Scale & polish – for periodontitis
Fillings
One surface amalgam Two surface amalgam
Three plus surface amalgam
Composite filling anterior small
Composite filling anterior large
Composite filling posterior small
Composite filling posterior medium
Composite filling posterior large
Root Canal Treatment
R.C.T. Incisor/Canine
R.C.T. Premolar
R.C.T. Molar
Open root canal for drainage
Extractions
Routine extraction – first tooth
Routine extraction – per additional tooth Surgical extraction
Dressings
Extractions – post-operative care
Veneers & Inlays
Veneer
Inlay
Crowns & Bridges
Crown Implant
Conventional bridge (any number of units)
Adhesive bridge (any number of units)
Re-fix crown
Re-cement crown
Re-cement bridge (any)
Dentures Acrylic upper or lower
Acrylic upper & lower
Chrome upper
Chrome lower
Reline dentures
Repair dentures
Other Treatments
Mouthguard Anaesthetic fee
Emergency treatment
Apisectomy
Fissure sealant
Topical fluoride application
Occlusal splint
Gingivectomy Mucoperio, Flap bone surgery
Abnormal haemorrhaging
Post & core
Gold post & core
Incising an abscess
Supplementary Benefits
Orthodontics (children only – annual
aggregate) Overnight hospital stay
Call-out fee
NHS treatments reimbursed at:
Routine Treatment Annual Aggregate
Maximums:
Accident Treatment Annual Aggregate
Maximums:
Oral Cancer Treatment Allowance
Pearl Plan
£15.00
£19.00
£30.00
£5.00
£9.00
£15.00
£17.00
£30.00
£15.00 £18.00
£23.00
£22.00
£25.00
£22.00
£25.00
£35.00
£45.00
£60.00
£80.00
£40.00
£30.00
£15.00 £50.00
£20.00
£20.00
£80.00
£90.00
£130.00 £130.00
£320.00
£160.00
£20.00
£20.00
£20.00
£100.00
£200.00
£160.00
£160.00
£30.00
£30.00
£45.00 £60.00
£30.00
£50.00
£20.00
£20.00
£50.00
£20.00 £50.00
£40.00
£40.00
£60.00
£20.00
£325.00 £35.00
£50.00
100%
£1,250
£1,250
£20,000
Gold Plan
£45.00
£65.00
£96.00
£11.00
£31.00
£37.00
£63.00
£110.00
£65.00 £82.00
£117.00
£78.00
£95.00
£78.00
£95.00
£105.00
£155.00
£190.00
£240.00
£80.00
£60.00
£30.00 £80.00
£40.00
£40.00
£320.00
£410.00
£470.00 £470.00
£1,080.00
£540.00
£50.00
£50.00
£50.00
£400.00
£800.00
£540.00
£540.00
£60.00
£60.00
£75.00 £100.00
£60.00
£110.00
£40.00
£40.00
£100.00
£40.00 £100.00
£80.00
£90.00
£120.00
£40.00
£775.00 £65.00
£100.00
100%
£3,750
£3,750
£20,000
Platinum Plan
100%
100%
100%
100%
100%
100%
100%
100%
100% 100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100% 100%
100%
100%
100%
100%
100% 100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100% 100%
100%
100%
100%
100%
100%
100% 100%
100%
100%
100%
100%
100% 100%
100%
100%
£5,000
£5,000
£20,000
4
6
How to claim – 4 easy steps
Befo
re
you
go
At th
e den
tist
Step
1
Treatment undertaken
or outstanding before
the plan start date will
not be covered.
Step
2
If you are receiving
NHS treatment, ensure
that this is clearly stated
on the receipt.
Su
bm
itting
you
r claim
Step
3
If you don’t provide an
itemised receipt or if
the claim form is
incorrectly completed
your payment may be
delayed.
Step
4
One claim per person.
Please give as much
information as you can
to ensure speedy
settlement of your
claim.
Check your plan start
date.
Receive your treatment
and pay the dentist.
Obtain an itemised
receipt and ensure your
dentist completes
sections B, C & D of
the claim form as
appropriate.
Complete section A of
the claim form, sign
and date the
declaration, and attach
itemised receipt and
submit to the claim
team within 60 days of
the date of treatment.
Your claim will be processed and payment sent within
seven working days (providing we receive full
information about your treatments).
7
What do I do in a dental emergency? Suffering dental pain can be a distressing experience – here’s what you can do
in a dental emergency, and some dental first aid tips. In the UK – simply attend a dentist of your choice or call us if you need assistance finding one. All
the plan levels include cover for emergency treatment, see the Plan Benefits section for details.
Overseas – if you have a dental emergency while you are abroad, either on holiday or business, you
simply visit any dentist. If you are unable to locate a dentist contact our 24 hour helpline and we’ll
find one for you.
Out of hours – if you are in pain at night or during the weekend you are still able to see a dentist as
all our plans cover you for call out fees and treatment following an accident or emergency.
Dental first aid tips
Clean the area around the sore tooth thoroughly.
Rinse the mouth vigorously with lukewarm salt water to dislodge trapped food
or debris.
Do not use very hot or very cold water as this may cause further pain.
Do not place aspirin on the gum or on the aching tooth.
If the face is swollen, apply a cold compress and seek help from a dentist as
soon as possible.
Cold water rinses may temporarily ease the pain from a throbbing tooth.
Avoid laying down as this raises the blood pressure and increases pain.
24 hour emergency helpline
United Kingdom: 0845 519 2098
International: +44 (0)845 519 2098
8
Policy summary
This policy summary provides a brief overview of this dental insurance which is underwritten by PTI
Insurance Company Limited. In conjunction with this policy summary the following forms the full
terms and conditions; the policy terms and conditions found on pages 11 to 20, and any endorsement
provided to you.
What are Premier Dental Care Plan Benefits?
All plans provides you with 100% reimbursement of treatment costs undertaken as an NHS patient in
the United Kingdom, in addition to varying levels of reimbursement towards the cost of routine
preventative and restorative private dental treatment anywhere in the world.
Pre-existing conditions are included subject to specified exclusions.
9
What are the main exclusions and limitations of the Premier Dental Care Plan?
As with all insurance policies, a number of exclusions and limitations apply. The following is a
summary of the main exclusions and limitations of the policy.
Exclusions For Further Information
Cosmetic treatments and treatments not clinically necessary.
For full information please
see the General Exclusions
section in the terms and
conditions.
Any treatment resulting from self-inflicted injury.
For full information please
see the General Exclusions
section in the terms and
conditions.
Reimbursement for travelling expenses or telephone calls in
connection with any treatments or charges for completing the claim
form.
For full information please
see the General Exclusions
section in the terms and
conditions.
Any claims for the replacement of dentures damaged whilst not being
worn.
For full information please
see the General Exclusions
section in the terms and
conditions.
Costs which we consider are not reasonable and necessarily incurred.
All benefits will be paid in accordance with customary and accepted
levels of charges for the treatment received. The charges must be
reasonable, necessary, incurred wholly and exclusively for the
purposes of treatment and in line with our dental advisors opinion.
For full information please
see the General Exclusions
section in the terms and
conditions.
Treatment received prior to the commencement of the period of cover,
and treatment received after the Period of Cover ceases.
For full information please
see the General Exclusions
section in the terms and
conditions.
Any treatment relating to damage or injury caused whilst
participating in any contact sport when the appropriate tooth
protection was not being worn.
For full information please
see the General Exclusions
section in the terms and
conditions.
10
Period of insurance
This policy runs for one calendar year commencing 1 September 2014 to 31 August 2015 unless you
join part way through the scheme year. In this case your cover will run from the point at which you
join the scheme until 31 August 2015.
Claims notification
Full details of the process for submitting a claim can be found on page 6 of this policy handbook. If
you need advice about making a claim please call our helpline on 0800 633 5037.
All claims must be received by us within 60 days of the date of treatment.
Where treatment costs are charged, you must pay for the treatment and submit original receipts along
with the completed claim form in order to make a claim for reimbursement.
How do I complain?
We aim to provide a first class product and service to you. However, there may be times when you
feel we have not done so. If you wish to complain about any matter, please contact us and we will do
our best to address your concerns. Your feedback is vital to helping us improve.
If you are dissatisfied with the outcome of our investigation you may request the Financial
Ombudsman Service (FOS) to consider your complaint. You should contact the FOS
(0845 0800 1800) to find out whether you will be eligible to have your complaint considered by the
FOS. If you purchase your insurance as part of a group scheme you will need to meet specific criteria
depending upon your particular circumstances.
Full details of the complaints procedure can be found in the terms and conditions on page 18.
Compensation arrangements
PTI Insurance Company Limited is covered by the Financial Services Compensation Scheme
(FSCS). You may be entitled to compensation from the FSCS if we cannot meet our obligations.
Insurance advising and arranging is covered at 90% of the claim, without any upper limit.
Details of our regulators
PTI Insurance Company Limited is regulated in Gibraltar by the Financial Services Commission
(www.fsc.gi) and is a member of the Association of British Insurers and the Financial Ombudsman
Service.
11
Terms & Conditions
12
We have defined below words or phrases used throughout this Policy. To avoid repeating these definitions please note
that where these words or phrases appear they have the precise meaning described below unless otherwise stated.
Where words or phrases are not listed within this section, they will take on their usual meaning within the English
language.
Wording Definition
Accident
Injury caused by direct impact outside of oral cavity to an Insured Person’s teeth
and gums (this includes damage to dentures whilst being worn).
Child/Children
Claims Administrator
Persons under 25 years of age at the Commencement/Review Date who are
permanently resident with You or persons under the age of 25 years of age at the
Commencement/Review Date who are in full time education.
Denis UK Limited, P.O. Box 6809, Basingstoke, Hampshire, RG24 4NH.
Telephone 0800 633 5037 or visit www.denisglobal.com.
Commencement Date
The date on which the Insured Person’s Cover commences.
Cosmetic Treatment
Treatment not necessary to maintain dental health and which is solely for the
purpose of improving the Insured Person’s appearance.
Cover
Cover for Treatment and/or Emergency Treatment subject to the terms and
conditions of the Policy.
Date of Entry
The date on which an Insured Person was included under this Policy.
Dentist
A fully qualified dental practitioner registered with the General Dental Council or
any other person properly qualified to perform the Dental Services.
Dental Services
The dental services described in this Policy.
Emergency Treatment
Dental Services or supplies provided to an Insured Person for the immediate relief
of severe pain, trauma, swelling or bleeding by their Dentist outside normal
surgery hours or by any other Dentist whilst the Insured Person is away from
home.
Insured Person/You/Your
A person for whom we receive and accept a completed Application Form and a
premium is paid and who is entitled to Cover in accordance with the terms of this
Policy.
Orthodontic Treatment
Treatment undertaken by a Dentist for the prevention and correction of
irregularities of the teeth.
Partner
An Insured Person’s spouse or partner who permanently resides with an Insured
Person in a domestic relationship.
Period of Cover
The Period of Cover as set out in this document and any subsequent period for
which the Policyholder pays a premium which We accept.
Policy
This contract being Our contract with the Policyholder providing the Cover as
detailed in this document. The application forms part of the Policy and must be
read together with this booklet (as amended from time to time).
Policyholder
The company or organisation from who premium is received. In the event of a
claim it is understood that settlement will be made to the principal Insured Person
on behalf of the Policyholder. Payments are not made to Partners or Dependants.
Review Date
The anniversary of the common renewal date of the Policy, as indicated on the
Application Form, when the Policyholder has the option to renew the Policy.
Treatment
Dental Services or supplies described in this document which are clinically
necessary for the maintenance and/or restoration of the oral health of an Insured
Person provided that such services are:
a. provided by a Dentist;
b. provided in accordance with accepted standards of dental practice;
c. received by an Insured Person during a period of cover.
United Kingdom (UK)
This comprises England, Scotland, Wales, Northern Ireland, the Channel Islands
and the Isle of Man.
We/Our/Us/Insurer PTI Insurance Company Limited.
Definitions
13
1. Treatments
Insured Persons are limited to the number of Treatments as detailed below during any one Period of Cover.
The relative date for determining the benefits available for Treatment shall be the actual date of that Treatment.
All expenditure for which benefit is claimed must be reasonable, clinically necessary and incurred wholly and
exclusively for the purpose of Treatment.
2. Children
Where Children are insured under the policy:
i. the level of cover must be the same as that selected by You;
ii. the maximum reimbursement, annual maximums and limits per year, shall be shared amongst all of
Your Children up to a maximum of three Children;
iii. Child orthodontic benefit is payable for Treatment received up to the Childs seventeenth birthday.
3. Child Orthodontic Treatment
a. Child orthodontic benefit is payable for Treatment received following the Childs eighth birthday
up to the Childs seventeenth birthday.
b. We will assess an Insured Persons Orthodontic Treatment in line with the Dental Health
component of the Index of Orthodontic Treatment Need (IOTN). Only grade 3 and higher where
there is a definite health need will be considered for cover.
c. Orthodontic Treatment for aesthetic or Cosmetic reasons is not covered under this Policy.
d. Child orthodontic Treatment in progress (appliances placed prior to eligibility under this policy) is
covered on a pro-rate basis.
e. Benefit is issued once the appliance has been fitted (benefit will not be issued prior to final
placement of the brace).
4. NHS Treatment
a. NHS Treatment benefits are payable only when claiming for Treatment undertaken as an NHS
patient.
b. You must supply a clear, itemised NHS receipt to claim under the NHS benefit.
c. Should You submit a claim for NHS Treatment with no clear evidence that the Treatment has been
carried out under the NHS, then Your clam will be assessed as described above within the private
routine and restorative Treatment limits.
Cover
The purpose of this Policy is to provide an Insured Person with Dental Services as described in Appendix A on
page 20 of this document during the period of Cover for Treatment by a Dentist at a dental surgery. We will
pay benefits to the maximum value shown according to the plan selected in Your application process provided
that such Treatment is clinically necessary and received by the Insured Person during the Period of Cover.
The following benefit rules apply to all Premier Dental Care Plan levels of cover.
Treatment Type Limits per Year
Examinations
Examination
Extensive Examination
Full Case Assessment
2
1
1
x-Rays
Small
Medium
Panoral
4
4
1
Scale & Polish
Simple
For periodontitis
Restorative Treatments
Dental Implants
2
2
2
Benefits
Benefit Rules
14
5. Dentist Identification
For Your protection and to comply with regulations regarding professional registration and conduct, Your
claim must positively identify the Dentist who rendered Treatment. The Dentists GDC number provides
this identification and must be entered on the claim form.
6. Double Charging
The Policy covers the Insured Person for Treatment rendered by both NHS and private Dentists.
However, Treatments (for example an examination, scale & polish or x-ray or other NHS Band 1 charged
Treatment) may not be claimed as both an NHS and a private Treatment. Reimbursement will be the
lower of the relevant Treatment charges.
7. Pre-existing Conditions
This Policy covers pre-existing conditions on all plan levels subject to stated exclusions.
8. Tooth Numbering
In order to provide effective management of dental health claims it is important that We know which
tooth has received Treatment. Dentists will be conversant with tooth numbering and will be able to enter
the relevant tooth number on Your claim form. The tooth number must be in FDI format.
9. Frequency of Treatments
Fillings: Cover is available once per tooth in a 2 year period.
Root Canal Treatment: Cover is available once per tooth in a 2 year period.
Crown, inlay, denture: Cover is available once per tooth in a 3 year period for the placement of a crown,
inlay or denture.
10. Annual Maximums
The maximum amount payable in any one Period of Cover shall not exceed the amount stated for the
applicable plan as detailed in Appendix A on page 20.
11. Policy Period
If as a newly eligible employee You join the Dental Plan after the beginning of the scheme year Your
insurance will run from the date on which You join the plan until the end of the Policy year.
12. Dental Implants & Fixtures
a) The insured benefit is paid on receipt of a valid claim where the dental surgeon is positively
identified by his or her GDC number.
b) The Dental Implant site must be identified by the FDI tooth number of the tooth position it fills.
c) Dental Implants placed in the site of 2nd or 3rd molars are excluded from benefit.
d) The insured benefit is only paid once per beneficiary per tooth site and the Insurer is not liable for
any future costs incurred by Dental Implant complications such as rejection, fracture or infection.
e) Teeth lost prior to the purchase of Premier Dental Care cover are not covered under the
benefit.
f) Dental Implant cover does not extend to the replacement of existing crowns or fixtures.
g) No benefit shall be payable in respect of any Dental Implant Treatment undertaken within 90
calendar days of the Commencement Your Date of Premier Dental Care cover .
h) Placement of a Dental Implant into a pre-existing edentulous space or where a Dentist/specialist
Dentist deems it not clinically appropriate, or replacement following the failure of a Dental
Implant to integrate or due to a subsequent breakdown of integration.
i) No benefit shall be available for any Dental Implant Treatment which was necessary, prescribed,
planned or is currently taking place at the Commencement Date of Your cover
15
Benefits will not be available for:
1. services or supplies for the Treatment which a Dentist is unable to provide due to circumstances beyond
the control of such Dentist and/or PTI Insurance Company Limited;
2. services or supplies which are not described in Appendix A of this Policy or which are specifically
excluded under the General Exclusions;
3. Cosmetic Treatments and Treatments not clinically necessary;
4. Treatment involving the necessity of hospital in-patient, day-patient or out-patient care;
5. services or supplies which are experimental in nature, or not normally supplied by a dental practice, or
which are not clinically necessary;
6. Orthodontic Treatment (other than Child orthodontics covering children up to their seventeenth birthday);
7. any Treatment resulting from self-inflicted injury;
8. Treatment received prior to the commencement of the Period of Cover, and Treatment received after the
Period of Cover ceases;
9. any Treatment once the annual maximum number of Treatments or maximum annual benefit limit has
been reached;
10. reimbursement for travelling expenses or telephone calls in connection with any Treatments or charges
for completing the claim form;
11. charges resulting from missed appointments;
12. any Claims for the replacement of dentures damaged whilst not being worn;
13. for costs which we consider are not reasonable and necessarily incurred. All benefits will be paid in
accordance with customary and accepted levels of charges for the Treatment received. The charges must
be reasonable, necessary, incurred wholly and exclusively for the purposes of Treatment and in line with
our dental advisors opinion;
14. any Treatment relating to damage or injury caused whilst participating in any contact sport when the
appropriate tooth, mouth or head protection was not being worn;
15. injuries sustained while engaged in illegal, unlawful or anti-social activities;
16. Oral Cancer diagnosed, suspected, or for which tests were conducted or planned or for which a referral to
a specialist had been made prior to the Insured Person joined the plan;
17. Oral Cancer resulting from smoking or chewing tobacco products (including betel nut juice);
18. War and Terrorism Mass Destruction Exclusion Clause
Notwithstanding any provision to the contrary within this insurance or any endorsement thereto it is
agreed that this insurance shall exclude war, invasion, acts of foreign enemies, hostilities (whether war be
declared or not), civil war, rebellion, revolution, insurrection, or military or usurped power or terrorism
but only as the sole result of the utilisation of nuclear, chemical or biological weapons of mass destruction
howsoever these may be distributed or combined.
For the purpose of this clause:
i) Terrorism means an act, or acts, of any person, or group(s) of persons, committed for political,
religious, ideological or similar purposes with the intention to influence any government and/or to put the
public, or any section of the public, in fear. Terrorism can include, but not be limited to, the actual use of
force or violence and/or the threat of such use. Furthermore, the perpetrators of terrorism can either be
acting alone, or on behalf of, or in connection with any organisation(s) or governments(s).
ii) Utilisation of nuclear weapons of mass destruction means the use of any explosive nuclear weapon
or device or the emission, discharge, dispersal, release or escape of fissile material emitting a level of
radioactivity capable of causing incapacitating disablement or death amongst people or animals.
iii) Utilisation of chemical weapons of mass destruction means the emission, discharge, dispersal,
release or escape of any solid, liquid or gaseous chemical compound which, when suitably distributed, is
capable of causing incapacitating disablement or death amongst people or animals.
iv) Utilisation of biological weapons of mass destruction means the emission, discharge, dispersal,
release or escape of any pathogenic (disease producing) micro-organism(s) and/or biologically produced
toxin(s) (including genetically modified organisms and chemically synthesised toxins) which are capable
of causing incapacitating disablement or death amongst people or animals.
General Exclusions
16
The following conditions apply:
Compliance with Policy Terms
Our liability under this Policy will be conditional upon each Insured Person complying with terms and
conditions of this Policy.
1. Selection of Plan Benefits
The plan benefit schedule selected by Your Partner or Children must be the same as that selected by You.
2. Changing Employment
Cover will automatically cease when You leave the employment of the Policyholder.
3. Policy Duration and Payment
a. The Policy period shall be for one calendar year commencing 1 September 2014 and expiring 31 August
2015 and may be continued subject to the terms in force at the time of each Review Date.
b. If an Insured Person obtains cover after the Review Date, the Period of Cover shall be for the period up
until the following Review Date and annually renewable thereafter.
c. You shall pay monthly premiums by deduction from salary.
d. The amount payable shall be that prevailing generally at the Commencement Date or if later, the
appropriate Review Date.
e. The amount payable may be changed by Us from time to time. However, this Policy will not be subject to
any alteration in payment rates generally introduced until the next Review Date.
4. Cancellation
a. If an Insured Person cancels Cover the Insured Person will not be allowed to obtain Cover at a later date.
b. Whilst We shall not cancel this Policy because of eligible claims made by an Insured Person We may at
any time terminate an Insured Person’s Cover or subject his/her Cover to different terms if he/she or the
policyholder has at any time:
i. misled Us by mis-statement or concealment;
ii. knowingly claimed benefits for any purpose other than as are provided for under this Policy;
iii. agreed to any attempt by a third party to obtain unreasonable financial gain to Our detriment;
iv. otherwise failed to observe the terms and conditions of this Policy.
c. If We cancel the Policy We shall give You 30 days notice sent by first class post to Your last known
address. If We do so You may be entitled to a proportionate refund of premium.
5. Pregnancy
In the event of pregnancy an Insured Member may continue with their cover or cancel their cover with the
option of re-joining the Dental Plan at a later date.
6. Claims Procedure
a. Claims must be submitted using the Dental Care Plan claim form;
b. The Insured Person should pay for the Treatment provided and on the claim form he/she should ask the
Dentist to detail the Treatment, indicate the fee charged and sign the form. Then attach the receipts to the
form and return to the Claims Administrator (see Definitions).
c. Reimbursement is available only if the Treatment is provided by a Dentist.
d. If any benefit is provided or any payment is made under this Policy as a result of an action by a third
party then the Insured Person must:
i. give Us full details of the potential claim against a third party;
ii. allow Us to pursue any loss under this Policy at Our expense;
iii. help Us to take legal action if We ask You to.
7. Claims Notification
All claims must be notified (and supporting documentation supplied) within 60 days of the date of
completion of the item of Treatment. We will not be liable in respect of any claim notified late.
8. Overseas Dental Emergencies – Claims Procedure
If an Insured Person requires Emergency Treatment when abroad simply obtain the Treatment required and
request the invoice to be written in English and on return to the UK forward it to the Claims Administrator
(see Definitions). Reimbursement will be in Pound Sterling at the equivalent benefit scale using the
exchange rate in force at the date of the claim settlement. The Insured Person shall be responsible for
paying for the translation of receipts, claim forms or supporting documents not completed in English and
this charge shall be deducted from the value of the claim reimbursement.
General Conditions
17
9. Overseas Routine & Restorative Dental Treatment – Claims Procedure
If an Insured Person requires Routine or Restorative Treatment when abroad simply obtain the Treatment
required and request the claim form and invoice to be written in English and forward it to the Claims
Administrator (see Definitions). Reimbursement will be at the equivalent benefit scale using the exchange
rate in force at the date of the claim settlement. The Insured Person shall be responsible for paying for the
translation of receipts, claim forms or supporting documents not completed in English, and this charge
shall be deducted from the value of the claim reimbursement.
10. Accidents – Claims Procedure
In the event of needing Treatment following an Accident or a sports injury, the Insured Person must inform
the Claims Administrator (see Definitions) within 7 days of the Accident or as soon as reasonably possible.
We may require confirmation of the Accident and Treatment before agreeing to any reimbursements
necessary.
11. Arbitration
When there is a dispute over the amount to be paid for a claim under this Policy, the dispute must be
referred to any arbitrator to be agreed between You and Us in accordance with the law at the time. When
this happens, a decision must be made before You can take any legal action against Us.
12. Alteration
We may alter any of the terms of this Policy at any Review Date. Details of the change will be advised to
You at such time.
13. Fraudulent or Unfounded Claims If any claim under this Policy is in any respect fraudulent or unfounded all benefit paid and/or payable in
relation to that claim shall be forfeited and (if appropriate) recoverable.
14. Other Insurance
Without prejudice to any other right or remedy We may have against any third party, if there is any other
insurance covering any of the same benefits the Policyholder must disclose or procure that the relevant
Insured Person discloses the same to Us. We shall not be liable to pay or contribute more than Our rateable
proportion. Any payment or contribution over and above such liability shall be at Our absolute discretion
and shall be without prejudice to this condition.
15. Waiver
Waiver by Us of any term or condition of this Policy will not prevent Us from relying on such terms or
conditions afterwards.
16. Settlement of Claims All settlements will be made by bank transfer to the nominated bank account of the principal Insured
Person.
Its Aims
To provide one or more of the following during the term of Your plan –
A refund of a proportion of dental costs for You subject to the exclusions listed in this Policy document;
A refund of a proportion of dental costs for You, Your Partner and Children, subject to the exclusions listed
in this Policy document.
You decide at the start or renewal of this plan which of these events You want covered.
Your Commitment
You agree to disclose any requested information in support of Your plan. If You do not, Your cover could
be affected.
Risk Factors
Your plan is annually renewable. You may need to increase Your contributions when Your plan is
reviewed in order to maintain Your chosen level of benefit.
Will My Contribution Change During The Term of my Contract?
The plan is annually renewable and the terms are set at the outset of each Policy year.
Can Children Have Dental Plan Cover?
Children under 18 years of age receive free NHS Treatment, but You may wish to carry insurance for
private Treatment. Children up to 25 years of age who are permanently resident with You or who are in full
time education can also be covered by this Policy.
They must be on the same plan level as You have chosen.
Policy Overview
18
All partner and children’s premiums are Your responsibility and will be deducted from Your monthly
salary as one total amount.
Can I Cancel Or Amend My Membership?
Once You have joined the scheme Your basis of cover will remain as selected for the remainder of the
Policy year unless You have a qualifying life event.
Can I Change My Level Of Cover?
Yes but only on the anniversary date of the Policy.
When Does The Cover Commence?
For those selecting during the annual election period cover commences on 1 September 2014. New
employees who were not employed by the Policyholder during the annual election period may elect to join
the Premier Dental Care Plan within one calendar month of commencing their employment with the
Policyholder. For new joiners cover will commence on the first day of the month following Your selection.
Are Pre-Existing Conditions Covered?
As a member You will be accepted for the plan regardless of Your dental fitness. Pre-existing conditions
with the exception of stated exclusions are covered on Pearl Plan, Gold Plan and Platinum Plan.
What Is The Cost Of The Dental Plan?
Type of cover
Single Partner Family Single Parent
Family
Level
of
Cover
Pearl Plan
£13.75
£27.50
£41.25
£27.50
Gold Plan £30.10 £60.20 £90.30 £60.20
Platinum Plan £43.25 £86.50 £129.75 £86.50
Please note that these premiums are quoted per month and are inclusive of Insurance Premium Tax at the current
rate.
We have every reason to believe that You will be totally satisfied with Your Policy. However, should You have
any concern relating to Your Policy or Our service, please write quoting the Policy number together with full
details of Your complaint to:
PTI Insurance Company Limited’s Representative
Insurance House
Prisma Park
Berrington Way
Basingstoke
Hampshire
RG24 8GT
If You are still not satisfied You can ask the Financial Ombudsman Service (which is entirely independent) at
the address below to review Your case without effecting Your right to take legal action;
The Financial Ombudsman Service
South Quay Plaza
183 Marsh Wall
LONDON, E14 9SR
Tel: 0845 080 1800
Please note that the Financial Ombudsman Service will not consider Your complaint until You have received a
final decision from PTI Insurance Company Limited.
Complaints Procedure
19
We are covered by the Financial Services Compensation Scheme (FSCS). You may be entitled to compensation
from the FSCS if We cannot meet our obligations. Insurance advising and arranging is covered at 90% of the
claim, without any upper limit.
We have not provided You with a personal recommendation or advice as to whether this Policy is suitable for
Your specific needs. This product meets the demands and needs of an individual who seeks protection against
the costs of Accident and Emergency Treatment and routine dental Treatment.
This contract shall be governed by and construed in accordance with English Law unless:
i. You and the Insurer agree otherwise; or
ii. at the date of the contract You are resident of (or, in the case of a business, the registered office or principal
place of business is situated in) Scotland, Northern Ireland, Channel Islands or the Isle of Man, in which
case (in the absence of agreement to the contrary) the law of that country will apply.
The data controllers involved in the administration of Your Policy and claims will have access to Your personal
information as well as to information about Your dental health which is regarded as Sensitive Personal Data. The
data controllers are subject to the Data Protection Act of 1998 and take all precautions necessary to protect that
data. Under the Act, data may be transferred between companies and outside of the EEC provided that the data
controllers of companies named in the Policy abide by the provision of the Act. By agreeing to this dental cover
You also provide consent to the data controllers of companies named in this Policy to handle and store any such
data as may be required to manage the benefits as laid out in this Policy.
You have 14 days from completing Your application process in which to change Your mind
Here are some questions to help You decide.
Do You understand what Your Policy will do for You?
Before You complete the application process You should have read the Policy Overview which forms
part of the Policy Document, which details how the Plan will work for You. This should answer Your
questions.
If there is anything which is still unclear please contact Denis UK Limited 0800 633 5037. If You wish to
proceed with the Policy what should You do?
Simply ignore this notice.
If You wish to cancel what should You do?
If You wish to cancel Your Cover please de-select the benefit on Your employee benefits website, or call
Denis UK Limited on 0800 633 5037.
You must cancel Your Cover on or before the 14th
day following the completion of Your application
process.
Will You lose anything by cancelling?
PTI Insurance Company Limited will repay You any money you have paid to it free of charges provided
no claims have been submitted and paid during this Period of Cover. The reimbursement will be paid to
You via payroll within 60 days of Your instruction to cancel cover.
Compensation Arrangements
Applicable Law
Your Right to Change Your Mind
Statement of Demands & Needs
Data Protection
20
Maximum Payable per Procedure and rules
Annual Aggregate Maximums
Routine Treatment
Accident Treatment
£1,250 £1,250
£3,750 £3,750
£5,000 £5,000
2140 Oral Cancer £20,000 £20,000 £20,000
Code
Treatment description
Qty per policy
period Pearl Gold Platinum
Specific rules pertaining
to procedure
Private Treatments 2010 Normal Examination 2 £15.00 £45.00 100% 2011 Extensive Examination 1 £19.00 £65.00 100% 2012 Full case assessment 1 £30.00 £96.00 100% 2021 Small X-ray 4 £5.00 £11.00 100% 2022 Medium X-ray 4 £9.00 £31.00 100% 2023 Panoral X-ray 1 £15.00 £37.00 100% 2030 Scale & polish 2 £17.00 £63.00 100% 2031 2035 2033
Scale & polish for periodontitis Fissure sealant Topical fluoride application
2 £30.00 £20.00 £20.00
£110.00 £40.00 £40.00
100% 100% 100%
2041 One surface amalgam £15.00 £65.00 100% 2042 Two surface amalgam £18.00 £82.00 100% 2043 Three plus surface amalgam £23.00 £117.00 100% 2044 Composite filling anterior small £22.00 £78.00 100% 2045 Composite filling anterior large £25.00 £95.00 100% 2046 Composite filling posterior small £22.00 £78.00 100% 2047 Composite filling posterior medium £25.00 £95.00 100% 2048 Composite filling posterior large £35.00 £105.00 100% 2061 R.C.T. Incisor/Canine £45.00 £155.00 100% 2062 R.C.T. Premolar £60.00 £190.00 100% 2063
R.C.T. Molar Open root canal for drainage
£80.00 £40.00
£240.00 £80.00
100% 100%
2070 2071
Routine extraction – first extraction Routine extraction – per additional tooth
£30.00 £15.00
£60.00 £30.00
100% 100%
2072 2076 2072 2077 2079 2075
Surgical extraction Dressings Extractions – post-operative care Gingivectomy Mucoperio, Flap bone surgery Abnormal haemorrhaging
£50.00 £20.00 £20.00 £20.00 £50.00 £40.00
£80.00 £40.00 £40.00 £40.00
£100.00 £80.00
100% 100% 100% 100% 100% 100%
2083 Veneer £80.00 £320.00 100% 2082 Inlay £90.00 £410.00 100% 2092 2135
Crown Implant
2
£130.00 £130.00
£470.00 £470.00
100% 100%
2123
Post & core Gold post & core
£40.00 £60.00
£90.00 £120.00
100% 100%
2097 Conventional bridge £320.00 £1,080.00 100% 2098 Adhesive bridge £160.00 £540.00 100% 2096 Re-fix crown £20.00 £50.00 100% 2096 Re-cement crown £20.00 £50.00 100% 2096 Re-cement bridge (any) £20.00 £50.00 100% 2111 Acrylic Full Denture U or L £100.00 £400.00 100% 2113 Acrylic Full Denture U and L £200.00 £800.00 100% 2115 Chrome Denture upper £160.00 £540.00 100% 2116 Chrome Denture lower £160.00 £540.00 100% 2118 Reline dentures £30.00 £60.00 100% 2119 Repair dentures £30.00 £60.00 100% 2121 Mouthguard £45.00 £75.00 100% 2122 Anaesthetic fee £60.00 £100.00 100% 2002 Emergency treatment £30.00 £60.00 100% 2064 Apisectomy £50.00 £110.00 100% 2030 Child orthodontics £325.00 £775.00 100% Up to 17 years 2150 2003 2073
Overnight hospital stay Call-out fee Incising an abscess Occlusal splint
£35.00 £50.00 £20.00 £50.00
£65.00 £100.00 £40.00
£100.00
100% 100% 100% 100%
2200
NHS Treatments NHS Band 1
100% 100%
100%
100%
100% 100%
100%
100%
100% 100%
100%
100%
2201 NHS Band 2
2202
NHS Band 3
NHS Band 4
Appendix A
21
How to contact us
PTI Insurance Company Limited. Registered in Gibraltar No. 33927. Registered Office: Suite 935, Europort,
Gibraltar. PTI Insurance Company Limited are regulated in Gibraltar by the Financial Services Commission
(www.fsc.gi) is a member of the Association of British Insurers and the Financial Ombudsman Service. © Dental Insurance Solutions Limited – 7 August 2014
24 Hour emergency helpline To assist you in locating a dentist anywhere in the world in the event of a dental injury or emergency.
Call: 0845 519 2098 (in the UK) +44 (0)845 519 2098 (outside the UK)
General enquiries If you have any queries at all, please do not hesitate to contact one of our advisors.
Call: 0800 633 5037 E-mail: [email protected]
Need help finding a dentist? We are only too happy to help you locate a dental practice in your area through our Find-a-Dentist service.
Call: 0845 519 2098 (in the UK) +44 (0)845 519 2098
(outside the UK)
Dental Claims helpline Should you have any questions regarding a claim or require a claim form please contact our Dental Claims Helpline.
Call: 0800 633 5037 E-mail: [email protected]
Continuing with your dental plan If your company ceases to offer dental cover as an employee benefit, or if you have to leave your current company, please do not hesitate to contact us to discuss how you can continue to benefit from our services.
Call: 0845 094 0552
E-mail: [email protected] Website: www.columbusdentalplan.com
