CO-ORDINATION OF BENEFITS
(Payment from more than one Plan)
This Plan includes a Co-ordination of Benefits Provision . This provision operates in the event that the member or their dependents are covered under more
than one group dental plan, and ensures that while claim may be made under all plans, total reimbursement received does not exceed the actual expense incurred . If a plan does not have such a provision, that plan must be the first payer for eligible expenses covered under that plan .
When both plans include the provision, expenses should be first submitted to the plan which covers the insured as a member/employee .
For dependent children, expenses should first be submitted to the Plan of the spouse whose birthday falls first in the year . Any amount not paid may then be submitted to the other spouse’s plan .
When submitting claims under the second plan, information and payment details provided by the first plan should be included .
NOTE: The co-ordination of benefits may apply to two members (spouses) who are both paying into the NLTA plan.
Benefits after Termination
In most cases no dental benefits are payable for expenses incurred after the date insurance terminates, even if a treatment plan has been filed and benefits have been approved by the underwriter prior to the date insurance terminates .
However, benefits are payable:
1 . Where an impression for a crown, inlay or onlay had been taken prior to the date insurance terminated and the appliance is installed after the
insurance terminates . Dental expenses in connection with this procedure and incurred within 30 days after the termination of insurance are eligible .
2 . Dependent coverage ceased due to a member’s death and, within 90 days following the death, a dependent of the deceased employee has dental work done which is part of a series of planned essential treatment which had begun, or for which definite dental appointments had been made prior to the member’s death .
Dependent coverage may be continued after the death of a member provided the dependents were insured at the time of the member’s death, and provided the dependents continue to pay the required premium and continue to satisfy the definition of dependent .