Percentage Payable

The percentage payable is the maximum percentage of your costs that the plan will reimburse you, for you and your dependents’ Covered Expenses, after any deductible is satisfied. 

Deductible

The deductible is the amount of Covered Expenses which you must pay each calendar year before benefits are payable under this plan.   

Calendar Year Maximum

The Calendar Year Maximum is the maximum amount the plan will allow any one individual for Dental Care Benefits in a single calendar year.

Lifetime Maximum

The Lifetime Maximum is the maximum amount this plan will allow any one individual for Dental Care benefits in their lifetime. 

Free Choice of Dentist

You may choose any licensed dentist or licensed denturist practicing within the scope of his or her profession.

What the Insurance Covers

The dental benefits described in this section apply to both the Member and their eligible Dependents.  This plan covers work included in a comprehensive list of dental expenses, which appears later.  Many dental conditions can properly be treated in more than one way.  The final choice of treatment is always between the patient and the dentist.  This Plan is designed to help pay your dental expenses but not on the basis of treatment that is more expensive than necessary for good dental care.  Thus, if a condition is being treated for which two or more services included in the list are suitable under customary dental practices, the benefit under this Plan will be based on the least expensive of the services. 

If a dental service is performed that isn't in the list, but the list contains one or more other services that under customary dental practices are suitable for the condition being treated, then for the purpose of the Plan, the least expensive of the suitable services listed will be considered to have been performed. 

The final choice of treatment is always between the patient and the dentist.  You are financially responsible to your dentist for the cost of dental work performed.  This Plan will reimburse you to the limits described herein. 

See "Charges Not Eligible for Dental Insurance" later in this section of the website for additional exclusions.

Pre-Determination of Benefits

Pre-Determination of Benefits permits the review of the proposed treatment in advance and allows for a resolution of any questions before, rather than after, the work has been done.  Additionally, both you and the dentist will know in advance what the Plan will allow assuming you, or the Dependent, remain covered.  A “Treatment Plan” is strongly recommended when dental work is expected to exceed $500.

1. Treatment Plan" is the dentist's report that:
2. itemizes the dentist's recommended services,
3. shows the dentist's charge for each service, and
4. is accompanied by supporting X-rays, or a letter of expertise.

The "Treatment Plan" will be returned to the dentist, with a copy to you, showing the estimated benefits. 

What An "Eligible Charge" Is

An "Eligible Charge" is one the dentist makes to you for a covered dental service furnished to you or a covered Dependent, provided the service is included in the list of Covered Dental Expenses and not listed under Exclusions. 

All expenses are assessed on a reasonable and customary basis.  Lab fees may be cut back accordingly.

A charge is considered incurred on the date the service is received, rather than on the date the charge is made.  In the case of root canal therapy, crowns, dentures or bridgework, which may require multiple appointments, the date the expense is incurred will be the date the service is finally completed.  For dentures or bridgework, this date will be the date the prosthetic device is installed.  For crowns, this will be the date the permanent crown is installed and for root canal therapy, this will be the date the canal is closed.

Termination of Benefits

No benefits for Covered Dental Expenses will be paid for expenses incurred after the policy terminates, or after the individual’s coverage terminates.

The following exceptions apply only if the treatments specified are covered under this policy and there is no replacement dental insurance coverage after such termination:

1. Where an impression for a denture, bridge or crown was taken or root canal therapy was started prior to the termination of insurance, dental expense in connection with these procedures and incurred within 30 days of termination will be considered as incurred prior to termination.
2. Where Orthodontic Treatment has commenced and a treatment plan has been submitted in advance to the Insurer, dental expenses in connection with such treatment and incurred within 90 days of termination will be considered as incurred prior to termination.

Covered Dental Expenses

The percentage payable and the Calendar Year Maximum are specified in the “SUMMARY OF BENEFITS”.   Charges for reasonable and customary services and supplies specified below shall be considered covered expenses when incurred by you or a covered dependent.  Eligible expenses include Basic and Preventive Treatment, Endodontics, Periodontics, Oral Surgery, Major Restorative and limited Prosthodontics.  An expense is eligible to the extent that coverage is not prohibited by provincial health insurance plans or because of other limitations described below or in the “SUMMARY OF BENEFITS”.

Basic Procedures:

1. oral examinations including scaling, polishing and cleaning of teeth 
2. topical application of sodium or stannous fluoride
3. dental x-rays: single diagnostic x-rays; complete series or equivalent
4. oral hygiene instruction
5. consultations
6. extractions
7. oral surgery including excision of impacted teeth
8. amalgam, acrylic, silicate or composite fillings
9. retentive pins
10. anaesthesia where reasonably and customarily required in connection with other covered procedures
11. occlusal equilibration is limited to eight units per calendar year
12. treatment of periodontal and other diseases of gums and tissues of the mouth,(special periodontal appliances)
13. emergency endodontic procedures and root canal therapy
14. prefabricated full coverage restorations for primary teeth
15. passive space maintainers, those that do not move the teeth, and pit and fissure sealants for Dependent Children under the age of 18 only, for molar and bicuspid teeth
16. caries, trauma and pain control
17. study casts, once every twelve (12) months

Major Procedures:

1. metal inlays and crowns, used to restore natural teeth to their normal functions where the tooth, as a result of extensive caries or fracture, cannot be restored with a filing.   When a tooth can be restored with silver amalgam, silicate or synthetic restorations, benefits will be determined based on the usual costs of such a restoration.
2. repairing, relining and rebasing of dentures to the frequency specified in the “SUMMARY OF BENEFITS’
3. denture adjustments
4. initial installation of partial or full removable dentures
5. replacement of existing partial or full removable denture(s) providing:
   a. the existing appliance is at least 5 years old and cannot be made serviceable; or, 
   b. the existing appliance is replaced as a result of the initial placement of an opposing denture.
   Replacement of lost or stolen dentures, the duplication of dentures and personalization or characterization of dentures is not covered.  A temporary appliance is considered to be permanent if not replaced within 12 months from the date the temporary appliance was inserted.
6. initial installation of fixed bridgework
7. bridge repairs and recementation
8. replacement of existing fixed bridgework providing:
   a. the existing fixed prosthetic device is at least 5 years old and cannot be made serviceable; or,
   b. the replacement is required because of extraction, loss or fracture of one or more sound natural teeth after the individual became insured under this plan.
   A temporary bridge is considered to be permanent if not replaced within 12 months from the date the temporary bridge was inserted.

Orthodontic Treatment

Orthodontic treatment includes the diagnosis or correction of teeth irregularities and malocculsion of jaws, by wire appliances, braces or other mechanical aids, commonly known as “straightening of the teeth”.  These include active space maintainers, or orthodontic appliances for the purpose of repositioning or moving the teeth. 
Expenses are covered at the percentage and to the maximum shown in the “SUMMARY OF BENEFITS”.  This benefit is only available to eligible dependent children under the age of 19. 

A Pre-Treatment Plan is always required for this benefit.  Treatment will generally extend over a two or three year time span.   The Claims Office will respond to the Pre-Treatment Plan with an explanation of how the monthly reimbursement process will work for the duration of the Orthodontic treatment.   Claim payment is on a reimbursement basis, subject to the submission of paid receipts.

Charges Not Eligible For Dental Insurance

Payment will not be made for any dental procedure required due to an injury or dental disease for which you, or your dependent, were advised to receive treatment or for which treatment first began before the effective date for that dental procedure.
The following items are not considered as covered expenses:

1. replacement of a lost or stolen prosthetic device
2. services and supplies that are partially or wholly cosmetic in nature
3. supplies or services which are not furnished by a legally qualified dentist or denturist acting within the scope of his license
4. charges for completion of claim forms, broken appointments, counselling, travel, communication costs or for advice by telephone
5. charges for protective athletic appliances
6. expenses incurred as a result of intentionally self-inflicted injuries (while sane or insane) or as a result of committing or attempting to commit a criminal offence
7. expenses for treatment required as a result of war, (declared or not) or participation in a riot, insurrection or civil commotion
8. expenses for services or treatment that are payable by Workplace Safety & Insurance Law (or Similar legislation) or any government plan, or which are received without charge or which a government health plan prohibits being paid
9. services or supplies for implantology, including tooth implantation, transplantation and surgical insertion of fabricated implants
10. services or supplies in connection with any procedures excluded as an eligible expense
11. any hospital charges for board and room and related services and supplies
12. any dental examinations required by a third party
13. services or supplies which are not medically necessary to the care and treatment of any existing or suspected injury or disease
14. any charges which would not normally have been made but for the presence of this insurance or for which you or your dependent are not obligated to pay
15. dental treatment which is primarily experimental or for dietary planning,  congenital or  developmental malformation
16. any dental procedure required due to teeth extracted, missing or fractured before the effective date of your coverage for that procedure except as specifically stated for appliance replacement above
17. any charges which were considered an insured service of any provincial government plan at the time this plan/benefit was issued and subsequently were modified, suspended or discontinued
18. any services covered in whole or in part by any government plan, services for which no charge is made, or services which the insurer is not permitted by law to cover.

Co-ordination with Other Benefits

This plan has been designed to help you meet the cost of disease or injury.  Since it is not intended that you receive benefits greater than the actual expenses incurred, any dental care coverage you have under other “plans” will be taken into account in determining the amount of benefit payable under this plan, that is, the benefits under this plan will be coordinated with the benefits of the other plans.

Plan means any contract of group insurance or other arrangement for members of a group (whether on an insured basis or not), prepaid dental care coverage, or student accident insurance.

Specifically, this plan will pay either its regular benefits in full, or a reduced amount which, when added to the benefits available under the other plan, or plans, will equal 100% of “allowable expenses”.

Allowable expense means any necessary, reasonable and customary expense, incurred while eligible for benefits under this plan, part or all of which would be payable under any of the plans, but not any expenses contained in the list of Exclusions.

The manner in which this is done determines which plan pays first (and thus where to submit the claim first) and which plan(s) pays next.  The plan that does not have a co-ordination of benefits provision pays before the plan that does (most, if not all, insurance company plans have such a provision).
For any person who is covered under more than one plan, benefits will be payable first under the plan where he is the insured Member and secondarily where he is covered as a dependent. 

Dependent children are covered first by the parent whose birthday comes first in the year, and any unpaid balance can then be submitted to the other parent’s plan. 
If priority cannot be established in the above manner, the benefits shall be pro-rated between or amongst the plans in proportion to the amounts that would have been paid under each plan had there been coverage by just that plan.

To implement this provision, the Trust Fund and the insurer may:

1. Subject to the consent of the covered person, if required by law, obtain from or release to any other person, corporation or organization any information deemed to be needed; or
2. Pay to or recover from any person, corporation or organization any excess payment; any payment so made will be deemed to be benefits paid and, to the extent of such payments, will fully discharge the Trust Fund and the insurer from all liability under this plan.

Extension of Dental Care in the Event of Your Death

Dental Care coverage for dependents shall continue without premium payment following your death up to a maximum of 12 months from the date of death but not beyond the date your spouse remarries or the date the dependent is no longer a dependent, as defined in this website, or to the date the policy or benefit terminates, whichever is earlier.

Any extended benefits payable are subject to the provisions and limitations of the plan.

Proof of Loss

Written proof stating the occurrence, character and extent of loss must be submitted for each benefit to the administrator within 12 months after the date of the loss, but not more than 3 months after the date coverage for Dental Care Benefits terminates.

How to File a Dental Care Claim

Claim forms may be obtained from the Trust Fund’s administrator or the Claims Office or from the website at www.bpagroup.com.  Your dentist’s office will have a supply of generic dental claim forms that are also acceptable.  Please note that an original claim form signed by your dentist must be mailed to the Claims Office.  Electronic submission of claims is not accepted.
Before submitting the claim form, ensure that all questions, have been answered, that you have signed your name and clearly identified yourself by full name, return mailing address and your employer and Union.   You must attach any statements related to the claim that may have been received from any other plan. Faulty or missing information will only result in a delay in processing your claim.

If the claim is for your Dependent, provide the Dependent's first name, date of birth and relationship to you.
When you are sure that all of the above has been completed, forward the form to the Claims Office.  Your benefit cheque will be mailed directly to you, or if you wish you may assign benefits to be paid directly to your dentist. 

To prevent fraud it is the member’s responsibility to verify the information contained in each Explanation of Benefits, in order to ensure you actually received all of the services and are not being reimbursed for more than you actually spent on Dental services.