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These Exclusions Are For The Following Renaissance Individual Dental Plans

(Both of these plans are Dental Insurance)

1. Benefits for Periodontal Prophylaxes (teeth cleaning by a specialist) are payable twice per benefit year.
2. Benefits for prophylaxes and oral examinations are payable twice per benefit year.
3. A third prophylaxis is payable per benefit year for individuals with a documented history of periodontal disease and a fourth prophylaxis is payable for two consecutive calendar years following periodontal surgery.
4. Benefits for bitewing X-rays are payable once per benefit year.
5. Benefits for full mouth X-rays (which include bitewing X-rays) are payable once in any five consecutive years.
6. Crowns, onlays, dentures, bridges, and substructures are limited to once in a seven-year period.
7. Benefits for Temporomandibular Disorders (TMD) are limited to those services normally provided by a dentist to relieve oral symptoms associated with malfunctioning of the temporomandibular joint. This does not include services that would normally be provided under medical care.
8. Composite resin (white) restorations and porcelain crowns are Covered Services on posterior teeth.
9. Fluoride treatments are payable twice per benefit year for people up to age 14.

1. Treatment of injuries or illness as covered by worker’s compensation or employer’s liability laws.
   Since Savon is not Insurance, if you have workers' compensation or are self-employed, you are still entitled to your Savon benefits.
   
   
2. Services received without cost from any federal, state or local agency. This exclusion will not apply if prohibited by law.
3. Cosmetic surgery or procedures purely for cosmetic reasons.
4. Services for congenital (hereditary) or developmental malformations. Such malformations include, but are not limited to, cleft palate and upper and lower jaw malformations. This does not exclude those services provided under orthodontic benefits, if a plan benefit.
5. Treatments to restore tooth structure lost or worn from wear, erosion, attrition or abrasion.
6. Orthodontia or braces
   This is especially important for anyone in need of braces.
   
   
7. Treatment to rebuild or maintain chewing surfaces due to teeth out of alignment or occlusion, or treatment to stabilize teeth. For example: equilibration, periodontal splinting, and double abutments or bridges.
8. Oral hygiene and dietary instructions, treatment for drugs or other medication, experimental procedures, conscious sedation and extra oral grafts (grafting of tissues formed outside the mouth to oral tissues).
9. Charges by any hospital or other surgical or treatment facility and any additional fees charged by the dentist for treatment in any such facility.
10. Services by a dentist beyond the scope of his or her license.
11. Administrative charges for claim forms and online submissions.

1. Services for injuries or conditions paid pursuant to Workers’ Compensation or Employer’s Liability laws. Services that are received from any government agency, political subdivision, community agency, foundation, or similar entity. NOTE: This provision does not apply to any programs provided under Title XIX of the Social Security Act, that is, Medicaid; Since Savon is not Insurance, if you have workers' compensation or are self-employed, you are still entitled to your Savon benefits.


2. Services or appliances started prior to the date the person became eligible under this Policy, excluding orthodontic treatment in progress (if a Covered Service);
3. Charges for failure to keep a scheduled visit with the Dentist;
4. Charges for completion of forms or submission of claims;
5. Services, items or supplies for which no valid dental need can be demonstrated, as determined by RLHICA;
6. Services, items or supplies that are specialized techniques, as determined by RLHICA;
7. Services, items or supplies that are investigational in nature, including services, items or supplies required to treat complications from investigational procedures, as determined by RLHICA;
8. Treatment by other than a Dentist, except for services performed by a licensed dental hygienist or other licensed provider under the scope of his or her license as permitted by applicable state law;
9. Services, items or supplies excluded by the policies and procedures of RLHICA;
10. Services, items or supplies which are not rendered in accordance with accepted standards of dental practice, as determined by RLHICA;
11. Services, items or supplies for which no charge is made, for which the patient is not legally obligated to pay or for which no charge would be made in the absence of RLHICA coverage;
12. Services, items or supplies received as a result of dental disease, defect or injury due to an act of war, declared or undeclared;
13. Services, items or supplies that are generally covered under a hospital, surgical/medical or prescription drug program;
14. Services, items or supplies that are not within the categories of Benefits that have been selected by the Policyholder and are not covered in this Policy;
15. Prescription drugs, non-prescription drugs, premedications, localized delivery of chemotherapeutic agents, relative analgesia, non-intravenous conscious sedation, therapeutic drug injections, hospital visits, desensitizing medicaments and techniques, behavior management, athletic mouthguards, house/extended care facility visits, mounted occlusal analysis, complete occlusal adjustments, enamel microabrasions, odontoplasty or bleaching;
16. Correction of congenital or developmental malformations, cosmetic surgery or dentistry for aesthetic reasons as determined by RLHICA;
17. Any appliance, restoration or surgical procedure used to (a) change vertical dimension; (b) restore or maintain occlusion; (c) replace tooth structure lost as a result of abrasion, attrition, abfraction or erosion; or (d) splint or stabilize teeth for periodontal reasons.

1. RLHICA’s obligation for payment of Benefits ends on the last day of the month in which coverage is terminated under this Policy;
2. When services in progress are interrupted and completed later by another Dentist, RLHICA will review the claim to determine the amount of payment, if any, to each Dentist;
3. Care terminated due to the death of a Certificate Holder or Eligible Dependent will be paid to the limit of RLHICA’s liability for the services completed or in progress;
4. The Maximum Payment will be limited to the amount specified in the Declarations Section of this Policy;
5. If a Deductible amount is specified in the Declarations Section, RLHICA will not be obligated to pay, in whole or in part, for any services, items or supplies to which the Deductible applies until the Deductible amount is met.