1063-Guardian Life Ins CoThe Guardian Life Insurance Company of America
A Mutual Life Insurance Company
7 Hanover Square, New York, New York 10004
Incorporated 1860 by the Laws of the State of New York
EMPLOYER RIDER
Group Plan Number: G- 00407347 -IC
Policyholder: Trustees of the Business and Management Services Industry Insurance Trust Fund
Participating Employer: CITY OF SANFORD
Rider Effective Date: October 1, 2005
It is hereby agreed that the provisions which follow are added to the group policy for the participating
employer named above:
Premium Payments: The first premium payment for this plan is due on the Rider Effective Date. Further
payments are due on the 1st of each month thereafter, as long as this plan stays in effect.
There is a 31 day grace period for all payments except the first. We must receive all payments within 31 days
of the applicable premium due date. If we don't, this plan will automatically end at the end of the grace period.
You will owe us all unpaid premiums for the period this plan was in force.
Term of Rider - Renewal Privilege: This rider is issued for an initial term which starts on the Rider Effective
Date and ends on the day before the first policy anniversary date.
You can renew this rider for further one year terms on each plan anniversary, subject to all of the terms of the
group policy and this rider. Provided we give you 45 days advance written notice, we have the right to cancel
this rider, or any coverage hereunder, on the policy anniversary date or premium due date, if, on that date,
either:
• less than ten employees are insured under this rider; or
• with respect to contributory Dental Expense insurance, less than 35% of those employees who are
eligible for insurance under this plan are insured; or
• with respect to any other contributory coverages, less than 75% of those employees who are eligible for
insurance under this rider are insured.
If this rider also provides dependent coverage on a contributory basis, provided we give you 45 days advance
written notice, we can cancel that coverage on any policy anniversary date or premium due date, if, on that
date, less than 75% of those employees eligible for such dependent coverage are insured.
For non - contributory plans, 100% of the employees eligible for insurance, must be enrolled for coverage. If
dependent coverage is provided, all eligible dependents must be enrolled. Provided we give you 45 days
advance written notice, we have the right to cancel this rider, or any coverage hereunder on the policy
anniversary date or the premium due date, if, on that date, the number of employees or dependents, if
dependent coverage is provided, falls below 100% of those eligible for coverage.
This rider and all coverages hereunder will also end if you stop engaging in the business in which you were
engaged on the Rider Effective Date. You must notify us in writing when the nature of your business activity
changes or when you sell that business. And we must give you 45 days advance written notice of the
cancellation.
If we give you 45 days advance written notice, we may, as of the first day of any policy month, change the
premium rates we charge for this plan.
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You can cancel this plan at any time by giving us 31 days advance written notice. This notice must be sent to
our Home Office. And you will owe us all unpaid premiums for the period this plan is in force.
Associated Companies: If you ask us in writing to include an associated company under this plan, and we
give you our written approval, we'll treat employees of that company like your employees. Our written approval
will include the starting date of the company's coverage by this plan. Each eligible employee of that company
must still meet all of the terms and conditions of this plan before he'll be insured.
You must notify us in writing when a company stops being associated with you. On the date a company stops
being an associated company, this plan will end for all of that company's employees, except those employed
by you or another covered associated company as active eligible employees on such date.
Definitions
Associated company means a corporation or other business entity affiliated with the employer through
common ownership of stock or assets.
Eligible dependent is defined in the provision entitled "Dependent Coverage ".
Employee means a person who works for the employer at the employer's place of business, and whose
income is reported for tax purposes using a W -2 form.
Plan means the Guardian group plan purchased by you, except in the provision entitled "Coordination of
Benefits" where "plan" has a special meaning. See that provision for details.
We, Us, Our and Guardian mean The Guardian Life Insurance Company of America.
You and Your mean the employer who purchased this plan.
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SCHEDULE OF INSURANCE AND PREMIUM RATES
This plan's classifications, and the option packages of benefits which are available to
covered persons who are members of each classification, are shown below.
Class Description
Class 0001 ALL ELIGIBLE EMPLOYEES
Option Packages Available
Employees may choose from the benefit packages available to members of their
class. The option packages are summarized in "Summary of Option Packages"
below.
Members of Class 0001 may choose from benefit option packages A and B.
Summary of Option Packages
The following are summaries of the benefit option packages available. For a complete
explanation of the benefits provided by this plan, including all limitations and
exclusions, please read the entire plan.
Option A Employee and Dependent Dental with benefits for preventive services paid at a rate of
100 %, basic services paid at a rate of 80% and major services paid at a rate of 50 %.
A benefit year deductible of $50.00 applies to the services. A lower level of benefits is
paid if the covered person does not use the services of a preferred provider.
Option B Employee and Dependent Dental with benefits for preventive services paid at a rate of
100 %, basic services paid at a rate of 80% and major services paid at a rate of 50 %.
A benefit year deductible of $50.00 applies to the services. A lower level of benefits is
paid if the covered person does not use the services of a preferred provider.
GP -1 -SI
00407347/00000.0/K34490
All Options Schedule of Benefits
Employee and Dependent Dental Expense
Option A
Cash Deductible PPO Benefit Year Cash Deductible for Non - Orthodontic Services:
Group Services ........... ............................... None
Group 2 and 3 Services ...... ............................... $50.00
for each covered person
Non -PPO Benefit Year Cash Deductible for Non - Orthodontic Services:
Group Services ........... ............................... None
Group 2 and 3 Services ...... ............................... $50.00
for each covered person
Option B
Cash Deductible PPO Benefit Year Cash Deductible for Non- Orthodontic Services:
Group Services ........... ............................... None
Group 2 and 3 Services ...... ............................... $50.00
for each covered person
Non -PPO Benefit Year Cash Deductible for Non - Orthodontic Services:
Group 1, 2 and 3 Services ... ............................... $100.00
for each covered person
Option A
Payment Rates Payment Rate for Services Furnished By A Preferred Provider:
Group Services ........... ............................... 100%
Group Services ............... ............................80%
Group Services ............... ............................50%
Payment Rate for Services Not Furnished By A Preferred Provider:
Group Services ........... ............................... 100%
Group Services ............... ............................80%
Group Services ............... ............................50%
Option B
Payment Rates Payment Rate for Services Furnished By A Preferred Provider:
Group Services ........... ............................... 100%
Group Services ............ ............................... 80%
Group Services ............ ............................... 50%
Payment Rate for Services Not Furnished By A Preferred Provider:
Group Services ............ ............................... 70%
Group Services ............ ............................... 40%
Group Services ............ ............................... 25%
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Schedule of Benefits
Employee and Dependent Dental Expense (Cont.)
Option A
Payment Limits PPO Benefit Year Payment Limit
for Non - Orthodontic Services - up to ........................... $1,500.00
Non -PPO Benefit Year Payment Limit
for Non - Orthodontic Services - up to ........................... $1,000.00
Note: A covered person may be eligible for a rollover of a portion of his or her
unused Benefit Year Payment Limit for Non - Orthodontic Services. See "Rollover of
Benefit Year Payment Limit for Non - Orthodontic Services" for details.
A "benefit year" is a 12 month period which starts on January 1st and ends on
December 31 st of each year.
Option B
Payment Limits Benefit Year Payment Limit
for Non - Orthodontic Services - up to .......................... $ 1,000.00
Note: A covered person may be eligible for a rollover of a portion of his or her
unused Benefit Year Payment Limit for Non - Orthodontic Services. See "Rollover of
Benefit Year Payment Limit for Non - Orthodontic Services" for details.
A "benefit year" is a 12 month period which starts on January 1st and ends on
December 31st of each year.
Once each year, during the group enrollment period from September 1st to
September 30th, an employee may elect to enroll in one of the dental expense plan
options offered by the employer, or to transfer to another dental expense plan option
offered by the employer. Coverage under the new plan option starts on the October 1
that next follows election. Coverage under the former plan option ends on that date.
Late entrant penalties do not apply to an employee and his or her eligible dependents
who enroll during this period.
All Options Schedule of Benefits
Effective Dates for Changes to Insurance
All Options
Changes in Any increase or decrease in the amount of insurance on any individual shall become
Insurance Amounts effective on the effective date of a change in the Employee's classification, except
that any increase in the amount of insurance on an Employee or a Qualified
Dependent eligible for benefits under an established benefit period shall become
effective:
• in the case of an Employee not actively at work, on the day on which he
returns to active work on a full -time basis (or the day on which his benefit
period terminates, whichever is later) or
• in the case of an Eligible Dependent confined to a hospital, on the day on
which the dependent is discharged from the hospital (or the day on which his
benefit period terminates, whichever is later).
In no event shall the insurance of an Eligible Dependent of an Employee who is not
actively at work on a full -time basis be increased or decreased prior to the date such
Employee returns to active work on a full -time basis.
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Schedule of Premium
The monthly premium rates, in U.S. dollars, for the insurance provided under this plan
are listed below.
All Options Premium Rates
Dental Expense Insurance
Option A Class 0001
Rate per
Employee
$ 19.21
Option B Class 0001
Rate per
Employee
$ 13.72
per Employee
and Insured
Spouse with no
Insured Child
$ 40.46
per Employee
and Insured
Spouse with no
Insured Child
$ 27.51
per Employee per Employee
and Insured and Insured
Child with no Family
Insured Spouse
$ 41.63 $ 68.50
per Employee
and Insured
Child with no
Insured Spouse
per Employee
and Insured
Family
$ 49.10
We have the right to change any premium rate(s) set forth above at the times and in the manner established
by the provision of the group plan entitled "Premiums ".
All Options
A specimen copy of the master group policy provisions which apply to the plan of insurance for the
participating employer named on the first page of this rider, is attached hereto and incorporated herein. The
originals of such provisions are part of the master group policy which was delivered in the State of Rhode
Island to the Citizens Savings Bank and Citizens Trust Company (Trustee) as Policyholder.
All Options
If this plan of insurance includes major medical, dental or prescription drug coverages, these coverages
provide benefits for employees and dependents.
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00407347/00000.0/K34490
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This rider shall form a part of the group policy. You, the policyholder and The Guardian are subject to all of
the terms and conditions contained in the group policy and this rider.
Dated at Bethlehem, PA This 6th Day of October , 2005
The Guardian Life Insurance Company of America
Second Vice President & Actuary, Group Insurance
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00407347/00000.0/K34490 p.9
All Options
Trustees. The term "trustees" shall mean the Citizens Savings Bank and Citizens Trust Company.
Participating Employers - Eligible Employer. An Eligible Employer may become a Participating Employer by
filing, through the Trustees, with the Home Office of the Insurance Company an agreement executed by the
employer adopting the terms of the Trust Agreement and by receiving the Insurance Company's approval, in
writing, of its inclusion as a Participating Employer. The date the employer becomes a Participating Employer
shall be stated in the Employer Rider pertaining to such Employer. "Employer Rider" as used any place in this
Policy shall mean each separate rider or riders, attached to and forming part of this Policy, identifying and
specifically applying to each employer who is a Participating Employer under this Policy and which contains
details of the plan of insurance pertaining to the employees of each such Participating Employer.
"Eligible Employer" as used above shall mean any employer engaged in the industry covered under this
Policy.
Participation Date. The date as of which an Employer becomes a Participating Employer is referred to herein
as the Participation Date with respect to such Employer and its Employees.
Employees Eligible. Those employees identified in the Employee Riders are eligible for insurance under this
Policy for the insurance coverages specified therein.
Termination of Employee Coverage. An Employee's insurance on behalf of himself under this Policy shall
automatically terminate:
(1) If his employment terminates.
(2) If he ceases to be a member of the classes of employees eligible for the insurance.
(3) If this Policy terminates.
(4) If this Policy is discontinued with respect to the Employees of his Participating Employer.
Termination of employment shall be deemed to occur when the Employee ceases active service on a full -time
basis with his Participating Employer, except to the extent this requirement is modified in the Employer Rider
pertaining to each Participating Employer.
Schedule of Insurance and Premium Rates:
Schedule. This Group Policy, together with any amendments thereto, contains all the insurance coverages
which may be provided by the Employer Rider. The insurance benefits, and the amount thereof, for which the
employee is eligible under this Policy on behalf of himself, and on behalf of his dependents if they are covered
under this Policy, shall be in accordance with the provisions of the Employer Rider pertaining to each
Participating Employer. The classification of each individual Employee shall be determined by the Policyholder
from time to time without discrimination among persons in like circumstance, and such determination shall be
final and conclusive.
TGP -1 -MET P140.9047 -R
All Options
Premiums: Premiums under this Policy are due and payable, as specified on the first page of this Policy, by
the Policyholder at an office of the Insurance Company or to an authorized representative. By mutual
agreement between the Policyholder and the Insurance Company the interval of payment may be changed,
with appropriate adjustment to provide for payment annually, semi - annually, quarterly, or monthly.
The premium due under this Policy on each premium due date shall be the sum of the premium charges for
the insurance coverages provided for Participating Employers under this Policy and shall be based upon the
rates set forth in the Employer Riders, provided that (a) on the first anniversary of any such Rider and on the
00407347/00000.0/K34490 p.10
first day of any month thereafter, and (b) on any date the extent of coverage for a Participating Employer
under any such Rider is changed by amendment to this Policy, or to such Rider, the Insurance Company may,
by advance written notice to the Policyholder, change the rates at which further premiums due for the
Insurance provided under such Rider shall be computed. Such change shall apply to premiums due on and
after the effective date of the change stated in such notice. The Insurance Company, however, shall not have
the right to change the rates under (a) above more than once during any twelve consecutive months, with
respect to an Employer Rider.
Adjustment of Premiums Payable Other Than Monthly or Quarterly: If under the foregoing provisions, a
premium rate is changed, (or if under the provision "Computation of Group Life Insurance Premiums ", an
average premium rate is changed) after an annual or semi - annual premium became payable with respect to
coverage on or after the date of such change, such premium shall be adjusted by a proportionate increase or
decrease for such unexpired period for which such premium became payable. If the adjustment results in a
decrease in such premium which became payable the amount of the decrease for such unexpired period shall
be payable to the Policyholder by the Insurance Company. If the adjustment results in an increase in such
premium which became payable the amount of the increase for such unexpired period shall be considered a
premium due on the date of such change, and the Policy provisions concerning grace period shall apply
thereto.
Liability of Trustees to Pay Premiums: The Trustees (the Policyholder hereunder) shall be exempt from
personal liability with respect to the premiums required by this Policy to be paid by them, but shall be liable for
such premiums only in their fiduciary capacity.
Grace in Payment of Premiums - Termination of Policy: A grace period of thirty-one days, without interest
charge, will be allowed the Policyholder for the payment of the premium due under this Policy on any due date
except the first. If any premium with respect to the Employees of any Participating Employer is not paid before
the expiration of the grace period, this Policy shall automatically terminate with respect to all Employees of
such Participating Employer at the expiration of the grace period, except that if the Policyholder shall have
given the Insurance Company written notice in advance of an earlier date of termination during the grace
period, this Policy shall terminate with respect to all Employees of such Participating Employer as of such
earlier date. The Policyholder shall be liable to the Insurance Company for all unpaid premiums with respect to
the Employees of a Participating Employer for the period (including a pro -rata premium for the grace period or
fraction thereof) during which this Policy was in force with respect to such Employees.
This Policy shall terminate immediately upon termination of an insurance coverage under this Policy if, as the
result of the termination of such coverage, no benefits remain in effect under this Policy.
Term of Policy and Employer Riders - Renewal Privilege: This Policy is issued for a term of one (1) year
from its effective date. All Policy years and Policy months shall be calculated from the effective date. All
periods of insurance under the Employer Riders shall begin and end at 12:01 A.M. Standard Time at the
Policyholder's place of business.
The Policyholder may renew this Policy for a further term of one (1) year, on the first and each successive
anniversary of its effective date; provided, however, that the Insurance Company has the right to: (A) decline
to renew this Policy on any anniversary, and (B) to decline to renew a particular insurance coverage on the
first anniversary, or on any premium due date thereafter, if with regard to (A) the number of Employees
insured under this Policy, or with regard to (B) the number of Employees insured for such Coverage, shall be
less than twenty -five. If, in accordance with the preceding paragraph, the Policy is not renewed, all Employer
Riders shall thereupon terminate as of the date the Policy terminates. Subject to the foregoing, the
renewability of the insurance provided under an Employer Rider shall be in accordance with the provisions of
such Rider.
Renewal is conditioned upon payment of the premium then due, computed as provided in the Section entitled
"Premiums ".
TGP -2 -MET -R P140.0002 -R
00407347/00000.0/K34490 p.11
All Options
The Contract: The Policy and any riders or amendments hereto, and the Application of the Participating
Employer, a copy of which is attached hereto or endorsed hereon and made a part hereof, constitute the
entire contract between the parties.
The Policy may be amended at any time, without the consent of the Employees insured hereunder or any
other person having a beneficial interest therein, upon written request made by the Participating Employer and
agreed to by the Insurance Company, but any such amendment shall be without prejudice to any claims
arising prior to the date of the change. No agent is authorized to alter or amend this Policy, to waive any
conditions or restrictions contained herein, to extend the time for paying a premium, or to bind the Insurance
Company by making any promise or representation or by giving or receiving any information. No change in
this Policy shall be valid unless evidenced by an endorsement or rider hereon signed by the President, a Vice
President, a Secretary, the Actuary, and Associate Actuary, an Assistant Secretary or an Assistant Actuary of
the Insurance Company, or by an amendment hereto signed by the Policyholder and by one of the aforesaid
officers of the Insurance Company.
Wherever in this Policy a personal pronoun in the masculine gender is used or appears, it shall be taken to
include the feminine also, unless the context clearly indicates the contrary.
Incontestability: This Policy shall be incontestable after two years from its date of issue except for
non - payment of premiums. With respect to a Participating Employer, the policy shall be incontestable based
on statements made in the application after two years from the Employer Rider Effective Date.
With respect to the insurance on an Employee and /or his eligible dependents, their insurance shall be
incontestable after two years from his effective date, except for violation by the Employee of the conditions, if
any, of this Policy relative to military or naval service.
Clerical Error - Misstatements: Neither clerical error by the Policyholder, a Participating Employer, or by the
Insurance Company in keeping any records pertaining to insurance under this Policy, nor delays in making
entries thereon, shall invalidate insurance otherwise validly in force or continue insurance otherwise validly
terminated, but upon discovery of such error or delay an equitable adjustment of premiums shall be made.
If the age of an employee, or any other relevant facts, be found to have been misstated, and the premiums
are thereby affected, an equitable adjustment of premiums shall be made, and if such misstatement affects
the existence on the amount of insurance, the true facts shall be used in determining whether insurance is in
force under the terms of this Policy and in what amount.
Statements: No statements shall avoid the insurance under this Policy, or be used in defense of a claim
hereunder unless in the case of the Participating Employer, it is contained in the Application for this Policy,
signed by him and in the case of an Employee, it is contained in a written request or application signed by
him and a copy of which has been furnished to him or to his beneficiary.
All statements shall be deemed representations and not warranties.
Employee's Certificate: The Insurance Company will issue to the Participating Employer, for delivery to each
Employee insured hereunder, a copy of his application and certificate booklet which shall state the essential
features of the insurance to which the Employee is entitled and to whom the benefits are payable, and in case
of group life insurance, the provisions of the section "Conversion Privilege." Any such certificate shall not
constitute a part of this Policy and shall in no way modify any of the terms and conditions set forth in this
Policy.
In the event this Policy is amended by changes which affect the description of the essential features of the
insurance contained in an Employee's Certificate, a rider or revised certificate reflecting such changes will be
issued to the Policyholder for delivery to the Employee.
TOP -3- MET -87 P140.0004 -R
00407347/00000.0/K34490 p.12
All Options
Dividends: The portion, if any, of the divisible surplus of the Insurance Company allocable to this Policy at
each Policy anniversary shall be determined annually by the Board of Directors of the Insurance Company and
shall be credited to this Policy as a dividend on such anniversary, provided this Policy is continued in force by
the payment of all premiums to such anniversary.
Any dividend under this Policy shall be paid to the Policyholder in cash, or at the option of the Policyholder it
may be applied to the reduction of the premiums then due.
If the dividends under this Policy should be in excess of the Policyholder's cost of insurance, such excess
shall be applied for the sole benefit of the Employees.
Payment of any dividend to the Policyholder shall completely discharge the liability of the Insurance Company
with respect to the dividend so paid.
Assignment: The right of the Insured Employee to assign any interest under this policy shall be governed as
follows:
(1) With respect to Group Term Life Insurance (Including Employee Basic Term Life Insurance and
Employee Supplemental Term Life Insurance if provided under the Policy), the Insured Employee may,
subject to the following conditions, assign all rights or interest of every kind which he now has, or
hereafter may acquire, in such insurance, including, but not limited to, those stated under the applicable
provisions in this Policy entitled "BENEFICIARY ", "CONVERSION PRIVILEGE" and "OPTIONAL MODES
OF SETTLEMENT ", provided (a) such assignment be irrevocable and absolute in form, for no value, with
the Insured Employee retaining no further interest in such insurance; and (b) the assignment be made to
only ONE of the following: the spouse, child or grandchild, parent or grandparent, brother or sister of the
Insured Employee, or the trustee of a trust established for the benefit of one or more of these.
(2) With respect to Accident and Health Insurance, neither the Insured Employee's certificate nor the right to
insurance benefits hereunder is assignable, except that the benefits, if any, payable for hospital, surgical
or medical expense may be assigned to the institution or person providing the service on account of
which such benefits become payable.
The Insurance Company shall not be charged with notice of any assignment of interest under this Policy until
the original assignment has been accepted and if filed with it at its Home Office. However, the Insurance
Company assumes no responsibility for the validity or effect of any such assignment and its position with
respect thereto is not altered by filing or recording the same, save as to notice thereof.
Records - Information to be Furnished: The Policyholder shall keep a record of Employees insured,
containing, for each Employee, the essential particulars of the insurance. The Policyholder shall, as prescribed
by the Insurance Company, periodically forward to the Insurance Company, on the Insurance Company's
forms, such information concerning the Employees eligible for insurance under this Policy as may reasonably
be considered to have a bearing on the administration of the insurance under this Policy and on the
determination of premium rates, and any other information which the Insurance Company may reasonably
require with regard to any matters pertaining to this Policy. Any records of the Policyholder, or of the
Participating Employers, as may have a bearing on the insurance under this Policy shall be open for
inspection by the Insurance Company at any reasonable time.
Claims of Creditors: Except so far as may be contrary to the laws of any state having jurisdiction in the
premises, the insurance and other benefits under this Policy shall be exempt from execution, attachment,
garnishment, or other legal or equitable process, for the debts or liabilities of the Employees or their
beneficiaries.
Assignment by Trustees or Participating Employers: Assignment or transfer of the interest of the
Policyholder or of any Participating Employer under this Policy shall not bind the Insurance Company without
its written consent thereto.
TOP -4 -MET -R P140.9050 -R
00407347/00000.0/K34490 p,13
AH Options
ATTACHED TO AND MADE PART OF GROUP INSURANCE POLICY NO. G - 00407347 -IC
issued by
The Guardian Life Insurance Company of America
to
Trustees of the Business and Management Services Industry Insurance Trust Fund
with respect to
CITY OF SANFORD
As of October 1, 2005, this rider amends this Policy as follows:
(1) The following provisions of this Policy are hereby deleted and replaced by the revised corresponding
provisions set forth below.
Premiums
Premiums due under this Policy must be paid by the Participating Employer at an office of The Guardian
or to a representative that we have authorized. The premiums must be paid as specified in the Employer
Rider, unless by agreement between the Participating Employer and The Guardian, the interval of payment
is changed. In that event, adjustment will be made to provide for payment annually, semi - annually,
quarterly or monthly.
The premium due under this Policy on each premium due date will be the sum of the premium charges
for the insurance coverages provided under the Employer Rider. The premium charges are based upon
the rates set forth in this Policy's "Schedule of Insurance and Premium Rates" section.
However, we may change such rates:
• on the first day of any policy month;
• on any date the extent or terms of coverage for a Participating Employer are changed by amendment of
this Policy, or of the Employer Rider;
• on any date our obligation under this Policy with respect to a Participating Employer is changed
because of statutory or other regulatory requirements; or
• on any date our obligation under an Employer Rider is changed because of a change in the benefits:
(a) with which the benefits provided by an Employer Rider are coordinated; or (b) which are
supplemented by the benefits provided by an Employer Rider.
We must give the Participating Employer 45 days written notice of the rate change. Such change will
apply to any premium due on and after the effective date of the change stated in such notice.
Adjustment of Premiums Payable Other Than Monthly or Quarterly
Under the above provision, if a premium rate is changed after an annual or semi - annual premium became
payable with respect to coverage on and after the date of such change, the premium will be adjusted by a
proportionate increase or decrease for the unexpired period for which the premium became payable. If the
adjustment results in a decrease, the amount of the decrease will be paid to the Participating Employer by
us. If the adjustment results in an increase, the amount of the increase will be considered a premium due
on the date of the rate change. This Policy's grace period provisions will apply to any such premium due.
00407347/ p.14
Grace in Payment of Premiums - Termination of Policy
A grace period of 31 days , without interest charge, will be allowed the Participating Employer for each
premium payment except the first. If any premium with respect to the employees of a Participating
Employer is not paid before the end of the grace period, such employees' coverage under this Policy
automatically ends at the end of the grace period. However, if the Participating Employer gives us 31 days
written notice in advance of an earlier termination date during the grace period, such employees' coverage
under this Policy ends as of such earlier date.
If the coverage of the employees of a Participating Employer ends during or at the end of the grace
period, the Participating Employer will still owe us premium for all the time coverage was in force with
respect to such employees during the grace period.
This Policy ends immediately on any date when an insurance coverage under this Policy ends and, as a
result, no benefits remain in effect under this Policy.
GP- 1- A- GP -90 -1
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Incontestability
P150.001 1-R
This Policy is incontestable after two years from its date of issue, except for non - payment of premiums
A Participating Employer's insurance under this Policy shall be incontestable after two years from his
Rider Effective Date, except for nonpayment of premiums.
No statement in any application, except a fraudulent statement, made by a person insured under this
Policy shall be used in contesting the validity of his insurance or in denying a claim for a loss incurred, or
for a disability which starts, after such insurance has been in force for two years during his lifetime.
If the Participating Employer's group plan replaces the group plan he had with another insurer, we may
rescind his plan based on misrepresentations made by the Participating Employer or a covered person in
a signed application for up to two years from the Rider Effective Date.
GP- 1- A- GP -90 -2
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The Contract
P150.0005 -R
The entire contract between the Guardian and the Participating Employer consists of this Policy and any
amendments thereto which pertain to his plan of insurance, including the Participating Employer's
Employer Rider, and the Participating Employer's application, a copy of which is attached hereto or
endorsed hereon.
We can amend this Policy or an Employer Rider at any time, without the consent of the insured
employees or any other person having a beneficial interest therein, as follows:
We can amend this Policy or an Employer Rider:
• upon written request made by the Participating Employer and agreed to by The Guardian;
• on any date our obligation under this Policy with respect to a Participating Employer is changed
because of statutory or other regulatory requirements; or
• on any date our obligation under an Employer Rider is changed because of a change in the benefits:
(a) with which the benefits provided by an Employer Rider are coordinated; or (b) which are
supplemented by the benefits provided by an Employer Rider.
If we amend the Policy or an Employer Rider, except upon request made by the Participating Employer,
we must give the Participating Employer written notice of such amendment.
00407347/00000.0/K34490
Any amendments to this Policy or an Employer Rider will be without prejudice to any claim arising prior to
the date of the change.
No person, except by a writing signed by the President, a Vice President or a Secretary of The Guardian,
has the authority to act for us to: (a) determine whether any contract, Policy or certificate of insurance is
to be issued; (b) waive or alter any provisions of any insurance contract or Policy, or any requirements of
The Guardian; (c) bind us by any statement or promise relating to the insurance contract issued or to be
issued; or (d) accept any information or representation which is not in a signed application.
All personal pronouns in the masculine gender used in this Policy, will be deemed to include the feminine
also, unless the context clearly indicates the contrary.
Clerical Error - Misstatements
Neither clerical error by the Policyholder, a Participating Employer or The Guardian in keeping any records
pertaining to insurance under this Policy, nor delays in making entries thereon, will invalidate insurance
otherwise validly in force or continue insurance otherwise validly terminated. However, upon discovery of
such error or delay, an equitable adjustment of premiums will be made.
Premium adjustments involving return of unearned premium to the Participating Employer will be limited to
the period of 90 days preceding the date of our receipt of satisfactory evidence that such adjustments
should be made.
If the age of an employee, or any other relevant facts, are found to have been misstated, and the
premiums are thereby affected, an equitable adjustment of premiums will be made. If such misstatement
involves whether or not an insurance risk would have been accepted by us, or the amount of insurance,
the true facts will be used in determining whether insurance is in force under the terms of this Policy and
the Employer Rider, and in what amount.
Statements
No statement will avoid the insurance under this Policy, or be used in defense of a claim hereunder
unless:
• in the case of the Participating Employer, it is contained in the application signed by him; or
• in the case of a covered person, it is contained in a written instrument signed by him.
All statements will be deemed representations and not warranties.
GP- 1- A- GP -90 -3
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P150.0154 -R
Assignment
An employee's right to assign any interest under this Policy is governed as follows:
• No death benefits (including any basic term life, supplemental term life, optional term life or accidental
death and dismemberment coverages) provided by this Policy, may be assigned.
• With respect to accident and health insurance, neither the employee's certificate nor his right to
insurance benefits under this Policy are assignable. The employee may direct us, in writing, to pay
hospital, surgical, major medical, or dental benefits to the recognized provider who provided the
covered service for which benefits became payable. We may honor such direction at our option. But,
such a direction is not considered an assignment of benefits and the employee may not assign his right
to take legal action under this Policy to such provider. And we assume no responsibility as to the
validity or effect of any such direction.
GP- 1- A- GP -90 -4 P150.0013 -R
00407347/00000.0/K34490 p.16
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Records - Information To Be Furnished
The Participating Employer must keep a record of the insured employees containing, for each employee,
the essential particulars of the insurance which apply to the employee. The Participating Employer must
periodically forward to us, on our forms, such information concerning the employees in the classes eligible
for insurance under this Policy, as set forth in the Employer Rider, as may reasonably be considered to
have a bearing on the administration of the insurance under this Policy and on the determination of the
premium rates. For benefits which are based on an employee's salary, changes in an employee's salary
must promptly be reported to us. The Participating Employer's payroll and other such records which have
a bearing on the insurance must be furnished to us for inspection at our request at any reasonable time.
(2) The following provisions are hereby added to this Policy:
Accident and Health Claims Provisions
An employee's right to make a claim under this Policy for any accident and health benefits provided under
an Employer Rider, is governed as follows:
Notice: An employee must send us written notice of an injury or sickness for which a claim is being made
within 20 days of the date the injury occurs or the sickness starts. This notice should include the
employee's name and plan number. If the claim is being made for one of the employee's covered
dependents, his name should also be noted.
Proof of Loss: We'll furnish the employee with forms for filing proof of loss within 15 days of receipt of
notice. But if we don't furnish the forms on time, we'll accept a written description and adequate
documentation of the injury or sickness that is the basis of the claim as proof of loss. The employee must
detail the nature and extent of the loss for which the claim is being made.
If an Employer Rider provides weekly loss of time benefits, the employee must send us written proof of
loss within 90 days of the end of each period for which we're liable. If an Employer Rider provides long
term disability income replacement benefits, the employee must send us written proof of loss within 90
days of the date we request it. For any other loss, the employee must send us written proof of loss within
90 days of the loss.
Late Notice of Proof: We won't void or reduce an employee's claim if he can't send us notice of proof of
loss within the required time. But he must send us notice and proof as soon as reasonably possible.
Payment of Benefits: If an Employer Rider provides benefits for loss of income, we'll pay them once
every 30 days for as long as we're liable, provided the employee submits periodic written proof of loss as
stated above. We'll pay all other accident and health benefits to which the employee is entitled under an
Employer Rider as soon as we receive written proof of loss.
We pay all accident and health benefits to the employee, if he is living. If he is not living, we have the
right to pay all accident and health benefits, except dismemberment benefits, to one of the following: (a)
the employee's estate; (b) the employee's spouse; (c) the employee's parents; (d) the employee's
children; (e) the employee's brothers and sisters; and (f) any unpaid provider of health care services. If an
Employer Rider provides benefits for dismemberment, see "Accidental Death and Dismemberment
Benefits" for how dismemberment benefits are paid.
When an employee files proof of loss, he may direct us, in writing, to pay health care benefits to the
recognized provider of health care who provided the covered service for which benefits became payable.
But we can't tell the employee that a particular provider provide such care. And the employee may not
assign his right to take legal action under this Policy to such provider.
00407347/00000.0/K34490 p,77
Limitations of Actions: An employee can't bring a legal action against this Policy until 60 days from the
date he files proof of loss. And he can't bring legal action against this Policy after three years from the
date he files proof of loss.
Workers' Compensation: The accident and health benefits provided by this Policy are not in place of,
and do not affect requirements for coverage by Workers' Compensation.
GP- 1- A- GP -90 -5
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Examination and Autopsy
P 150.0008 -R
We have the right to have a doctor of our choice examine the person for whom a claim is being made
under this Policy as often as we feel necessary. And we have the right to have an autopsy performed in
the case of death, where allowed by law. We'll pay for all such examinations and autopsies.
(3) As used in this rider:
"Accident and health" means any dental, dismemberment, hospital, long term disability, major medical,
out -of- network point -of- service, prescription drug, surgical, or weekly loss -of -time insurance provided under
an Employer Rider.
"Our," "The Guardian," "us" and "we" mean The Guardian Life Insurance Company of America.
"Policy" means the master group policy of insurance.
(4) This Policy's provision entitled "Liability of Trustees to Pay Premiums" is hereby deleted.
This rider is a part of this Policy. Except as stated in this rider, nothing contained in this rider changes or
affects any other terms of this Policy.
Dated at
This Day of
Trustees of the Business and Management Services Industry Insurance Trust Fund
Full or Corporate Name of Policyholder
Witness
GP- 1- A- GP -90 -6
I'VIII
Signature and Title
The Guardian Life Insurance Company of America
Second Vice President & Actuary, Group Insurance
P150.0009 -R
00407347/00000.0/K34490 PA 8
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AN IMPORTANT NOTICE ABOUT CONTINUATION RIGHTS
The following "Federal Continuation Rights" section may not apply to the employer's plan. The employee
must contact his employer to find out if:
(a) the employer is subject to the "Federal Continuation Rights" section, and therefore;
(b) the section applies to the employee.
OP- 1- R- NCC -87
P240.0058 -R
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Federal Continuation Rights
Important Notice: This section applies only to any dental, out -of- network point -of- service medical, major
medical, prescription drug or vision coverages which are part of this plan. In this section, these coverages are
referred to as "group health benefits."
This section does not apply to any coverages which apply to loss of life, or to loss of income due to disability.
These coverages can not be continued under this section.
Under this section, "qualified continuee" means any person who, on the day before any event which would
qualify him or her for continuation under this section, is covered for group health benefits under this plan as:
(a) an active, covered employee; (b) the spouse of an active, covered employee; or (c) the dependent child of
an active, covered employee. A child born to, or adopted by, the covered employee during a continuation
period is also a qualified continuee. Any other person who becomes covered under this plan during a
continuation provided by this section is not a qualified continuee.
Conversion: Continuing the group health benefits does not stop a qualified continuee from converting some
of these benefits when continuation ends. But, conversion will be based on any applicable conversion privilege
provisions of this plan in force at the time the continuation ends.
If an Employee's Group Health Benefits End: If an employee's group health benefits end due to his or her
termination of employment or reduction of work hours, he or she may elect to continue such benefits for up to
18 months, if he or she was not terminated due to gross misconduct.
The continuation: (a) may cover the employee or any other qualified continuee; and (b) is subject to "When
Continuation Ends ".
Extra Continuation for Disabled Qualified Continuees: If a qualified continuee is determined to be disabled
under Title II or Title XVI of the Social Security Act on or during the first 60 days after the date his or her
group health benefits would otherwise end due to the employee's termination of employment or reduction of
work hours, and such disability lasts at least until the end of the 18 month period of continuation coverage, he
or she or any member of that person's family who is a qualified continuee may elect to extend his or her 18
month continuation period explained above for up to an extra 11 months.
To elect the extra 11 months of continuation, a qualified continuee must give you written proof of Social
Security's determination of the disabled qualified continues's disability as described in "The Qualified
Continuee's Responsibilities ". If, during this extra 11 month continuation period, the qualified continuee is
determined to be no longer disabled under the Social Security Act, he or she must notify you within 30 days
of such determination, and continuation will end, as explained in "When Continuation Ends."
This extra 11 month continuation is subject to "When Continuation Ends ".
00407347/00000.0/K34490
An additional 50% of the total premium charge also may be required from all qualified continuees who are
members of the disabled qualified continuee's family by you during this extra 11 month continuation period,
provided the disabled qualified continuee has extended coverage.
GP -1 -R- COBRA -96 -1
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P235.0131 -R
If an Employee Dies While Insured: If an employee dies while insured, any qualified continuee whose group
health benefits would otherwise end may elect to continue such benefits. The continuation can last for up to
36 months, subject to "When Continuation Ends ".
GP -1 -R- COBRA -96 -2
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P235.0096 -R
If an Employee's Marriage Ends: If an employee's marriage ends due to legal divorce or legal separation,
any qualified continuee whose group health benefits would otherwise end may elect to continue such benefits.
The continuation can last for up to 36 months, subject to "When Continuation Ends ".
If a Dependent Child Loses Eligibility: If a dependent child's group health benefits end due to his or her
loss of dependent eligibility as defined in this plan, other than the employee's coverage ending, he or she may
elect to continue such benefits. However, such dependent child must be a qualified continuee. The
continuation can last for up to 36 months, subject to "When Continuation Ends ".
Concurrent Continuations: If a dependent elects to continue his or her group health benefits due to the
employee's termination of employment or reduction of work hours, the dependent may elect to extend his or
her 18 month or 29 month continuation period to up to 36 months, if during the 18 month or 29 month
continuation period, the dependent becomes eligible for 36 months of continuation due to any of the reasons
stated above.
The 36 month continuation period starts on the date the 18 month continuation period started, and the two
continuation periods will be deemed to have run concurrently.
Special Medicare Rule: If the employee becomes entitled to Medicare before a termination of employment or
reduction of work hours, a special rule applies for a dependent. The continuation period for a dependent, after
the employee's later termination of employment or reduction of work hours, will be the longer of: (a) 18
months (29 months if there is a disability extension) from the employee's termination of employment or
reduction of work hours; or (b) 36 months from the date of the employee's earlier entitlement to Medicare. If
Medicare entitlement occurs more than 18 months before termination of employment or reduction of work
hours, this special Medicare rule does not apply.
The Qualified Continuee's Responsibilities: A person eligible for continuation under this section must notify
you, in writing, of: (a) the legal divorce or legal separation of the employee from his or her spouse; (b) the
loss of dependent eligibility, as defined in this plan, of an insured dependent child; (c) a second event that
would qualify a person for continuation coverage after a qualified continuee has become entitled to
continuation with a maximum of 18 or 29 months; (d) a determination by the Social Security Administration
that a qualified continuee entitled to receive continuation with a maximum of 18 months has become disabled
during the first 60 days of such continuation; and (e) a determination by the Social Security Administration that
a qualified continuee is no longer disabled.
Notice of an event that would qualify a person for continuation under this section must be given to you by a
qualified continuee within 60 days of the latest of: (a) the date on which the event occurs; (b) the date on
which the qualified continuee loses (or would lose) coverage under this plan as a result of the event; or (c) the
date the qualified continuee is informed of the responsibility to provide notice to you and this plan's
procedures for providing such notice.
00407347/00000.0/K34490 p.20
Notice of a disability determination must be given to you by a qualified continuee within 60 days of the latest
of (a) the date of the Social Security Administration determination; (b) the date of the event that would qualify
a person for continuation; (c) the date the qualified continuee loses or would lose coverage; or (d) the date
the qualified continuee is informed of the responsibility to provide notice to you and this plan's procedures for
providing such notice. But such notice must be given before the end of the first 18 months of continuation
coverage.
Such notice must be given to you within 60 days of either of these events.
GP -1 -R- COBRA -96 -3
P235.0126 -R
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Your Responsibilities: You must notify the qualified continuee, in writing, of: (a) his or her right to continue
this plan's group health benefits; (b) the premium he or she must pay to continue such benefits; and (c) the
times and manner in which such payments must be made.
Such written notice must be given to the qualified continuee within 14 days of: (a) the date a qualified
continuee's group health benefits would otherwise end due to the employee's death or the employee's
termination of employment or reduction of work hours; (b) the date a qualified continuee notifies you, in
writing, of the employee's legal divorce or legal separation from his or her spouse, or the loss of dependent
eligibility of an insured dependent child; or (c) the date you declare bankruptcy under Title 11 of the United
States Code.
If you determine that an individual is not eligible for continued group health benefits under this plan, you must
notify the individual with an explanation of why such coverage is not available. This notice must be provided
within the time frame described above.
If a qualified continuee's continued group health benefits under this plan are cancelled prior to the maximum
continuation period, you must notify the qualified continuee as soon as practical following determinatin that the
continued group health benefits shall terminate.
Your Liability: You will be liable for the qualified continuee's continued group health benefits to the same
extent as, and in place of, us, if: (a) you fail to remit a qualified continuee's timely premium payment to us on
time, thereby causing the qualified continuee's continued group health benefits to end; or (b) you fail to notify
the qualified continuee of his or her continuation rights, as described above.
Election of Continuation: To continue his or her group health benefits, the qualified continuee must give you
written notice that he or she elects to continue. This must be done by the later of: (a) 60 days from the date a
qualified continuee receives notice of his or her continuation rights from you as described above; or (b) the
date coverage would otherwise end. And the qualified continuee must pay his or her first premium in a timely
manner.
The subsequent premiums must be paid to you, by the qualified continuee, in advance, at the times and in the
manner specified by you. No further notice of when premiums are due will be given.
The premium will be the total rate which would have been charged for the group health benefits had the
qualified continuee stayed insured under the group plan on a regular basis. It includes any amount that would
have been paid by you. Except as explained in "Extra Continuation for Disabled Qualified Continuees ", an
additional charge of two percent of the total premium charge may also be required by you.
If the qualified continuee fails to give you notice of his or her intent to continue, or fails to pay any required
premiums in a timely manner, he or she waives his or her continuation rights.
Grace in Payment of Premiums: A qualified continuee's premium payment is timely if, with respect to the
first payment after the qualified continuee elects to continue, such payment is made no later than 45 days
after such election. In all other cases, such premium payment is timely if it is made within 31 days of the
specified due date. If timely payment is made to the plan in an amount that is not significantly less than the
amount the plan requires to be paid for the period of coverage, then the amount paid is deemed to satisfy the
00407347/00000.0/K34490
requirement for the premium that must be paid; unless you notify the qualified continuee of the amount of the
deficiency and grant an additional 30 days for payment of the deficiency to be made. Payment is calculated to
be made on the date on which it is sent to you.
When Continuation Ends: A qualified continuee's continued group health benefits end on the first of the
following:
(1) with respect to continuation upon the employee's termination of employment or reduction of work
hours, the end of the 18 month period which starts on the date the group health benefits would
otherwise end;
(2) with respect to a qualified continuee who has an additional 11 months of continuation due to disability,
the earlier of: (a) the end of the 29 month period which starts on the date the group health benefits
would otherwise end; or (b) the first day of the month which coincides with or next follows the date
which is 30 days after the date on which a final determination is made that the disabled qualified
continuee is no longer disabled under Title II or Title XVI of the Social Security Act;
(3) with respect to continuation upon the employee's death, the employee's legal divorce, or legal
separation, or the end of an insured dependent's eligibility, the end of the 36 month period which starts
on the date the group health benefits would otherwise end;
(4) the date you cease to provide any group health plan to any employee;
(5) the end of the period for which the last premium payment is made;
(6) the date, after the date of election, he or she becomes covered under any other group health plan
which does not contain any pre- existing condition exclusion or limitation affecting him or her; or
(7) the date, after the date of election, he or she becomes entitled to Medicare.
GP- 1- R- COBRA -96 -4
P235.0127 -R
00407347/00000.0/K34490 p.22
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ELIGIBILITY FOR DENTAL COVERAGE
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EMPLOYEE COVERAGE
Eligible Employees
P489.0005 -R
Subject to the Conditions of Eligibility set forth below, and to all of the other conditions of the plan, all of your
employees who are in an eligible class will be eligible if they are active full -time employees.
For purposes of this plan, we will treat partners and proprietors like employees if they meet this plan's
conditions of eligibility.
Conditions of Eligibility
Full -time Requirement: We won't insure an employee unless he or she is an active full -time employee.
GP- 1- EC- 90 -1.0 P180.0168 -R
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Enrollment Requirement: If an employee must pay part of the cost of employee coverage, we won't insure
him until he enrolls in the plan and agrees to make the required payments. If he does this: (a) more than 31
days after he first becomes eligible; or (b) after he previously had coverage which ended because he failed to
make a required payment, we will consider the employee to be a late entrant.
If an employee initially waived dental coverage under this plan because he or she was covered under another
group plan, and he or she now elects to enroll in the dental coverage under this plan, the Penalty for Late
Entrants provision will not apply to him or her with regard to dental coverage provided his or her coverage
under the other plan ends due to one of the following events:
(a) termination of his or her spouse's employment;
(b) loss of eligibility under his or her spouse's plan;
(c) divorce;
(d) death of his or her spouse; or
(e) termination of the other plan.
But the employee must enroll in the dental coverage under this plan within 30 days of the date that any of the
events described above occur.
GP- 1- EC- 90 -2.0
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P180.0963 -R
The Waiting Period: Employees in an eligible class are eligible for dental insurance under this plan after they
complete the service waiting period established by the employer, if any.
GP- 1- EC- 90 -4.0
P489.0004 -R
00407347/00000.0/K34490
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Multiple Employment: If an employee works for both you and a covered associated company, or for more
than one covered associated company, we will treat him as if only one firm employs him. And such an
employee will not have multiple coverage under this plan. But, if this plan uses the amount of an employee's
earnings to set the rates, determine class, figure benefit amounts, or for any other reason, such employee's
earnings will be figured as the sum of his earnings from all covered employers.
GP- 1- EC- 90 -5.0
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When Employee Coverage Starts
P180.0328 -R
An employee must be actively at work, and working his regular number of hours, on the date his coverage is
scheduled to start. And he must have met all of the conditions of eligibility which apply to him. If an employee
is not actively at work on his scheduled effective date, we will postpone the start of his coverage until he
returns to active work.
Sometimes, a scheduled effective date is not a regularly scheduled work day. But an employee's coverage will
start on that date if he was actively at work, and working his regular number of hours, on his last regularly
scheduled work day.
The scheduled effective date of an employee's coverage is as follows:
• If an employee must pay part of the cost of employee coverage, then he must elect to enroll and agree
to make the required payments. If he does this on or before the eligibility date, his coverage is scheduled
to start on his eligibility date. If he does this after his eligibility date, his coverage is scheduled to start on
the date he signs his enrollment form.
• On non - contributory plans, subject to all the terms of this plan, an employee's coverage is scheduled to
start on his eligibility date.
GP- 1- EC- 90 -6.0
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When Employee Coverage Ends
P180.0969 -R
When Employee Coverage Ends: Except as explained in the "When Active Service Ends" section of this
plan, an employee's insurance will end on the first of the following dates:
• the last day of the month in which an employee's active full -time service ends for any reason other than
disability. Such reasons include retirement, layoff, leave of absence or the end of employment.
• the date an employee dies.
• the date the group plan ends, or is discontinued for a class of employees to which the employee
belongs; or
• the day prior to the last premium due date for which required payments are made for the employee.
• the last day of the month in which an employee stops being an eligible employee under this plan for any
reason not named above.
Also, an employee may have the right to continue certain group benefits for a limited time after his or her
coverage would otherwise end. The plan's benefit provisions explain these situations. Read the plan's
provisions carefully.
GP- 1- EC- 90 -8.0 P489.0006 -R
00407347/00000.0/K34490 p.24
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When Active Service Ends: You may continue an employee's dental expense insurance under this plan after
his active service with you ends only as follows:
• If an employee's active service ends because he is disabled you may continue his insurance subject to
all of the terms of this plan.
• If an employee's active service ends because he goes on a leave of absence or is laid off, you may
continue his insurance for the rest of the policy month in which the leave or layoff starts, plus 1 more full
policy month(s). However, if the employee joins any armed force before this period ends, you may
continue his insurance until the date he becomes a member of such armed force.
• If you continue an employee's benefits under this plan as set forth above, it must be based on a plan
which prevents individual selection by you.
• And, any such continuation is subject to the payment of premiums, and to all of the other terms and
conditions of this plan.
• The amount of an employee's insurance during any such continuation will be the amount in force on his
last day of active service, subject to any reductions that would have otherwise applied if he had
remained an active employee.
GP-1- EC- 90 -7.0
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An Employee's Right To Continue Group Insurance
During A Family Leave Of Absence
P489.0002 -R
Important Notice: This section may not apply to your plan. The employee must contact you to find out if:
• you must allow for a leave of absence under federal law, in which case;
• the section applies to the employee.
If An Employee's Group Insurance Ends: Group insurance may end for an employee because he or she
ceases full -time work due to an approved leave of absence. Such leave of absence must have been granted
to allow the employee to care for a seriously ill spouse, child or parent, or after the birth or adoption of a child,
or due to the employee's own serious health condition. If so, his or her group insurance will be continued. The
employee will be required to pay the same share of the premium as before the leave of absence.
When Continuation Ends: Insurance may continue until the earliest of:
(a) the date the employee returns to full -time work;
(b) the end of a total leave period of 12 weeks in any 12 month period;
(c) the date on which the employee's coverage would have ended had the employee not been on leave; or
(d) the end of the period for which the premium has been paid.
GP- 1- EC- 90 -7.0
P489.0062 -R
00407347/00000.0/K34490
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Definitions
GP- 1 -EC -90 -DEF -1
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P180.0155 -R
Eligible Dependent is defined in the provision entitled "Dependent Coverage ".
GP- 1 -EC -90 -DEF -2 P180.0156 -R
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Employee means a person who works for the employer at the employer's place of business, and whose
income is reported for tax purposes using a W -2 form.
GP- 1 -EC -90 -DEF -3 P180.0311 -R
All Classes
Full -time means the employee regularly works at least the number of hours in the normal work week set by
the employer (but not less than 40 hours per week), at his employer's place of business.
GP- 1 -EC -90 -DEF -4 P180.0493 -R
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Plan means the Guardian group plan purchased by the employer, except in the provision entitled
"Coordination of Benefits" where "plan" has a special meaning. See that provision for details.
GP- 1 -EC -90 -DEF -6 P180.0160 -R
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We, Us, Our and Guardian mean The Guardian Life Insurance Company of America.
GP- 1 -EC -90 -DEF -9 P180.0163 -R
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You and Your means the employer who purchased this plan.
GP- 1- EC -90- DEF -10 P180.0164 -R
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Dependent Coverage
GP- I- DEP- 90 -1.0 P200.0305 -R
00407347/00000.0/K34490 p -26
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Eligible Dependents for Dependent Dental Benefits: An employee's eligible dependents are: (a) his or her
legal spouse; (b) his or her unmarried dependent children who are under age 20; and (c) his or her unmarried
dependent children, from age 20 until their 26th birthday, if the child is dependent upon the employee for
support and is: (i) living in the employee's household; or (ii) a full -time or part-time student.
An adopted child is covered for dental benefits from: (a) the date the child is placed in the home; or (b) from
birth, in the event that the employee has made an adoption agreement before the child's birth. If the child is
added at birth, all of this plan's provisions regarding newborn children will apply to the adopted child.
GP -I- DEP- 90 -2.0 P200.0519 -R
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Adopted Children and Step - Children: An employee's "unmarried dependent children" include his or her
legally adopted children and, if they depend on the employee for most of their support and maintenance, his
or her step - children. We treat a child as legally adopted from the time the child is placed in the employee's
home for the purpose of adoption. We treat such a child this way whether or not a final adoption order is ever
issued.
Dependents Not Eligible: We exclude any dependent who is insured by this plan as an employee. And we
exclude any dependent who is on active duty in any armed force.
GP -I- DEP- 90 -3.0 P264.0005 -R
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Handicapped Children: An employee may have an unmarried child with a mental or physical handicap, or
developmental disability, who can't support himself or herself. Subject to all of the terms of this coverage and
the plan, such a child may stay eligible for dependent benefits past this coverage's age limit.
The child will stay eligible as long as he stays unmarried and unable to support himself or herself, if: (a) his or
her conditions started before he or she reached this coverage's age limit; (b) he or she became insured
before he or she reached the age limit, and stayed continuously insured until he or she reached such limit;
and (c) he or she depends on the employee for most of his or her support and maintenance.
If a claim submitted on behalf of the child is denied because the child has reached the limiting age, the
employee must submit proof that: (a) the child's condition started before he or she reached the age limit; (b)
the child became insured before he or she reached the age limit, and stayed continuously insured until he or
she reached such limit; and (c) the child depends on the employee for most of his or her support and
maintenance.
The child's coverage ends when the employee's does.
GP -I- DEP- 90 -4.0 P489.0028 -R
004 0 7 347/00000.0/K34490
All Options
Waiver of Dental Late Entrants Penalty: If an employee initially waived dental coverage for his or her
spouse or eligible dependent children because they were covered under another group plan, and he or she
now elects to enroll them in the dental coverage under this plan, the Penalty for Late Entrants provision will
not apply to them with regard to dental coverage provided their coverage under the other plan ends due to
one of the following events:
(a) termination of his or her spouse's employment;
(b) loss of eligibility under his or her spouse's plan;
(c) divorce;
(d) death of his or her spouse; or
(e) termination of the other plan.
But the employee must enroll his or her spouse or eligible dependent children in the dental coverage under
this plan within 30 days of the date that any of the events described above occur.
And, the Penalty for Late Entrants provisions for dental coverage will not apply to the employee's spouse or
eligible dependent children if: (a) he or she is under legal obligation to provide dental coverage due to a
court- order; and (b) he or she enrolls them in the dental coverage under this plan within 30 days of the
issuance of the court- order.
GP- I- DEP- 90 -5.0
All Options for All Classes
P200.0771 -Pt
When Dependent Coverage Starts: In order for an employee's dependent coverage to begin he or she must
already be insured for employee coverage or enroll for employee and dependent coverage at the same time.
Subject to the "Exception" stated below and to all of the terms of this plan, the date an employee's
dependent coverage starts depends on when he or she elects to enroll his or her initial dependents and
agrees to make any required payments.
If the employee does this on or before his or her eligibility date, the dependent's coverage is scheduled to
start on the later of the first of the month which coincides with or next follows the employee's eligibility date
and the date the employee becomes insured for employee coverage.
If the employee does this within the enrollment period, the coverage is scheduled to start on the later of the
first of the month which coincides with or next follows the date the employee signs the enrollment form; and
the date the employee becomes insured for employee coverage.
If the employee does this after the enrollment period ends, each of an employee's initial dependents is a late
entrant and is subject to any applicable late entrant penalties. The dependent's coverage is scheduled to start
on the first of the month which coincides with or next follows the date the employee signs the enrollment
form.
Once an employee has dependent coverage for his or her initial dependents, he or she must notify us when
he or she acquires any new dependents and agree to make any additional payments required for their
coverage.
If an employee does this within 31 days of the date the newly acquired dependent becomes eligible, the
dependent's coverage will start on the date the dependent first becomes eligible. If an employee fails to notify
us on time, the newly acquired dependent, when enrolled, is a late entrant and is subject to any applicable
late entrant penalties. The late entrant's coverage is scheduled to start on the date the employee signs the
enrollment form.
OP-1 -DEP-90-6.0 P489.0063 -R
00407347/00000.0/K34490 p•28
All Options
Exception: If a dependent, other than a newborn child, is confined to a hospital or other health care facility; or
is unable to carry-out the normal activities of someone of like age and sex on the date his or her dependent
benefits would otherwise start, we'll postpone the effective date of such benefits until the day after his or her
discharge from such facility; or until he or she resumes the normal activities of someone of like age and sex.
GP -I- DEP- 90 -7.0 P200.0708 -R
All Options
Coverage for Newborn Children: We cover an employee's newborn child, subject to the conditions below,
for dependent benefits starting from the moment of birth.
We also cover a newborn child of an insured family member (other than the employee's spouse) from the
moment of birth until the earlier of: (a) the date the covered employee is no longer insured under this
coverage; or (b) the end of eighteen months, starting from the moment of such child's birth.
The employee must notify us of the birth of the child within 31 days after the birth; and we will notify the
employee of any additional premium that is required. If the employee provides us notice of the birth of the
child within 31 days of the date of birth, no premium will be charged for the first 31 days of coverage. If the
employee does not provide this notice within that 31 day period, premium will be charged from the date of
birth.
Coverage for Adopted Children: We cover an employee's adopted child for dependent benefits from the
date of adoption or the date of placement in the employee's home for the purpose of adoption, whichever
comes first. The employee must notify us of the intent to adopt a child. In the case of a newborn child to be
adopted, we cover the child from the moment of birth but only if a written agreement to adopt such child has
been entered into by the employee prior to the birth of the child. A copy of the agreement must be sent to us
prior to the child's birth, or as soon thereafter as is reasonably possible.
Upon receipt of such notice or agreement, we will notify the employee of any additional premium required for
such child's coverage. Premium, if any, will be charged from the date of adoption, or the date of placement
for the purpose of adoption, whichever comes first. With respect to a newborn child to be adopted in accord
with a written agreement, premium, if any, will be charged from the date of birth.
The employee has 31 days from the date of notification to pay the additional premium. The child's coverage
will end if the employee doesn't pay the additional premium within 31 days. Coverage also ends if the child is
ultimately not placed in the employee's home.
We consider an adopted child, newborn or otherwise, to be a newborn child for purposes of benefits provided.
Coverage for Foster Children: We cover an employee's foster child or other child in court- ordered
temporary or other custody of the employee for dependent benefits starting from the date of placement in the
employee's home. The employee must give us written notice within 31 days of the date of placement.
We will then notify the employee of any additional premium he must pay. And, the employee must pay the
additional premium, if any, within 31 days from the date of notification to pay the additional premium.
Premium, if any, will be charged from the date of placement. The child's coverage will end if the employee
does not pay the additional premium within that 31 day period. Coverage also ends when the foster child is no
longer in the custody of the employee.
GP -I- DEP- 90 -8.0
P489.0087 -R
00407347/00000.0/K34490
All Options
When Dependent Coverage Ends: Dependent coverage ends for all of an employee's dependents when his
or her employee coverage ends. But if an employee dies while insured, we'll automatically continue dependent
benefits for those of his or her dependents who were insured when he or she died. We'll do this for six
months at no cost, provided: (a) the group plan remains in force; (b) the dependents remain eligible
dependents; and (c) in the case of a spouse, the spouse does not remarry.
If a surviving dependent elects to continue his or her dependent benefits under this plan's "Federal
Continuation Rights" provision, or under any other continuation provision of this plan, if any, this free
continuation period will be provided as the first six months of such continuation. Premiums required to be paid
by, or on behalf of a surviving dependent will be waived for the first six months of continuation, subject to
restrictions (a), (b) and (c) above. After the first six months of continuation, the remainder of the continuation
period, if any, will be subject to the premium requirements, and all of the terms of the "Federal Continuation
Rights" or other continuation provisions.
Dependent coverage also ends for all of an employee's dependents when the employee stops being a
member of a class of employees eligible for such coverage. And it ends when this plan ends, or when
dependent coverage is dropped from this plan for all employees or for an employee's class.
If an employee is required to pay all or part of the cost of dependent coverage, and he or she fails to do so,
his or her dependent coverage ends. It ends on the last day of the period for which he or she made the
required payments, unless coverage ends earlier for other reasons.
An individual dependent's coverage ends when he or she stops being an eligible dependent. This happens to
a child at 12:01 a.m. on the date the child attains this plan's age limit, when he or she marries, or when a
step -child is no longer dependent on the employee for support and maintenance. It happens to a spouse when
a marriage ends in legal divorce or annulment.
Read this plan carefully if dependent coverage ends for any reason. Dependents may have the right to
continue certain group benefits for a limited time.
GP -I- DEP- 90 -9.0 P489.0050 -R
All Options
Definitions
GP -I- DEP -90 -DEF -1 P200.0210 -R
All Options
Eligibility Date for dependent coverage is the earliest date on which: (a) the employee has dependents; and
(b) is eligible for dependent coverage.
GP -I- DEP -90 -DEF -2 P200.0211 -R
All Options
Eligible Dependent is defined in the provision entitled "Dependent Coverage."
GP -I- DEP -90 -DEF -3 P200.0212 -R
All Options
Enrollment Period means the 31 day period which starts on the date that the employee is eligible for
dependent coverage.
GP -I- DEP -90 -DEF -4 P200.0213 -R
00407347/00000.0/K34490 p.30
All Options
Initial Dependents means those eligible dependents the employee has at the time he or she first becomes
eligible for employee coverage. If at this time he or she does not have any eligible dependents, but later
acquires them, the first eligible dependents he or she acquires are his or her initial dependents.
GP- I- DEP -90 -DEF -8
All Options
P200.0217 -R
Newly Acquired Dependent means an eligible dependent the employee acquires after he or she already has
coverage in force for initial dependents.
GP -I- DEP -90 -DEF -9
All Options
P200.0218 -R
Plan means the Guardian group plan purchased by the employer, except in the provision entitled
"Coordination of Benefits" where "plan" has a special meaning. See that provision for details.
GP -I- DEP -90- DEF -11
All Options
P200.0220 -R
We, Us, Our and Guardian means The Guardian Life Insurance Company of America.
GP -I- DEP -90- DEF -14 P200.0223 -R
All Options
You and Your means the employer who purchased this plan.
GP -1- DEP -90- DEF -15
P200.0224 -R
0 0 4 07347/00000.0/K34490
Alf Options
DENTAL EXPENSE INSURANCE
This insurance will pay many of a covered person's dental expenses . We pay benefits for covered charges
incurred by a covered person. What we pay and terms for payment are explained below.
GP- 1- DG2000
P498.0007 -R
Option A
DentalGuard Preferred - This Plan's Dental Preferred Provider Organization
This plan is designed to provide high quality dental care while controlling the cost of such care. To do this,
the plan encourages a covered person to seek dental care from dentists and dental care facilities that are
under contract with Guardian's dental preferred provider organization (PPO), which is called DentalGuard
Preferred.
The dental PPO is made up of preferred providers in a covered person's geographic area. Use of the dental
PPO is voluntary. A covered person may receive dental treatment from any dental provider he or she
chooses. And he or she is free to change providers anytime.
But, this plan's payment limits differ based upon whether a covered person uses the services of a preferred
provider or a non - preferred provider. A covered person will usually be left with less out -of- pocket expense
when a preferred provider is used.
When an employee enrolls in this plan, he or she and his or her dependents receive a dental plan ID card and
information about current preferred providers.
A covered person must present his or her ID card when he or she uses a preferred provider. Most preferred
providers prepare necessary claim forms for the covered person, and submit the forms to us. We send the
covered person an explanation of this plan's benefit payments, but any benefit payable by us is sent directly
to the preferred provider.
What we pay is based on all of the terms of this plan. Please read this plan carefully for specific benefit
levels, deductibles, payment rates and payment limits.
A covered person may call the Guardian at the number shown on his or her ID card should he or she have
any questions about this plan.
GP- I- DGY2K -PPO
P498.0167 -R
Option B
DentalGuard Preferred - This Plan's Dental Preferred Provider Organization
This plan is designed to provide high quality dental care while controlling the cost of such care. To do this,
the plan encourages a covered person to seek dental care from dentists and dental care facilities that are
under contract with Guardian's dental preferred provider organization (PPO), which is called DentalGuard
Preferred.
The dental PPO is made up of preferred providers in a covered person's geographic area. Use of the dental
PPO is voluntary. A covered person may receive dental treatment from any dental provider he or she
chooses. And he or she is free to change providers anytime.
This plan usually pays a higher level of benefits for covered treatment furnished by a preferred provider.
Conversely, it usually pays less for covered treatment furnished by a non - preferred provider.
When an employee enrolls in this plan, he or she and his or her dependents receive a dental plan ID card and
information about current preferred providers.
00407347/00000.0/K34490 p•32
A covered person must present his or her ID card when he or she uses a preferred provider. Most preferred
providers prepare necessary claim forms for the covered person, and submit the forms to us. We send the
covered person an explanation of this plan's benefit payments, but any benefit payable by us is sent directly
to the preferred provider.
What we pay is based on all of the terms of this plan. Please read this plan carefully for specific benefit
levels, deductibles, payment rates and payment limits.
A covered person may call the Guardian at the number shown on his or her ID card should he or she have
any questions about this plan.
GP- I- DGY2K -PPO
All Options
Covered Charges
P498.0169 -R
If a covered person uses the services of a preferred provider, covered charges are the charges listed in the
fee schedule the preferred provider has agreed to accept as payment in full, for the dental services listed in
this plan's List of Covered Dental Services.
If a covered person uses the services of a non - preferred provider, covered charges are reasonable and
customary charges for the dental services listed in this plan's List of Covered Dental Services.
To be covered by this plan, a service must be: (a) necessary; (b) appropriate for a given condition; and (c)
included in the List of Covered Dental Services.
We may use the professional review of a dentist to determine the appropriate benefit for a dental procedure or
course of treatment.
By reasonable, we mean the charge is the dentist's usual charge for the service furnished. By customary, we
mean the charge made for the given dental condition isn't more than the usual charge made by most other
dentists. But, in no event will the covered charge be greater than the 90th percentile of the prevailing fee data
for a particular service in a geographic area.
When certain comprehensive dental procedures are performed, other less extensive procedures may be
performed prior to, at the same time or at a later date. For benefit purposes under this plan, these less
extensive procedures are considered to be part of the more comprehensive procedure. Even if the dentist
submits separate bills, the total benefit payable for all related charges will be limited to the maximum benefit
payable for the more comprehensive procedure. For example, osseous surgery includes the procedure scaling
and root planing. If the scaling and root planing is performed one or two weeks prior to the osseous surgery,
we may only pay benefits for the osseous surgery.
We only pay benefits for covered charges incurred by a covered person while he or she is insured by this
plan. A covered charge for a crown, bridge or cast restoration is incurred on the date the tooth is initially
prepared. A covered charge for any other dental prosthesis is incurred on the date the first master impression
is made. A covered charge for root canal treatment is incurred on the date the pulp chamber is opened. All
other covered charges are incurred on the date the services are furnished. If a service is started while a
covered person is insured, we'll only pay benefits for services which are completed within 31 days of the date
his or her coverage under this plan ends.
GP- I- DGY2K -CC
P498.0251 -R
0 0 4 07347/00000.0/K34490
All Options
APPEALS OF ADVERSE DETERMINATIONS
If a covered person or health care provider does not agree with an adverse determination, the covered person
or health care provider may submit an appeal as explained below.
The covered person or health care provider must file an appeal in writing concerning an adverse
determination. The appeal should contain sufficient detail to identify the nature of the problem. Any
documentation that the parties believe is relevant may be submitted to support an appeal.
The appeal should be directed to:
Group Quality Assurance - WRO
Guardian
P.O. Box 2457
Spokane, WA 99210 -2457
FAX: 1- 509 - 468 -6399
The written appeal will be referred to a Group Quality Assurance Dental Review Specialist who will open a
case file and conduct an investigation. In resolving an appeal, best efforts are made to obtain all relevant
information, including clinical records.
The health care provider will be contacted and given the opportunity to respond to the appeal. If appropriate,
the health care provider will be advised to submit copies of the patient's clinical records and any other
pertinent dental information.
For dental care services under review, the appeal decision shall be made by a licensed dentist, or a panel of
other appropriate health care providers with at least one licensed dentist on the panel.
An opinion will be forwarded in writing to all parties within 15 working days of the date that the appealis
received by us.
Definitions:
"Adverse determination" means a utilization review determination by a private review agent, Guardian, or a
health care provider acting on behalf of Guardian that:
a) a proposed or delivered dental care service which would otherwise be covered under the covered person's
contract is not or was not medically necessary, appropriate, or efficient; or
b) an alternate dental service is adequate and appropriate care in accordance with accepted dental standards;
and
c) may result in non - coverage of the dental service.
"Appeal" means a protest filed by a covered person, or dentist acting on behalf of a covered person,
regarding an adverse determination concerning the covered person.
"Health care provider" means:
a) an individual licensed to provide dental care services in the ordinary course of business or practice of a
profession and is a treating provider of the covered person; and
b) for purposes of this provision, is acting on behalf of the covered person.
GP-1-APPEAL-FL-02
P498.1088 -R
00407347/00000.0/ p.34
All Options
Alternate Treatment
If more than one type of service can be used to treat a dental condition, we have the right to base benefits on
the least expensive service which is within the range of professionally accepted standards of dental practice
as determined by us. For example, in the case of bilateral multiple adjacent teeth, or multiple missing teeth in
both quadrants of an arch, the benefit will be based on a removable partial denture. In the case of a
composite filling on a posterior tooth, the benefit will be based on the corresponding amalgam filling benefit.
Proof of Claim
So that we may pay benefits accurately, the covered person or his or her dentist must provide us with
information that is acceptable to us. This information may, at our discretion, consist of radiographs, study
models, periodontal charting, narratives or other diagnostic materials that document proof of claim and support
the necessity of the proposed treatment. If we don't receive the necessary information, we may pay no
benefits, or minimum benefits. However, if we receive the necessary information within 15 months of the date
of service, we will redetermine the covered person's benefits based on the new information.
GP- I- DGY2K -AT
P498.0002 -R
All Options
Pre - Treatment Review
When the expected cost of a proposed course of treatment is $300.00 or more, the covered person's dentist
should send us a treatment plan before he or she starts. This must be done on a form acceptable to
Guardian. The treatment plan must include: (a) a list of the services to be done, using the American Dental
Association Nomenclature and codes; (b) the itemized cost of each service; and (c) the estimated length of
treatment. In order to evaluate the treatment plan, dental radiographs, study models and whatever else will
document the necessity of the proposed course of treatment, must be sent to us.
We review the treatment plan and estimate what we will pay. We will send the estimate to the covered person
and /or the covered person's dentist. If the treatment plan is not consistent with accepted standards of dental
practice, or if one is not sent to us, we have the right to base our benefit payments on treatment appropriate
to the covered person's condition using accepted standards of dental practice.
The covered person and his or her dentist have the opportunity to have services or a treatment plan reviewed
before treatment begins. Pre- treatment review is not a guarantee of what we will pay. It tells the covered
person, and his or her dentist, in advance, what we would pay for the covered dental services listed in the
treatment plan. But, payment is conditioned on: (a) the services being performed as proposed and while the
covered person is insured; and (b) the deductible, payment rate and payment limits provisions, and all of the
other terms of this plan.
Emergency treatment, oral examinations, evaluations, dental radiographs and teeth cleaning are part of a
course of treatment, but may be done before the pre- treatment review is made.
We won't deny or reduce benefits if pre- treatment review is not done. But what we pay will be based on the
availability and submission of proof of claim.
GP- I- DGY2K -PTR
P498.0004 -R
0 0 4 07347/00000.0/K34490
All Options
Benefits From Other Sources
Other plans may furnish benefits similar to the benefits provided by this plan. For instance, an employee may
be covered by this plan and a similar plan through his or her spouse's employer. He or she may also by
covered by this plan and a medical plan. In such instances, we coordinate our benefits with the benefits from
that other plan. We do this so that no one gets more in benefits than the charges he or she incurs. Read
"Coordination of Benefits" to see how this works.
GP -I- DGY2K -OS P498.0005 -R
All Options
The Benefit Provision - Qualifying For Benefits
GP -I -DGY2K -BEN P498.0084 -R
All Options
Penalty For Late Entrants: During the first 6 months that a late entrant is covered by this plan, we won't pay
for the following services:
• All Group II Services.
During the first 12 months a late entrant is covered by this plan, we won't pay for the following services:
• All Group III Services.
Charges for the services we don't cover under this provision are not considered to be covered charges under
this plan, and therefore can't be used to meet this plan's deductibles.
We don't apply a late entrant penalty to covered charges incurred for services needed solely due to an injury
suffered by a covered person while insured by this plan.
A late entrant is a person who: (a) becomes covered by this dental plan more than 31 days after he or she is
eligible; or (b) becomes covered again, after his or her coverage lapsed because he or she did not make
required payments.
GP -I- DGY2K -LE
Option A
P498.0245 -R
How We Pay Benefits For Group I, II and III Non - Orthodontic Services: There is no deductible for Group
I services. We pay for Group I covered charges at the applicable payment rate.
The benefit year deductibles, shown in the schedule, apply to Group II and III services. There are different
benefit year deductible amounts for services provided by a preferred provider and a non preferred provider.
Each covered person must have covered charges from these service groups which exceed each applicable
deductible before we pay him or her any benefits for such charges. These charges must be incurred while the
covered person is insured.
Covered charges used to satisfy a covered person's Non -PPO deductible are also credited toward his or her
PPO deductible. And covered charges used to satisfy a covered person's PPO deductible are also credited
toward his or her Non -PPO deductible.
Once a covered person meets the deductible, we pay for his or her Group II and III covered charges above
that amount at the applicable payment rate for the rest of that benefit year.
P498.0195 -R
GP -I- DGY2K -BP
00407347/00000.0/K34490 p.36
Option B
How We Pay Benefits For Group I, 11 and III Non - Orthodontic Services: There is no deductible for Group
I services provided by a preferred provider. We pay for such Group I covered charges at the applicable
payment rate.
The benefit year deductibles, shown in the schedule, apply to Group I Non -PPO and all Group 11 and III
services. There are different benefit year deductible amounts for services provided by a preferred provider and
a non preferred provider. Each covered person must have covered charges from these service groups which
exceed each applicable deductible before we pay him or her any benefits for such charges. These charges
must be incurred while the covered person is insured.
Covered charges used to satisfy a covered person's Non -PPO deductible are also credited toward his or her
PPO deductible. And covered charges used to satisfy a covered person's PPO deductible are also credited
toward his or her Non -PPO deductible.
Once a covered person meets the deductible, we pay for his or her Group I Non -PPO and all Group II and III
covered charges above that amount at the applicable payment rate for the rest of that benefit year.
GP- I- DGY2K -BP
P498.0194 -R
Option A
All covered charges must be incurred while insured. And what we pay is subject to the benefit year payment
limit shown in the schedule and to all of the terms of this plan. There are different benefit year payment limits
which apply to benefits paid for the services of a preferred provider and a non preferred provider.
Benefits applied to a covered person's Non -PPO benefit year payment limit are also applied to his or her PPO
benefit year payment limit. And benefits applied to a covered person's PPO benefit year payment limit are also
applied to his or her Non -PPO benefit year payment limit.
P498.0209 -R
Option B
All covered charges must be incurred while insured. And what we pay is subject to the benefit year payment
limit shown in the schedule and to all of the terms of this plan.
GP- I- DGY2K -BP
P498.0210 -R
All Options
A covered person may be eligible for a rollover of a portion of his or her unused benefit year payment limit for
Group I, II and III Non - Orthodontic Services. See "Rollover of Benefit Year Payment Limit for Group I, 11 and III
Non - Orthodontic Services" for details.
GP -1 -DG- ROLL- 04 -2.1
P498.2168 -R
All Options
Rollover of Benefit Year Payment Limit for Group I, II and III Non - Orthodontic Services: A covered
person may be eligible for a rollover of a portion of his or her unused benefit year payment limit for Group I, II
and III Non - Orthodontic Services as follows:
If a covered person submits at least one claim for covered charges during a benefit year and, in that benefit
year, receives benefits that are in excess of any deductible or co -pay fees, and that, in total, do not exceed
the Rollover Threshold, he or she may be entitled to a Reward.
Note: If all of the benefits that a covered person receives in a benefit year are for services provided by a
preferred provider, he or she may be entitled to a greater Reward than if any of the benefits are for services
of a non - preferred provider.
00407347/00000.0/K34490
Rewards can accrue and are stored in the covered person's Bank. If a covered person reaches his or her
benefit year payment limit for Group I, II and III Non - Orthodontic Services, we pay benefits up to the amount
stored in the covered person's Bank. The amount of Reward stored in the Bank may not be greater than the
Bank Maximum.
A covered person's Bank may be eliminated, and the accrued Reward lost, if he or she has a break in
coverage of any length of time, for any reason.
The amounts of this plan's Rollover Threshold, Reward, and Bank Maximum are:
• Rollover Threshold $500.00
....................... ...............................
• Reward (if all benefits are for services provided by a preferred provider) ................ $350.00
• Reward (if any benefits are for services provided by a non - preferred provider) ........... $250.00
• Bank Maximum ........................ ...............................
$1,000.00
If this plan's dental coverage first becomes effective in October, November or December, this rollover
provision will not apply until January 1 of the first full benefit year. And, if the effective date of a covered
person's dental coverage is in October, November or December, this rollover provision will not apply to the
covered person until January 1 of the next full benefit year. In either case:
• only claims incurred on or after January 1 will count toward the Rollover Threshold; and
• Rewards will not be applied to a covered person's Bank until the benefit year that starts one year from
the date the rollover provision first applies.
If charges for any dental services are not payable for a covered person for a period set forth in the provisions
of this plan called Penalty for Late Entrants and Waiting Periods for Certain Services, this rollover provision
will not apply to the covered person until the end of such period. And, if such period ends within the three
months prior to the start of this plan's next benefit year, this rollover provision will not apply to the covered
person until the next benefit year, and:
• only claims incurred on or after the start of the next benefit year will count toward the Rollover
Threshold; and
• Rewards will not be applied to a covered person's Bank until the benefit year that starts one year from
the date the rollover provision first applies.
Definitions of terms used in this provision:
"Bank" means the amount of a covered person's accrued Reward.
"Bank Maximum" means the maximum amount of Reward that a covered person can store in his or her
Bank.
"Reward" means the dollar amount which may be added to a covered person's Bank when he or she
receives benefits in a benefit year that do not exceed the Rollover Threshold.
"Rollover Threshold" means the maximum amount of benefits that a covered person can receive during a
benefit year and still be entitled to receive a Reward.
GP -1 -DG- ROLL -04 -2
All Options
P498.2164 -R
Non - Orthodontic Family Deductible Limit: A covered family must meet no more than three individual
benefit year deductibles in any benefit year. Once this happens, we pay benefits for covered charges incurred
by any covered person in that covered family, at the applicable payment rate for the rest of that benefit year.
The charges must be incurred while the person is insured. What we pay is based on this plan's payment
limits and to all of the terms of this plan.
P498.0085 -R
GP- I- DGY2K -FL
00407347/00000.0/K34490 p.38
Option A
Payment Rates: Benefits for covered charges are paid at the following payment rates:
• Benefits for Group I Services performed by
a preferred provider .........................
100%
...............................
100%
• Benefits for Group I Services performed by
70%
a non - preferred provider ...................... ...............................
100%
• Benefits for Group 11 Services performed by
80%
a preferred provider .......................... ...............................
80%
• Benefits for Group II Services performed by
40%
a non - preferred provider ....................... ...............................
80%
• Benefits for Group III Services performed by
50%
a preferred provider .......................... ...............................
50%
• Benefits for Group III Services performed by
a non - preferred provider ....................... ...............................
50%
GP- I- DGY2K -PR
P498.0090 -R
Option B
Payment Rates: Benefits for covered charges are paid at the following payment rates:
• Benefits for Group I Services performed by
a preferred provider ......................... ...............................
100%
• Benefits for Group I Services performed by
a non - preferred provider ....................... ...............................
70%
• Benefits for Group II Services performed by
a preferred provider .......................... ...............................
80%
• Benefits for Group II Services performed by
a non - preferred provider ....................... ...............................
40%
• Benefits for Group III Services performed by
a preferred provider .......................... ...............................
50%
• Benefits for Group III Services performed by
a non - preferred provider ....................... ............................... 25%
GP- I- DGY2K -PR
P498.0090 -R
All Options
After This Insurance Ends: We don't pay for charges incurred after a covered person's insurance ends. But,
subject to all of the other terms of this plan, we'll pay for the following if the procedure is finished in the 31
days after a covered person's insurance under this plan ends: (a) a bridge or cast restoration, if the tooth or
teeth are prepared before the covered person's insurance ends; (b) any other dental prosthesis, if the master
impression is made before the covered person's insurance ends; and (c) root canal treatment, if the pulp
chamber is opened before the covered person's insurance ends.
GP- I -DGY2K -END
P498.0138 -R
00407347/00000.0/K34490
All Options
Extended Dental Expense Benefits
If a covered person's insurance ends, we extend dental expense benefits for that covered person under this
plan as explained below.
We only extend benefits for covered charges for dental procedures, if the procedures: (a) are recommended
in writing and begin before the covered person's insurance ends; (b) are for other than routine examination,
prophylaxis, x -rays, sealants or orthodontic services; and (c) are performed within 90 days after the covered
person's insurance ends. And what we pay is based on all of the terms of this plan.
Benefits will be paid until the earliest of: (a) the date all work is completed; (b) 90 days after the covered
person's insurance ends; or (c) the date the covered person becomes covered under another dental plan
providing coverage for similar dental procedures. However, if the succeeding plan excludes dental services
through the use of a waiting period, then the extension of benefits will not terminate.
We don't grant an extension if the covered person's insurance ended because of a voluntary termination of
coverage or because of failure to make required payments.
GP -I- DGY2K- EXT -FL P498.0450 -R
Special Limitations
GP -I -DGY2K -LMT P498.0140 -R
All Options
Teeth Lost, Extracted or Missing Before A Covered Person Becomes Covered By This Plan: A
covered person may have one or more congenitally missing teeth or may have had one or more teeth lost or
extracted before he or she became covered by this plan. We won't pay for a dental prosthesis which replaces
such teeth unless the dental prosthesis also replaces one or more eligible natural teeth lost or extracted after
the covered person became covered by this plan.
GP -I- DGY2K -TL
All Options
P498.0149 -R
If This Plan Replaces The Prior Plan: This plan may be replacing the prior plan you had with another
insurer. If a covered person was insured by the prior plan and is covered by this plan on its effective date, the
following provisions apply to such covered person.
• Teeth Extracted While Insured By The Prior Plan - The "Teeth Lost, Extracted or Missing Before A
Covered Person Becomes Covered By This Plan" provision above, does not apply to a covered
person's dental prosthesis which replaces teeth: (a) that were extracted while the covered person was
insured by the prior plan; and (b) for which extraction benefits were paid by the prior plan.
• Deductible Credit - In the first benefit year of this plan, we reduce a covered person's deductibles
required under this plan, by the amount of covered charges applied against the prior plan's deductible.
The covered person must give us proof of the amount of the prior plan's deductible which he or she
has satisfied.
• Benefit Year Non - Orthodontic Payment Limit Credit - In the first benefit year of this plan, we reduce
a covered person's benefit year payment limits by the amounts paid or payable under the prior plan.
The covered person must give us proof of the amounts applied toward the prior plan's payment limits.
P498.0143 -R
GP -I- DGY2K -PP
00407347/00000.0/K34490 p.40
All Options
Exclusions
We will not pay for:
• Any service or supply which is not specifically listed in this plan's List of Covered Dental Services.
• Any procedure performed in conjunction with, as part of, or related to a procedure which is not covered
by this plan.
• Educational services, including, but not limited to, oral hygiene instruction, plaque control, tobacco
counseling or diet instruction.
• Precision attachments and the replacement of part of a precision attachment, magnetic retention or
overdenture attachments.
• Overdentures and related services, including root canal therapy on teeth supporting an overdenture.
• Any restoration, procedure, appliance or prosthetic device used solely to: (1) alter vertical dimension;
(2) restore or maintain occlusion, except to the extent that this plan covers orthodontic treatment; (3)
treat a condition necessitated by attrition or abrasion; or (4) splint or stabilize teeth for periodontal
reasons.
• The use of general anesthesia, intramuscular sedation, intravenous sedation, non - intravenous sedation
or inhalation sedation, including but not limited to nitrous oxide, except when administered in
conjunction with covered periodontal surgery, surgical extractions, the surgical removal of impacted
teeth, apicoectomies, root amputations and services listed under the "Other Oral Surgical Procedures"
section of this plan.
• The use of local anesthetic.
• Cephalometric radiographs, oral /facial images, including traditional photographs and images obtained by
intraoral camera, except when performed as part of the orthodontic treatment plan and records for a
covered course of orthodontic treatment.
• Replacement of a lost, missing or stolen appliance or dental prosthesis or the fabrication of a spare
appliance or dental prosthesis.
• Prescription medication.
• Desensitizing medicaments and desensitizing resins for cervical and /or root surface.
• Duplication of radiographs, the completion of claim forms, OSHA or other infection control charges.
• Pulp vitality tests or caries susceptibility tests.
• Bite registration or bite analysis.
• Gingival curettage.
• The localized delivery of chemotherapeutic agents.
• Tooth transplants.
• Maxillofacial prosthetics that repair or replace facial and skeletal anomalies, maxillofacial surgery,
orthognathic surgery or any oral surgery requiring the setting of a fracture or dislocation.
• Temporary or provisional dental prosthesis or appliances except interim partial dentures /stayplates to
replace anterior teeth extracted while insured under this plan.
• Any service furnished solely for cosmetic reasons. This includes, but is not limited to: (1)
characterization and personalization of a dental prosthesis; (2) facings on a dental prosthesis for any
teeth posterior to the second bicuspid; (3) bleaching of discolored teeth; and (4) odontoplasty.
• Replacing an existing appliance or dental prosthesis with a like or unlike appliance or dental prosthesis;
unless(1) it is at least 5 years old and is no longer usable; or (2) it is damaged while in the covered
person's mouth in an injury suffered while insured, and can't be made serviceable.
00407347/00000.0/K34490
• A fixed bridge replacing the extracted portion of a hemisected tooth or the placement of more than one
unit of crown and /or bridge per tooth.
• The replacement of extracted or missing third molars /wisdom teeth.
• Any endodontic, periodontal, crown or bridge abutment procedure or appliance performed for a tooth or
teeth with a guarded, questionable or poor prognosis.
• Any procedure or treatment method which does not meet professionally recognized standards of dental
practice or which is considered to be experimental in nature.
• Any procedure, appliance, dental prosthesis, modality or surgical procedure intended to treat or
diagnose disturbances of the temporomandibular joint (TMJ).
• Treatment needed due to: (1) an on- the -job or job - related injury, or (2) a condition for which benefits
are paid by Worker's Compensation or similar laws.
• Treatment for which no charge is made. This usually means treatment furnished by: (1) the covered
person's employer, labor union or similar group, in its dental or medical department or clinic; (2) a
facility owned or run by any governmental body; and (3) any public program, except Medicaid, paid for
or sponsored by any governmental body.
• Evaluations and consultations for non - covered services; detailed and extensive oral evaluations.
• Orthodontic treatment, unless the benefit provision provides specific benefits for orthodontic treatment.
GP -I - DGY2K- EXCH +L P498.2447 -R
All Options
List Of Covered Dental Services
The services covered by this plan are named in this list. Each service on this list has been placed in one of
three groups. A separate payment rate applies to each group. Group I is made up of preventive services.
Group 11 is made up of basic services. Group III is made up of major services.
All covered dental services must be furnished by or under the direct supervision of a dentist. And they must
be usual and necessary treatment for a dental condition.
GP -I- DNTL -90 -13
All Options
Group 1 - Preventive Dental Services
(Non - Orthodontic)
Prophylaxis and Fluorides
P490.0147 -R
Prophylaxis - limited to a total of one prophylaxis or periodontal maintenance procedure (considered under
"Periodontal Services" ) in any 6 consecutive month period. Allowance includes scaling and polishing
procedures to remove coronal plaque, calculus, and stains.
Adult prophylaxis covered age 14 and older.
Additional prophylaxis when needed as a result of a medical (i.e., a non - dental) condition - covered once in
12 months, and only when the additional prophylaxis is recommended by the dentist and is a result of a
medical condition as verified in writing by the patient's medical physician. This does not include a condition
which could be resolved by proper oral hygiene or that is the result of patient neglect.
Fluoride treatment, topical application - limited to covered persons under age 14 and limited to one
treatment in any 6 consecutive month period.
Office Visits, Evaluations and Examination
00407347/00000.0/K34490 p.42
Office visits, oral evaluations, examinations or limited problem focused re- evaluations - limited to a total of
one in any 6 consecutive month period.
Emergency or problem focused oral evaluation - limited to a total of 1 in a 6 consecutive month period.
Covered if no other treatment, other than radiographs, is performed in the same visit.
After hours office visit or emergency palliative treatment and other non - routine, unscheduled visits. Limited
to a total of 1 in a 6 consecutive month period. Covered only when no other treatment, other than
radiographs, is performed during the same visit.
GP -I- DNTL -90 -14
A11 Options
Space Maintainers
P498.0181 -R
Space Maintainers - limited to covered persons under age 16 and limited to initial appliance only. Covered
only when necessary to replace prematurely lost or extracted deciduous teeth. Allowance includes all
adjustments in the first six months after insertion, limited to a maximum of one bilateral per arch or one
unilateral per quadrant, per lifetime.
- Fixed - unilateral
- Fixed - bilateral
- Removable - bilateral
- Removable - unilateral
Recementation of space maintainer performed more than 12 months after the initial insertion
Fixed and Removable Appliances
Fixed and Removable Appliances To Inhibit Thumbsucking - limited to covered persons under age 14 and
limited to initial appliance only. Allowance includes all adjustments in the first 6 months after insertion.
GP -I- DNTL -90 -15
All Options
Radiographs
P498.0182 -R
Allowance includes evaluation and diagnosis.
Full mouth, complete series or panoramic radiograph - Either, but not both, of the following procedures,
limited to one in any 60 consecutive month period.
- Full mouth series, of at least 14 films including bitewings
Panoramic film, maxilla and mandible, with or without bitewing radiographs.
Other diagnostic radiographs:
- Bitewing films - limited to either a maximum of 4 bitewing films or a set (7 -8 films) of vertical bitewings,
in one visit, once in any 12 consecutive month period.
- Intraoral periapical or occlusal films - single films
GP- I- DNTL -90 -15 P498.0183 -R
All Options
Dental Sealants
- Dental Sealants - permanent molar teeth only - Topical application of sealants is limited to the
unrestored, permanent molar teeth of covered persons under age 16 and limited to one treatment, per
tooth, in any 36 consecutive month period.
GP -I- DNTL -90 -14
P498.0184 -R
00407347/00000.0/K34490
All Options
Group II - Basic Dental Services
(Non - Orthodontic)
Diagnostic services - Allowance includes examination and diagnosis.
Consultations - Diagnostic consultation with a dentist other than the one providing treatment, limited to one
consultation for each covered dental specialty in any 12 consecutive month period. Covered only when no
other treatment, other than radiographs, is performed during the visit.
Diagnostic Services: Allowance includes examination and diagnosis.
Diagnostic casts when needed to prepare a treatment plan for three or more of the following performed
at the same time in more than one arch: dentures, crowns, bridges, inlays or onlays.
Histopathologic examinations when performed in conjunction with a tooth related biopsy.
Restorative Services - Multiple restorations on one surface will be considered one restoration. Benefits for
the replacement of existing amalgam and resin restorations will only be considered for payment if at least 12
months have passed since the previous restoration was placed if the covered person is under age 19, and 36
months if the covered person is age 19 and older. Also see the "Major Restorative Services" section.
Amalgam restorations - Allowance includes bonding agents, liners, bases, polishing and local anesthetic.
Resin restorations - limited to anterior teeth only. Coverage for resins on posterior teeth is limited to the
corresponding amalgam benefit. Allowance includes light curing, acid etching, adhesives, including resin
bonding agents and local anesthetic. Restorations that do not involve the incisal edge are considered a
single surface filling.
Silicate cement, per restoration
Composite resin
Stainless steel crown, prefabricated resin crown, and resin based composite crown - limited to once per
tooth in any 24 consecutive month period. Stainless steel crowns, prefabricated resin crowns and resin
based composite crowns are considered to be a temporary or provisional procedure when done within 24
months of a permanent crown. Temporary and provisional crowns are considered to be part of the
permanent restoration.
Pin retention, per tooth, covered only in conjunction with a permanent amalgam or composite restoration,
exclusive of restorative material.
GP -I- DNTL -90 -15
All Options
P498.1077 -R
Crown and Prosthodontic Restorative Services - Also see the "Major Restorative Services" section.
Crown and bridge repairs - allowance based on the extent and nature of damage and the type of material
involved.
Recementation, limited to recementations performed more than 12 months after the initial insertion.
Inlay or onlay
Crown
Bridge
Adding teeth to partial dentures to replace extracted natural teeth
Denture repairs - Allowance based on the extent and nature of damage and on the type of materials
involved.
00407347/0 p.44
Denture repairs, metal
Denture repairs, acrylic
Denture repair, no teeth damaged
Denture repair, replace one or more broken teeth
Replacing one or more broken teeth, no other damage
Denture rebase, full or partial denture - limited to once per denture in any 24 consecutive month period.
Denture rebases done within 12 months are considered to be part of the denture placement when the
rebase is done by the dentist who furnished the denture. Limited to rebase done more than 12 consecutive
months after the insertion of the denture.
Denture reline, full or partial denture - limited to once per denture in any 24 consecutive month period.
Denture relines done within 12 months are considered to be part of the denture placement when the reline
is done by the dentist who furnished the denture. Limited to reline done more than 12 consecutive months
after a denture rebase or the insertion of the denture.
Denture adjustments - Denture adjustments done within 6 months are considered to be part of the denture
placement when the adjustment is done by the dentist who furnished the denture. Limited to adjustments
that are done more than 6 consecutive months after a denture rebase, denture reline or the initial insertion
of the denture.
Tissue conditioning - Tissue conditioning done within 12 months is considered to be part of the denture
placement when the tissue conditioning is done by the dentist who furnished t he denture. Limited to a
maximum of 1 treatment, per arch, in any 12 consecutive month period.
GP -I- DNTL -90 -15
All Options
P498.1076 -R
Endodontic Services - Allowance includes diagnostic, treatment and final radiographs, cultures and tests,
local anesthetic and routine follow -up care, but excludes final restoration.
Pulp capping, limited to permanent teeth and limited to one pulp cap per tooth, per lifetime.
Pulp capping, direct
Pulp capping, indirect - includes sedative filling.
Vital pulpotomy, only when root canal therapy is not the definitive treatment
Gross pulpal debridement
Pulpal therapy, limited to primary teeth only
Root Canal Treatment
Root canal therapy
Root canal retreatment, limited to once per tooth, per lifetime
Treatment of root canal obstruction, no- surgical access
Incomplete endodontic therapy, inoperable or fractured tooth
Internal root repair of perforation defects
Other Endodontic Services
Apexification, limited to a maximum of three visits
Apicoectomy, limited to once per root, per lifetime
Root amputation, limited to once per root, per lifetime
Retrograde filling, limited to once per root, per lifetime
Hemisection, including any root removal, once per tooth
GP -I- DNTL -90 -15
P498.0219 -R
00407347/00000.0/K34490
All Options
Periodontal Services - Allowance includes the treatment plan, local anesthetic and post- treatment care.
Requires documentation of periodontal disease confirmed by both radiographs and pocket depth probings of
each tooth involved.
Periodontal maintenance procedure - limited to a total of one prophylaxis or periodontal maintenance
procedure in any 6 consecutive month period. Allowance includes periodontal pocket charting, scaling and
polishing. (Also see Prophylaxis under "Preventive Services ") Coverage for periodontal maintenance is
considered upon evidence of completed active periodontal therapy (periodontal scaling and root planing or
periodontal surgery).
Scaling and root planing, per quadrant - limited to once per quadrant in any 24 consecutive month period.
Covered when there is radiographic and pocket charting evidence of bone loss.
Full mouth debridement - limited to once in any 36 consecutive month period. Considered only when no
diagnostic, preventive, periodontal service or periodontal surgery procedure has been performed in the
previous 36 consecutive month period.
GP -I- DNTL -90 -15
All Options
P498.0220 -R
Non - surgical extractions - Allowance includes the treatment plan, local anesthetic and post- treatment care.
Uncomplicated extraction, one or more teeth
Root removal non - surgical extraction of exposed roots
Surgical Extractions - Allowance includes the treatment plan, local anesthetic and post - surgical care.
Services listed in this category and related services, may be covered by your medical plan.
Surgical removal of erupted teeth, involving tissue flap and bone removal
Surgical removal of residual tooth roots
Surgical removal of impacted teeth
Other Oral Surgical Procedures - Allowance includes diagnostic and treatment radiographs, the treatment
plan, local anesthetic and post - surgical care. Services listed in this category and related services, may be
covered by your medical plan.
Alveoloplasty, per quadrant
Removal of exostosis, per site
Incision and drainage of abscess
Frenulectomy, Frenectomy, Frenotomy
Biopsy and examination of tooth related oral tissue
Surgical exposure of impacted or unerupted tooth to aid eruption
Excision of tooth related tumors, cysts and neoplasms
Excision or destruction of tooth related lesion(s)
Excision of hyperplastic tissue
Excision of pericoronal gingiva, per tooth
Oroantral fistula closure
Sialolithotomy
Sialodochoplasty
Closure of salivary fistula
Excision of salivary gland
Maxillary sinusotomy for removal of tooth fragment or foreign body
Vestibuloplasty
GP -I- DNTL -90 -15 P498.1078 -R
00407347/00000.0/K34490 p.46
Alt Options
Other Services
General anesthesia, intramuscular sedation, intravenous sedation, non intravenous sedation or inhalation
sedation, including nitrous oxide, when administered in connection with covered periodontal surgery,
surgical extractions, the surgical removal of impacted teeth, apicoectomies, root amputations, surgical
placement of an implant and services listed under the "Other Oral Surgical Procedures" section of this
plan.
Injectable antibiotics needed solely for treatment of a dental condition.
GP -I- DNTL -90 -15
All Options
Group III - Major Dental Services
(Non- Orthodontic)
P498.0224 -R
Major Restorative Services - Crowns, inlays, onlays, labial veneers, and crown buildups are covered only
when needed because of decay or injury, and only when the tooth cannot be restored with amalgam or
composite filling material. Post and cores are covered only when needed due to decay or injury. Allowance
includes insulating bases, temporary or provisional restorations and associated gingival involvement. Limited to
permanent teeth only. Also see the "Basic Restorative Services" section.
Single Crowns
Resin with metal
Porcelain
Porcelain with metal
Full cast metal (other than stainless steel)
3/4 cast metal crowns
3/4 porcelain crowns
Inlays
Onlays, including inlay
Labial veneers
Posts and buildups - only when done in conjunction with a covered unit of crown or bridge and only when
necessitated by substantial loss of natural tooth structure.
Cast post and core in addition to a unit of crown or bridge, per tooth
Prefabricated post and composite or amalgam core in addition to a unit of crown or bridge, per tooth
Crown or core buildup, including pins
Implant supported prosthetics - Allowance includes the treatment plan and local anesthetic, when done in
conjunction with a covered surgical placement of an implant, on the same tooth.
Abutment supported crown
Implant supported crown
Abutment supported retainer for fixed partial denture
Implant supported retainer for fixed partial denture
Implant /abutment supported removable denture for completely edentulous arch
Implant/abutment supported removable denture for partially edentulous arch
Implant/abutment supported fixed denture for completely edentulous arch
Implant /abutment supported fixed denture for partially edentulous arch
Dental implant supported connecting bar
Prefabricated abutment
Custom abutment
00407347/00000.0/K34490
Implant services - Allowance includes the treatment plan, local anesthetic and post - surgical care. Limited to
the replacement of permanent teeth only. The number of implants we cover is limited to the number of
teeth extracted while insured under this plan.
Surgical placement of implant body, endosteal implant
Surgical placement, eposteal implant
Surgical placement transosteal implant
Other Implant services
Bone replacement graft for ridge preservation, per site, when done in conjunction with a covered surgical
placement of an implant in the same site, limited to once per tooth, per lifetime
Radiographic /surgical implant index - limited to once per arch in any 24 month period
Repair implant supported prosthesis
Repair implant abutment
Implant removal
GP -I- DNTL -90 -16
Att Options
P498.1083 -R
Prosthodontic Services - Specialized techniques and characterizations are not covered. Allowance includes
insulating bases, temporary or provisional restorations and associated gingival involvement. Limited to
permanent teeth only.
Fixed bridges - Each abutment and each pontic makes up a unit in a bridge
Bridge abutments - See inlays, onlays and crowns under "Major Restorative Services"
Bridge Pontics
Resin with metal
Porcelain
Porcelain with metal
Full cast metal
Dentures - Allowance includes all adjustments and repairs done by the dentist furnishing the denture in the
first 6 consecutive months after installation and all temporary or provisional dentures. Temporary or
provisional dentures, stayplates and interim dentures older than one year are considered to be a permanent
appliance.
Complete or Immediate dentures, upper or lower
Partial dentures - Allowance includes base, clasps, rests and teeth
Upper, resin base, including any conventional clasps, rests and teeth
Upper, cast metal framework with resin denture base, including any conventional clasps, rests and
teeth
Lower, resin base, including any conventional clasps, rests and teeth
Lower, cast metal framework with resin denture base, including any conventional clasps, rests and
teeth
Interim partial denture (stayplate), upper or lower, covered on anterior teeth only
Removable unilateral partial, one piece cast metal, including clasps and teeth
Simple stress breakers, per unit
GP -I- DNTL -90 -16 P498.1086 -R
00407347/00000.0/ p.48
All Options-
- Periodontal surgery - Allowance includes the treatment plan,- local- anesthetic and post - surgical care.
Requires documentation of- periodontal disease confirmed by both radiographs and pocket- depth- probings of
each tooth involved.-
- The following treatment is limited to a total of one of the- following,- once per tooth in any 12 consecutive
months.-
Gingivectomy, per tooth (less than 3 teeth) -
Crown lengthening - hard tissue-
- The following treatment is limited to a total of one of the- following- once per quadrant, in any 36
consecutive months.-
- Gingivectomy or gingivoplasty, per quadrant-
- Osseous surgery, including scaling and root planing, flap entry- and- closure, per quadrant-
- Gingival flap procedure, including scaling and root planing, per- quadrant-
- Distal or proximal wedge, not in conjunction with osseous surgery-
- Surgical revision procedure, per tooth-
- The following treatment is limited to a total of one of the- following,- once per quadrant in any 36
consecutive months.-
- Pedicle or free soft tissue grafts, including donor site, or- subepithelial connective tissue graft procedure,
when the tooth- is- present, or when dentally necessary as part of a covered surgical - placement of an
implant.-
- The following treatment is limited to a total of one of the- following,- once per area or tooth, per lifetime.-
- Guided tissue regeneration, resorbable barrier or nonresorbable- barrier- bone replacement grafts, when
the tooth is present-
Periodontal surgery related-
- Limited occlusal adjustment - limited to a total of two visits,- covered- only when done within a 6
consecutive month period after covered- scaling- and root planing or osseous surgery. Must have
radiographic- evidence of- vertical defect or widened periodontal ligament space.-
- Occlusal guards, covered only when done within a 6 consecutive- month- period after osseous surgery,
and limited to one per lifetime-
GP -I- DNTL -90 -16
All Options
Definitions
The terms that are italicized throughout this plan, are defined in this section
P498.0230 -R
Anterior Teeth means the incisor and cuspid teeth. The teeth are located in front of the bicuspids
(pre - molars).
Appliance means any dental device other than a dental prosthesis.
Benefit Year means a 12 month period which starts on January 1st and ends on December 31st of each
year.
Covered Dental Specialty means any group of procedures which falls under one of the following categories,
whether performed by a specialist dentist or a general dentist: restorative /prosthodontic services; endodontic
services, periodontic services, oral surgery and pedodontics.
GP- I- DGY2K -D1
P498.0009 -R
00407347/00000.0/K34490 p.49
AO Options
Covered Family means an employee and those of his or her dependents who are covered by this plan.
Covered Person means an employee or any of his or her covered dependents.
Dental Prosthesis means a restorative service which is used to replace one or more missing or lost teeth
and associated tooth structures. It includes all types of abutment crowns, inlays and onlays, bridge pontics,
complete and immediate dentures, partial dentures and unilateral partials. It also includes all types of crowns,
veneers, inlays, onlays, implants and posts and cores.
Dentist means any dental or medical practitioner we are required by law to recognize who: (a) is properly
licensed or certified under the laws of the state where he or she practices; and (b) provides services which
are within the scope of his or license or certificate and covered by this plan.
Emergency Treatment means bona fide emergency services which: (a) are reasonably necessary to relieve
the sudden onset of severe pain, fever, swelling, serious bleeding, severe discomfort, or to prevent the
imminent loss of teeth; and (b) are covered by this plan.
Injury means all damage to a covered person's mouth due to an accident which occurred while he or she is
covered by this plan, and all complications arising from that damage. But the term injury does not include
damage to teeth, appliances or dental prostheses which results solely from chewing or biting food or other
substances.
G P- 1- DGY2K -D2 P498.0014 -R
Aff Options
Non - Preferred Provider means a dentist or dental care facility that is not under contract with DentalGuard
Preferred as a preferred provider.
Orthodontic Treatment means the movement of one or more teeth by the use of active appliances. It
includes: (a) treatment plan and records, including initial, interim and final records; (b) periodic visits, limited
orthodontic treatment, interceptive orthodontic treatment and comprehensive orthodontic treatment, including
fabrication and insertion of any and all fixed appliances; (c) orthodontic retention, including any and all
necessary fixed and removable appliances and related visits. This plan does not pay benefits for orthodontic
treatment.
Payment Limit means the maximum amount this plan pays for covered services during either a benefit year
or a covered person's lifetime, as applicable.
Payment Rate means the percentage rate that this plan pays for covered services.
Plan means the Guardian group dental plan purchased by the planholder.
Posterior Teeth means the bicuspid (pre - molars) and molar teeth. These are the teeth located behind the
cuspids.
Preferred Provider means a dentist or dental care facility that is under contract with DentalGuard Preferred
as a preferred provider.
Prior Plan means the planholder's plan or policy of group dental insurance which was in force immediately
prior to this plan. To be considered a prior plan, this plan must start immediately after the prior coverage
ends.
Proof of Claim means dental radiographs, study models, periodontal charting, written narrative or any
documentation that may validate the necessity of the proposed treatment.
00407347/0 0000.0/K34490 p.50
We, Us, Our and Guardian mean The Guardian Life Insurance Company of America.
GP- I- DGY2K -D3
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COORDINATION OF BENEFITS
Important Notice: This provision applies to all health expense benefits under this plan. It does not apply to
death, dismemberment, or loss of income benefits.
Purpose of This Provision: An employee may be covered for health expense benefits by more than one
plan. For instance, he may be covered by this plan as an employee and by another plan as a dependent of his
spouse. If he is, this provision allows us to coordinate what we pay with what another plan pays. We do this
so the covered person doesn't collect more in benefits than he incurs in charges.
Definitions: "We" and "our" mean The Guardian Life Insurance Company of America.
"Plan" means any of the following that provides health expense benefits or services:
(A) group or franchise insurance plans;
(B) group Blue Cross plans, group Blue Shield plans, or other service or prepayment plans on a group
basis;
(C) union welfare plans, employer plans, employee benefits plans, trusteed labor and management plans, or
other plans for members of a group;
(D) programs or coverages required or provided by law, including mandatory no -fault auto insurance.
"Plan" does not include Medicaid, an indemnity -type policy, an excess insurance policy as defined in Florida
Law 627.635, a policy with coverage limited to specified illnesses or accidents, a Medicare supplement policy,
or any other government program or coverage which we are not allowed to coordinate with by law. Nor does it
include any plan we say we supplement. Plans that we supplement are named in the schedule.
"This plan" means the part of our group plan subject to this provision.
"Member" means the person who receives a certificate or other proof of coverage from a plan that covers
him for health expense benefits.
"Dependent" means a person who is covered by a plan for health expense benefits, but not as a member.
"Allowable expense" means any necessary, reasonable, and usual expense for health care incurred by a
member or dependent under both this plan and at least one other plan. When a plan provides service instead
of cash payment, we view the reasonable cash value of each service as an allowable expense and as a
benefit paid. We also view benefits payable by another plan as an allowable expense and as a benefit paid,
whether or not a claim is filed under that plan.
"Claim determination period" means a calendar year in which a member or dependent is covered by this plan
and at least one other plan and incurs one or more allowable expense under such plans.
How This Provision Works: We apply this provision when a member or dependent is covered by more than
one plan. When this happens we consider each plan separately when coordinating payments.
In order to apply this provision, one of the plans is called the primary plan. All other plans are called
secondary plans. The primary plan pays first, ignoring all other plans. The secondary plans then pay the
remaining unpaid allowable expenses, but no plan pays more than it would have without this provision.
If a plan has no coordination provision, it is primary. But, during any claim determination period, when this plan
and at least one other plan have coordination provisions, the rules that govern which plan pays first are as
follows:
(A) A plan that covers a person as a member pays first; the plan that covers a person as a dependent pays
second;
(B) A plan that covers a person as an active employee or as a dependent of such employee pays first. A
plan that covers a person as a laid -off or retired employee or as a dependent of such employee pays
second.
00407347/00000.0/K34490 p.52
But, if the plan that we're coordinating with does not have a similar provision for such persons, then (B)
will not apply.
(C) Except for dependent children of separated or divorced parents, the following governs which plan pays
first when the person is a dependent of a member:
A plan that covers a dependent of a member whose birthday falls earliest in the calendar year pays
first. The plan that covers a dependent of a member whose birthday falls later in the calendar year pays
second. The member's year of birth is ignored.
But, if the plan that we're coordinating with does not have a similar provision for such persons, then (C)
will not apply and the other plan's coordination provision will determine the order of benefits.
(D) For a dependent child of separated or divorced parents, the following governs which plan pays first
when the person is a dependent of a member:
(1) When a court order makes one parent financially responsible for the health care expenses of the
dependent child, then that parent's plan pays first.
(2) If there is no such court order, then the plan of the natural parent with custody pays before the plan
of the stepparent with custody; and
(3) The plan of the stepparent with custody pays before the plan of the natural parent without custody.
If rules (A), (B), (C) and (D) don't determine which plan pays first, the plan that has covered the person for
the longer time pays first.
If, when we apply this provision, we pay less than we would otherwise pay, we apply only that reduced
amount against payment limits of this plan.
Our Right to Certain Information: In order to coordinate benefits, we need certain information. An employee
must supply us with as much of that information as he can. But if he can't give us all the information we need,
we have the right to get this information from any source. And if another insurer needs information to apply its
coordination provision, we have the right to give that insurer such information. If we give or get information
under this section we can't be held liable for such action.
When payments that should have been made by this plan have been made by another plan, we have the right
to repay that plan. If we do so, we're no longer liable for that amount. And if we pay out more than we should
have, we have the right to recover the excess payment.
Small Claims Waiver: We don't coordinate payments on claims of less than $50.00. But if, during any claim
determination period, more allowable expenses are incurred that raise the claim above $50.00, we'll count the
entire amount of the claim when we coordinate.
GP -1 -R- COB -FL -86
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ATTACHED TO AND MADE A PART OF GROUP INSURANCE POLICY NO. G- 00407347 -IC
issued by
The Guardian Life Insurance Company of America
(herein called the Insurance Company)
to
Trustees of the Business and Management Services Industry insurance Trust Fund
with respect to
CITY OF SANFORD
(herein called the Policyholder)
As of October 1, 2005, this plan is amended, as explained below, with respect to any of this plan's provisions.
As used in this rider:
"Covered Person" means an employee or dependent, including the legal representative of a minor or
incompetent, insured by this plan.
"Reasonable pro -rata Expenses" are those costs, such as lawyers fees and court costs, incurred to effect a
third party payment, expressed as a percentage of such payment.
"Third Party" means anyone other than The Guardian, the employer or the covered person.
We will not pay any benefits under this plan, to or on behalf of a covered person, who has received payment
in whole or in part from a third party, or its insurer for past or future medical or dental charges or loss of
earnings, resulting from the negligence, intentional act, or no -fault tort liability of a third party.
If a covered person makes a claim to us for medical, dental or loss of earnings benefits under this plan prior
to receiving payment from a third party or its insurer, the covered person must agree, in writing, to repay us
from any amount of money they receive from the third party, or its insurer.
The repayment will be equal to the amount of benefits paid by us. However, the covered person may deduct
the reasonable pro -rata expenses, incurred in effecting the third party payment, from the repayment to us.
The repayment agreement will be binding upon the covered person whether: (a) the payment received from
the third party, or its insurer, is the result of a legal judgement, an arbitration award, a compromise settlement,
or any other arrangement; or (b) the third party, or its insurer, has admitted liability for the payment; or (c) the
medical or dental charges or loss of earnings are itemized in the third party payment.
00407347/00000.0/K p.54
This rider is a part of this plan. Except as stated in this rider, nothing contained in this rider changes or affects
any other terms of this plan.
Dated at
This
Day of
Trustees of the Business and Management Services Industry Insurance Trust Fund
Full or Corporate Name of Policyholder
Witness
Ma
Signature and Title
The Guardian Life Insurance Company of America
/ Y"1�4
Second Vice President & Actuary, Group Insurance
GP- 1- TPL -90 P600.0003 -R
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STATEMENT OF ERISA RIGHTS
As a participant, an employee is entitled to certain rights and protections under the Employee Retirement
Income Security Act of 1974 (ERISA). ERISA provides that all plan participants shall be entitled to:
Receive Information About The Plan and Benefits
(a) Examine, without charge, at the plan administrator's office and at other specified locations, such as
worksites and union halls, all documents governing the plan, including insurance contracts and collective
bargaining agreements, and a copy of the latest annual report (Form 5500 Series) filed by the plan with
the U. S. Department of Labor and available at the Public Disclosure Room of the Pension and Welfare
Benefit Administration.
(b) Obtain, upon written request to the plan administrator, copies of documents governing the operation of
the plan, including insurance contracts, collective bargaining agreements and copies of the latest annual
report (Form 5500 Series) and updated summary plan description. The administrator may make a
reasonable charge for the copies.
(c) Receive a summary of the plan's annual financial report. The plan administrator is required by law to
furnish each participant with a copy of this summary annual report.
Continue Group Health Plan Coverage
Continue health care coverage for the employee, his or her spouse or dependents if there is a loss of
coverage under the plan as a result of a qualifying event. The employee and his or her dependents may have
to pay for such coverage. The employee should review the summary plan description and the documents
governing the plan on the rules governing his or her COBRA continuation coverage rights.
Prudent Actions By Plan Fiduciaries
In addition to creating rights for plan participants, ERISA imposes duties upon the people who are responsible
for the operation of the employee benefit plan. The people who operate the plan, called "fiduciaries" of the
plan, have a duty to do so prudently and in the interest of plan participants and beneficiaries. No one,
including the employer, an employee's union, or any other person may fire an employee or otherwise
discriminate against him or her in any way to prevent the employee from obtaining a welfare benefit or
exercising his or her rights under ERISA.
Enforcement Of An Employee's Rights
If an employee's claim for a welfare benefit is denied or ignored, in whole or in part, he or she has a right to
know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal
any denial, all within certain time schedules.
Under ERISA, there are steps an employee can take to enforce the above rights. For instance, if an employee
requests a copy of plan documents or the latest annual report from the plan and does not receive them within
30 days, he or she may file suit in a state or Federal court. In such a case, the court may require the plan
administrator to provide the materials and pay the employee up to $110 a day until he or she receives the
material, unless the materials were not sent because of reasons beyond the control of the administrator. If an
employee has a claim for benefits which is denied or ignored, in whole or in part, he or she may file suit in a
federal court. If it should happen that plan fiduciaries misuse the plan's money or if an employee is
discriminated against for asserting his or her rights, the employee may seek assistance from the U.S.
Department of Labor, or he or she may file suit in a Federal court. The court will decide who should pay court
costs and legal fees. If an employee is successful, the court may order the person he or she sued to pay
these costs and fees. If the employee loses, the court may order him or her to pay these costs and fees, for
example, if it finds that the employee's claim is frivolous.
00407347/00000.0/K34490 p.56
Assistance with Questions
If an employee has questions about the plan, he or she should contact the plan administrator. If an employee
has questions about this statement or about his or her rights under ERISA, or if the employee needs
assistance in obtaining documents from the plan administrator, he or she should contact the nearest office of
the Pension and Welfare Benefits Administration, U.S. Department of Labor listed in the telephone directory or
the Division of Technical Assistance and Inquiries, Pension and Welfare Benefits Administration, U.S.
Department of Labor, 200 Constitution Avenue N.W., Washington D.C. 20210. An employee may also obtain
certain publications about his or her rights and responsibilities under ERISA by calling the publications hotline
of the Pension and Welfare Benefits Administration.
Qualified Medical Child Support Order
Federal law requires that group health plans provide medical care coverage of a dependent child pursuant to a
qualified medical child support order ( QMCSO). A "qualified medical child support order" is a judgment or
decree issued by a state court that requires a group medical plan to provide coverage to the named
dependent child(ren) of an employee pursuant to a state domestic relations order. For the order to be qualified
it must include:
• The name of the group health plan to which it applies.
• The name and last known address of the employee and the child(ren).
• A reasonable description of the type of coverage or benefits to be provided by the plan to the child(ren).
• The time period to which the order applies.
A dependent enrolled due to a QMCSO will not be considered a late enrollee in the plan.
Note: A QMCSO cannot require a group health plan to provide any type or form of benefit or option not
otherwise available under the plan except to the extent necessary to meet medical child support laws
described in Section 90 of the Social Security Act.
If an employee has questions about this statement, he or she should see the plan administrator.
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The Guardian's Responsibilities
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The dental expense benefits provided by this plan are guaranteed by a policy of insurance issued by The
Guardian. The Guardian also supplies administrative services, such as claims services, including the payment
of claims, preparation of employee certificates of insurance, and changes to such certificates.
P800.0041 -R
Atf Options
The Guardian is located at 7 Hanover Square, New York, New York 10004.
P800.0038 -R
00407347/00000.0/K34490 p.58
GROUP HEALTH BENEFITS CLAIMS PROCEDURE
If an employee seeks benefits under the plan he or she should complete, execute and submit a claim form.
Claim forms and instructions for filing claims may be obtained from the Plan Administrator.
Guardian is the Claims Fiduciary with discretionary authority to determine eligibility for benefits and to construe
the terms of the plan with respect to claims. Guardian has the right to secure independent professional
healthcare advice and to require such other evidence as needed to decide an employee's claim.
In addition to the basic claim procedure explained in the employee's certificate, Guardian will also observe the
procedures listed below. These procedures are the minimum requirements for benefit claims procedures of
employee benefit plans covered by Title 1 of the Employee Retirement Income Security Act of 1974( "ERISA ")
Definitions
"Adverse determination" means any denial, reduction or termination of a benefit or failure to provide or make
payment(in whole or in part) for a benefit. A failure to cover an item or service: (a) due to the application of
any utilization review; or (b) because the item or service is determined to be experimental or investigational, or
not medically necessary or appropriate, is also considered an adverse determination.
"Group Health Benefits" means any dental, out -of- network point -of- service medical, major medical, vision care
or prescription drug coverages which are a part of this plan.
"Pre- service claim" means a claim for a medical care benefit with respect to which the plan conditions receipt
of the benefit, in whole or in part, on approval of the benefit in advance of receipt of care.
"Post- service claim" means a claim for payment for medical care that already has been provided.
"Urgent care claim" means a claim for medical care or treatment where making a non - urgent care decision:
(a) could seriously jeopardize the life or health of the claimant or the ability of the claimant to regain maximum
function, as determined by an individual acting on behalf of the plan applying the judgment of a prudent
layperson who possesses an average knowledge of health and medicine; or (b) in the opinion of a physician
with knowledge of the claimant's medical condition, would subject the claimant to severe pain that cannot be
adequately managed without the care.
Note: Any claim that a physician with knowledge of the claimant's medical condition determines is a claim
involving urgent care will be treated as an urgent care claim for purposes of this section.
Timing For Initial Benefit Determination
The benefit determination period begins when a claim is received. Guardian will make a benefit determination
and notify a claimant within a reasonable period of time, but not later than the maximum time period shown
below. A written or electronic notification of any adverse benefit determination must be provided.
Urgent Care Claims. Guardian will make a benefit determination within 72 hours after receipt of an urgent
care claim.
If a claimant fails to provide all information needed to make a benefit determination, Guardian will notify the
claimant of the specific information that is needed as soon as possible but no later than 24 hours after receipt
of the claim. The claimant will be given not less than 48 hours to provide the specified information.
Guardian will notify the claimant of the benefit determination as soon as possible but not later than the earlier
of:
• the date the requested information is received; or
• the end of the period given to the claimant to provide the specified additional information.
The required notice may be provided to the claimant orally within the required time frame provided that a
written or electronic notification is furnished to the claimant not later than 3 days after the oral notification.
00407347/00000.0/K34490
Pre - Service Claims. Guardian will provide a benefit determination not later than 15 days after receipt of a
pre - service claim. If a claimant fails to provide all information needed to make a benefit determination,
Guardian will notify the claimant of the specific information that is needed as soon as possible but no later
than 5 days after receipt of the claim. A notification of a failure to follow proper procedures for pre- service
claims may be oral, unless a written notification is requested by the claimant.
The time period for providing a benefit determination may be extended by up to 15 days if Guardian
determines that an extension is necessary due to matters beyond the control of the plan, and so notifies the
claimant before the end of the initial 15 -day period.
If Guardian extends the time period for making a benefit determination due to a claimant's failure to submit
information necessary to decide the claim, the claimant will be given at least 45 days to provide the requested
information. The extension period will begin on the date on which the claimant responds to the request for
additional information.
Post- Service Claims. Guardian will provide a benefit determination not later than 30 days after receipt of a
post - service claim. If a claimant fails to provide all information needed to make a benefit determination,
Guardian will notify the claimant of the specific information that is needed as soon as possible but no later
than 30 days after receipt of the claim.
The time period for completing a benefit determination may be extended by up to 15 days if Guardian
determines that an extension is necessary due to matters beyond the control of the plan, and so notifies the
claimant before the end of the initial 30 -day period.
If Guardian extends the time period for making a benefit determination due to a claimant's failure to submit
information necessary to decide the claim, the claimant will be given at least 45 days to provide the requested
information. The extension period will begin on the date on which the claimant responds to the request for
additional information.
Concurrent Care Decisions. A reduction or termination of an approved ongoing course of treatment (other
than by plan amendment or termination) will be regarded as an adverse benefit determination. This is true
whether the treatment is to be provided: (a) over a period of time; (b) for a certain number of treatments; or
(c) without a finite end date. Guardian will notify a claimant at a time sufficiently in advance of the reduction or
termination to allow the claimant to appeal.
In the case of a request by a claimant to extend an ongoing course of treatment involving urgent care,
Guardian will make a benefit determination as soon as possible but no later than 24 hours after receipt of the
claim.
Adverse Benefit Determination
If a claim is denied, Guardian will provide a notice that will set forth:
• the specific reason(s) for the adverse determination;
• reference to the specific plan provision(s) on which the determination is based;
• a description of any additional material or information necessary to make the claim valid and an
explanation of why such material or information is needed;
• a description of the plan's claim review procedures and the time limits applicable to such procedures,
including a statement indicating that the claimant has the right to bring a civil action under ERISA
Section 502(a) following an adverse benefit determination;
• identification and description of any specific internal rule, guideline or protocol that was relied upon in
making an adverse benefit determination, or a statement that a copy of such information will be
provided to the claimant free of charge upon request;
• in the case of an adverse benefit determination based on medical necessity or experimental treatment,
notice will either include an explanation of the scientific or clinical basis for the determination, or a
statement that such explanation will be provided free of charge upon request; and
• in the case of an urgent care adverse determination, a description of the expedited review process.
00407347/00000.0/K34490 p.50
Appeal of Adverse Benefit Determinations
If a claim is wholly or partially denied, the claimant will have up to 180 days to make an appeal.
A request for an appeal of an adverse benefit determination involving an urgent care claim may be submitted
orally or in writing. Necessary information and communication regarding an urgent care claim may be sent to
Guardian by telephone, facsimile or similar expeditious manner.
Guardian will conduct a full and fair review of an appeal which includes providing to claimants the following:
• the opportunity to submit written comments, documents, records and other information relating to the
claim;
• the opportunity, upon request and free of charge, for reasonable access to, and copies of, all
documents, records and other information relating to the claim; and
• a review that takes into account all comments, documents, records and other information submitted by
the claimant relating to the claim, without regard to whether such information was submitted or
considered in the initial benefit determination.
In reviewing an appeal, Guardian will
• provide for a review conducted by a named fiduciary who is neither the person who made the initial
adverse determination nor that person's subordinate;
• in deciding an appeal based upon a medical judgment, consult with a health care professional who has
appropriate training and experience in the field of medicine involved in the medical judgment;
• identify medical or vocational experts whose advice was obtained in connection with an adverse benefit
determination; and
• ensure that a health care professional engaged for consultation regarding an appeal based upon a
medical judgment shall be neither the person who was consulted in connection with the adverse benefit
determination, nor that person's subordinate.
Guardian will notify the claimant of its decision regarding review of an appeal as follows:
Urgent Care Claims. Guardian will notify the claimant of its decision as soon as possible but not later than 72
hours after receipt of the request for review of the adverse determination.
Pre - Service Claims. Guardian will notify the claimant of its decision not later than 30 days after receipt of the
request for review of the adverse determination.
Post- Service Claims. Guardian will notify the claimant of its decision not later than 60 days after receipt of
the request for review of the adverse determination.
Alternative Dispute Options
The claimant and the plan may have other voluntary alternative dispute resolution options, such as mediation.
One way to find out what may be available is to contact the local U.S Department of Labor Office and the
State insurance regulatory agency.
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