HomeMy WebLinkAboutCONTRACT TO METLIFE FOR DENTAL SERVICES MetLife
Metropolitan Life Insurance Company
200 Park Avenue, New York, New York 10166
Metropolitan Life Insurance Company ("MetLife"), a stock company, will pay the benefits specified in the
Exhibits of this policy subject to the terms and provisions of this policy. The Schedule of Exhibits lists
each Exhibit to this policy,to whom it applies and its effective date.
Policyholder: Augusta Georgia
Group Policy No.: 166979-1-G
EFFECTIVE DATE
This policy will take effect on January 1,2017.
POLICY ANNIVERSARIES
Policy anniversaries will be January 1, 2018 and each subsequent January 1.
PREMIUM PAYMENTS
This policy is issued in return for the payment by the Policyholder of required Premiums. Premiums are
payable at the home office of MetLife or to its authorized agent. The first Premium is due on and must be
paid by this policy's effective date. Any later Premiums are due monthly in advance on the first day of
each Policy Month. These dates are the Premium Due Dates.
POLICY SITUS
This policy is issued for delivery in and governed by the laws of Georgia.
Signed as of this policy's effective date at MetLife's home office in New York, New York.
4 °. ;sw-‘.w1"44e
41"-`` 0 - r_cf,014444.4,„,_
7 Steven
'A. Kandarian
Timothy J. RingChairman of the Board, President and Chief
Vice President and Secretary Executive Officer
Signed by Date
(A MetLife licensed agent or resident agent as required by law.)
GROUP DENTAL INSURANCE POLICY NON-DIVIDEND PAYING
GPNP99 166979-1-G Page 1
as endorsed by GPENDI3-05/hh and GPENDI3-08
TABLE OF CONTENTS
Page
Section
POLICY FACE PAGE 1
Effective Date 1
Policy Anniversaries
1
1
4
5
5
5
5
5
5
5
5
6
7
8
8
9
9
9
9
9
9
10
10
10
10
Premium Payments
Policy Situs
DEFINITIONS
SCHEDULE OF INSURANCE
ELIGIBILITY AND EFFECTIVE DATES OF INSURANCE
CONTRIBUTIONS
PREMIUM RATE(S)
Initial Rate(s)
Frequency of Premium Payment
Computation of Premium
Premiums for Changes in Insurance
Right to Change Premium Rates
Retrospective Rate Changes
GRACE PERIOD
END OF INSURANCE PROVIDED BY THIS POLICY
REINSTATEMENT
GENERAL PROVISIONS
Entire Contract
Policy Changes or Waivers
Incontestability: Statements Made by the Policyholder
Incontestability: Statements Made by Covered Persons
Certificates
Assignment
Information Needed and Policy Administration
Misstatement of Age
GPNP99 Page 2
as endorsed by GPEND13-05/hh and GPEND13-08 1
166979-1-G
TABLE OF CONTENTS(continued)
Section Page
Non-Dividend Paying 10
Conformity with Law 10
SCHEDULE OF EXHIBITS SCH/EXHIBITS
EXHIBIT 1: Schedule of Premium Rates EXHIBITI
EXHIBIT 2: Certificate Forms EXHIBIT2
GPNP99 166979-1-G Page 3
as endorsed by GPENDI3-05/hh and GPENDI3-08
DEFINITIONS
As used in this policy, the terms listed below will have the meanings defined below. When defined terms
are used in this policy, they will appear with initial capitalization. The plural use of a term defined in the
singular will share the same meaning.
Contribution means the amount the Policyholder may require the Employee to pay towards the total
Premium that MetLife charges for the insurance provided by this policy.
Contributory Insurance means insurance for which the Policyholder may require the Employee to pay at
least part of the Premium.
Covered Person means an Employee and/or a Dependent as set forth in the Exhibit which applies to the
Employee.
Employee is described in the Exhibit which applies to the Employee.
Employer means the Policyholder shown on page 1.
Noncontributory Insurance means insurance for which the Policyholder may not require the Employee to
pay any part of the Premium.
Policy Anniversary is defined on page 1.
Policy Month. The first Policy Month will begin on the effective date shown on page 1. Subsequent Policy
Months will begin on the same day of each subsequent calendar month.
Policy Period means as used in the Retrospective Rate Changes section on page 7, a period which
begins on January 1, 2017 and ends on December 13, 2018.
A subsequent Policy Period may be agreed to by MetLife and the Policyholder.
Premium means the amount the Policyholder must pay to MetLife for all the insurance provided under this
policy.
Premium Due Date is defined on page 1.
Signed means any symbol or method executed or adopted by a person with the present intention to
authenticate a record, and which is on or transmitted by paper or electronic media, and which is consistent
with applicable law.
Written or Writing means a record which is on or transmitted by paper or electronic media, and which is
consistent with applicable law.
GPNP99 166979-1-G Page 4
as endorsed by GPENDI3-05/hh and GPENDI3-08
SCHEDULE OF INSURANCE
The Schedules of Insurance which apply under this policy are set forth in the Exhibits.
ELIGIBILITY AND EFFECTIVE DATES OF INSURANCE
The Eligibility and Effective Dates of Insurance provisions that apply under this policy are set forth in the
Exhibits.
CONTRIBUTIONS
The maximum amount that an Employee may be required to contribute to the cost of Contributory Insurance
will not exceed the Premium charged for the amounts of such insurance.
PREMIUM RATE(S)
Initial Rate(s)
The initial Premium rate(s)are shown in Exhibit 1.
Frequency of Premium Payment
Premiums for this policy will be paid as shown on page 1. MetLife and the Policyholder may agree that
payment be made in advance every 3, 6 or 12 months.
Computation of Premium
The Premium due on any Premium Due Date is determined by the total amount of insurance provided by
this policy on such Premium Due Date, multiplied by the appropriate Premium rate(s) which are then in
effect subject to any Premium adjustments, if applicable.
MetLife may use any reasonable method to compute Premiums due under this policy.
Premiums for Changes in Insurance
For insurance that takes effect after the first day of a Policy Month, Premium will be charged from the first
day of the next Policy Month. However, if a policy amendment or evidence of good health is required for
such insurance, Premium will be charged as of the date such insurance takes effect.
If this policy ends, or if insurance ends for a class of persons, Premium will be charged to the date insurance
ends. If insurance ends for other reasons, Premium will be charged to the end of the Policy Month in which
insurance ends.
GPNP99 166979-1-G Page 5
as endorsed by GPENDI3-05/hh and GPENDI3-08
PREMIUM RATES (Continued)
Right to Change Premium Rates
MetLife may change Premium rates for changes which materially affect the risk assumed for the insurance
provided by this policy, as follows:
1. when this policy is amended or endorsed;
2. when a class of eligible persons is added to or deleted from this policy for any reason including
corporate restructuring,acquisition, spin-off or similar situations;
3. when a Policyholder's subsidiary, affiliate, division, branch or other similar entity is added to or deleted
from this policy for any reason including corporate restructuring, acquisition, spin-off or similar
situations;
4. when there is a significant change in the geographic distribution of insured Employees;
5. when applicable law or regulation,or the administration of such law or regulation:
a. requires a change in:
i. the insurance provided by this policy; and/or
ii. the class of persons eligible for insurance under this policy; or
b. results in a change in the amount of benefits paid under this policy;or
6. when a Premium Due Date coincides with or next follows:
a. a change greater than 10% in the number of Covered Persons since the later of the policy
Effective Date and the last date Premium rates were changed; or
b. a change greater than 10% in the amount of insurance provided by this policy since the later of
the policy Effective Date and the last date Premium rates were changed.
In addition, MetLife may change Premium rates:
1. except as may be stated in Exhibit 1, on any date on or after the first Policy Anniversary; this will be
done no more frequently than every 12 months and only if MetLife notifies the Policyholder, in Writing,
at least 31 days before such change; and
2. on any other date agreed to by MetLife and the Policyholder.
The new Premium rates will apply only to Premiums due on or after the date the rate change takes effect.
GPNP99 166979-1-G Page 6
as endorsed by GPENDI3-05/hh and GPENDI3-08
PREMIUM RATES(Continued)
Retrospective Rate Changes
Rate Reduction For Failure to Provide Service Levels(Performance Guarantee). At the end of a Policy
Period, MetLife may reduce the Policyholder's Premium for such Policy Period as the result of its failure to
provide the service levels agreed to in Writing by an officer of MetLife and the Policyholder. The Premium
will be reduced by an amount not to exceed 2.0% of the Dental Insurance Premium paid during the Policy
Period.
All the benefits provided under this policy will be combined to determine the rate reduction, if any.
GPNP99 166979-1-G Page 7
as endorsed by GPENDI3-05/hh and GPENDI3-08
GRACE PERIOD
Each Premium due after the effective date of this policy may be paid up to 31 days after its Premium Due
Date. This period is the grace period. The insurance provided by this policy will stay in effect during this
period. MetLife will notify the Policyholder in Writing that, if the Premium is not paid by the end of the
grace period, this policy will end at the end of the last day of the grace period. If MetLife fails to give
Written notice to the Policyholder, this policy will continue in effect until the date such notice is given.
Policyholder's intent to end this policy during the grace period. The Policyholder may notify MetLife in
Writing prior to the end of the grace period of its intent to end this policy before the end of the grace period.
In this case,this policy will end on the later of:
1. the date stated in the notice; or
2. the date MetLife receives the notice.
If the Policyholder replaces this policy with another group insurance policy but does not give MetLife notice
of intent to end this policy,the grace period provisions will apply.
Grace period extensions. MetLife may extend the grace period by giving Written notice to the
Policyholder. Such notice will state the date this policy will end if the Premium remains unpaid.
Premiums must be paid for a grace period, any extension of such period and any period insurance under
this policy was in effect for which Premium was not paid.
END OF INSURANCE PROVIDED BY THIS POLICY
The Policyholder can end this policy by giving 60 days advance Written notice to MetLife.The policy will end
on the later of:
1. the date stated in the notice; or
2. the date MetLife receives the notice.
MetLife can end this policy as follows:
1. on the date Premium is not paid when due,subject to the Grace Period provisions; or
2. on any Premium Due Date, by giving the Policyholder 31 days advance Written notice, if less than:
a. 25%of persons eligible under this policy are insured for Contributory Insurance;
b. 10 Employees are insured by this Policy;
3. on any Premium Due Date, by giving the Policyholder 60 days advance Written notice, if the
Policyholder fails to provide information on a timely basis or perform any obligations required by this
policy or any applicable law; or
GPNP99 166979-1-G Page 8
as endorsed by GPENDI3-05/hh and GPENDI3-08
END OF INSURANCE PROVIDED BY THIS POLICY(Continued)
4. on any Policy Anniversary, except during a Rate Guarantee Period as may be provided in Exhibit 1, by
giving the Policyholder 31 days advance Written notice.
This policy will end on the date on which the last certificate in effect under this policy ends.
If this policy ends, all Premiums due must be paid. If MetLife accepts Premium after the date this policy
ends, such acceptance will not act to reinstate the policy. MetLife will refund any unearned Premium.
REINSTATEMENT
The Policyholder may request to reinstate this policy within one year from the date it ended. The request
must be in Writing and it must provide MetLife with information that MetLife requires to consider such
request. If MetLife approves the request, the policy will be reinstated on the date stated in Writing by
MetLife.
GENERAL PROVISIONS
Entire Contract. The entire contract is made up of the following:
1. this policy, including its Exhibits;
2. the Policyholder's application; and
3. the amendments and endorsements to this policy, if any.
Policy Changes or Waivers. The terms and provisions of this policy may be changed, at any time, without
the consent of the Covered Persons or anyone else with a beneficial interest in it. MetLife will issue
amendments or endorsements to effect such changes. MetLife will only make changes that are consistent
with applicable law. An amendment or endorsement will not affect the insurance provided under certificates
issued before the effective date of the change, unless retroactivity is consistent with applicable law.
An officer of MetLife must approve in Writing any change or waiver of the terms and provisions of this policy.
A sales representative, or other MetLife employee, who is not an officer of MetLife does not have MetLife's
authority to approve such changes or waivers. A change or waiver will be evidenced by an amendment
Signed by an officer of MetLife and the Policyholder or an endorsement Signed by an officer of MetLife. A
copy of the amendment or endorsement will be provided to the Policyholder for attachment to this policy.
Incontestability: Statements Made by the Policyholder. Any statement made by the Policyholder will be
considered a representation and not a warranty. MetLife will not use such statement to avoid insurance,
reduce benefits or defend a claim unless it is contained in a Written application. MetLife will not use such
statement to contest life insurance after it has been in force for 2 years from its effective date, or date of last
reinstatement, unless the statement is fraudulent.
Incontestability: Statements Made by Covered Persons. Any statement made by a Covered Person will
be considered a representation and not a warranty. MetLife will not use such statement to avoid insurance,
reduce benefits or defend a claim unless the following requirements are met:
1. the statement is in a Written application or enrollment form;
2. the Covered Person has Signed the application or enrollment form;and
3. a copy of the application or enrollment form has been given to the Covered Person or his beneficiary.
MetLife will not use a Covered Person's statements which relate to insurability to contest life insurance after
it has been in force for 2 years during his life, unless the statement is fraudulent. In addition, MetLife will not
use such statements to contest an increase or benefit addition to such insurance after the increase or
benefit has been in force for 2 years during his life, unless the statement is fraudulent.
GPNP99 166979-1-G Page 9
as endorsed by GPENDI3-05/hh and GPENDI3-08
GENERAL PROVISIONS(Continued)
Certificates. MetLife will issue certificates to the Policyholder for delivery to each Covered Person, as
appropriate. Such certificate will describe the Covered Person's benefits and rights under this policy.
"Certificate"includes any of MetLife's insurance riders, notices or other attachments to the certificate.
Assignment. The rights and benefits under this policy are not assignable prior to a claim for benefits,
except as required by law or as permitted by MetLife.
Information Needed and Policy Administration. All information necessary to compute Premiums and
carry out the terms of this policy will be provided by the Policyholder to MetLife. Such information:
• Will be provided in a timely manner and in a format as agreed to by MetLife and the Policyholder;
• Will be provided, maintained and administered as agreed to in Writing by MetLife and the
Policyholder;and
• If maintained by the Policyholder, may be examined by MetLife at any reasonable time.
If MetLife or the Policyholder makes a clerical error in keeping or providing the information, the Premium
and/or benefits will be adjusted as warranted, according to the correct information. An error will not end
insurance validly in effect, nor will it continue insurance validly ended or create insurance coverage where
no coverage existed.
Any act undertaken by the Policyholder that relates to the insurance provided under this policy must be
consistent with the terms of such insurance and with MetLife's requirements; including but not limited to the
eligibility requirements of the Policyholder's plan as set forth in the certificates to this policy.
Misstatement of Age. If a Covered Person's age is misstated, the correct age will be used to determine if
insurance is in effect and,as appropriate, adjust the Premium and/or benefits.
Non-Dividend Paying. This policy does not pay dividends.
Conformity with Law. If the terms and provisions of this policy do not conform to any applicable law, this
policy shall be interpreted to so conform.
GPNP99 166979-1-G Page 10
as endorsed by GPENDI3-05/hh and GPENDI3-08
SCHEDULE OF EXHIBITS
Exhibit
Number Exhibit Type Applies To Effective Date
1 Schedule of Premium Rates All Covered Persons January 1,2017
2 Certificate Forms All Covered Persons January 1,2017
GPNP99 166979-1-G
SCH/EXHIBITS DATE: January 1,2017
as endorsed by GPENDI3-05/hh and GPENDI3-08
EXHIBIT 1
SCHEDULE OF PREMIUM RATES
The initial monthly Premium rates for the insurance provided by this policy are as follows:
Rate Guarantee Period
Subject to the Right to Change Premium Rates provision on page 6, the Premium rates for:
• Dental Insurance will be in effect for the 24 month period which begins on January 1,2017.
Dental Insurance:
Amount Per Employee
Employee only $17.52
Employee and one Dependent $35.52
Employee, Spouse and Child(ren) $53.28
Subject to the Right to Change Premium Rates provision on page 6, the above initial monthly Dental
Insurance Premium rates will not be increased by more than 5%for the period which begins on January 1,
2019 and ends December 31,2019.
GPNP99 166979-1-G Page 1
EXHIBITI January 1,2017
as endorsed by GPENDI3-05/hh and GPENDI3-08
EXHIBIT 2
CERTIFICATE FORMS
Certificate
Number Certificate Form Applies To Effective Date
1 GCERT2000 All Full-Time and Retired January 1,2017
Employees- Dental Insurance
GPNP99 166979-1-G Page 1
EXHIBIT2 January 1,2017
as endorsed by GPENDI3-05/hh and GPENDI3-08
MetLife*
Metropolitan Life Insurance Company
200 Park Avenue,New York,New York
APPLICATION FOR GROUP INSURANCE
The applicant named below is applying for Group Insurance to provide coverage for the class(es)of persons specified
below.
APPLICANT DATA
1 Full legal name of Applicant: Auguste Georgie
2. Address:
535 Tettair Street (the"Policyholder)
City Augusta State GA Zip 30901
EFFECTIVE DATE
The effective date of the applied for group insurance will be 01/01/2017
this application and the applicant's payment of the Premium due on or before such dat�ect to MetLife's acceptance of
SITUS
Group Policy forms will be Issued for delivery in and governed by the laws of Georgia
COVERAGE DATA
Employees I Members
Dependents
Dental Insurance
Dental insurance
PREMIUM DATA
Premiums will be paid: t Monthly n peer .
y -C7ther- ._..__--- _-_____ . ._ --- ---
Attached is an advance payment of: $ D , 19 0
AGREEMENT
The Applicant signing below agrees to accept the terms and provisions of all Group Policy forms issued pursuant to
this application;including all Exhibits,amendments and endorsements,it any.
Fraud Warning.Any person who knowingly and with intent to defraud any insurance company or other person files an
application for insurance or statement of claim containing any materially false information, or conceals for the purpose
of misleading,information concerning any fact material thereto commits a fraudulent insurance act,which Is a crime
and subjects such person to cri nd CMI enalties.
(Signature Applicant's Authorized Representative) f h f f
fjr+� ((Print Name and-Title of Authorized Represeniatiddde)
142 itr igned as r
(f(! (p Date:
iState}
(Signa oft c ed etl�fe Agent or Resident (Agent's n's ct �en
Age as required by I ) Siete License No.) 1t Name of Agent)
GAPP'I 3-02
NW
YOUR BENEFIT PLAN
Augusta Georgia
All Full-Time and Retired Employees
Dental Insurance for You and Your Dependents
Certificate Date: January 1, 2017
Augusta Georgia
535 Telfair St
Augusta, GA 30901
TO OUR EMPLOYEES:
All of us appreciate the protection and security insurance provides.
This certificate describes the benefits that are available to you.We urge you to read it carefully.
Augusta Georgia
MetLife
Metropolitan Life Insurance Company
200 Park Avenue, New York, New York 10166
CERTIFICATE OF INSURANCE
Metropolitan Life Insurance Company("MetLife"), a stock company, certifies that You and Your Dependents
are insured for the benefits described in this certificate, subject to the provisions of this certificate. This
certificate is issued to You under the Group Policy and it includes the terms and provisions of the Group
Policy that describe Your insurance. PLEASE READ THIS CERTIFICATE CAREFULLY.
This certificate is part of the Group Policy. The Group Policy is a legal contract between MetLife and the
Policyholder and may be changed or ended without Your consent or notice to You.
Policyholder: Augusta Georgia
Group Policy Number: 166979-1-G
Type of Insurance: Dental Insurance
MetLife Toll Free Number(s):
For Claim Information FOR DENTAL CLAIMS: 1-800-942-0854
THIS CERTIFICATE ONLY DESCRIBES DENTAL INSURANCE.
FOR CALIFORNIA RESIDENTS: REVIEW THIS CERTIFICATE CAREFULLY. IF YOU
ARE 65 OR OLDER ON YOUR EFFECTIVE DATE OF THIS CERTIFICATE, YOU MAY
RETURN IT TO US WITHIN 30 DAYS FROM THE DATE YOU RECEIVE IT AND WE
WILL REFUND ANY PREMIUM YOU PAID. IN THIS CASE, THIS CERTIFICATE WILL
BE CONSIDERED TO NEVER HAVE BEEN ISSUED.
THE BENEFITS OF THE POLICY PROVIDING YOUR COVERAGE ARE GOVERNED PRIMARILY BY THE
LAW OF A STATE OTHER THAN FLORIDA.
THE GROUP INSURANCE POLICY PROVIDING COVERAGE UNDER THIS CERTIFICATE WAS ISSUED
IN A JURISDICTION OTHER THAN MARYLAND AND MAY NOT PROVIDE ALL THE BENEFITS
REQUIRED BY MARYLAND LAW.
For Residents of North Dakota: If You are not satisfied with Your Certificate, You may return it to Us within
20 days after You receive it, unless a claim has previously been received by Us under Your Certificate. We
will refund within 30 days of Our receipt of the returned Certificate any Premium that has been paid and the
Certificate will then be considered to have never been issued. You should be aware that, if You elect to
return the Certificate for a refund of premiums, losses which otherwise would have been covered under Your
Certificate will not be covered.
For New Mexico Residents: This type of plan is NOT considered "minimum essential coverage"under
the Affordable Care Act and therefore does NOT satisfy the individual mandate that You have health
insurance coverage. If You do not have other health insurance coverage,You may be subject to a
federal tax penalty.
GCERT2000
fp as amended by GEND16-NM-DSC
1
WE ARE REQUIRED BY STATE LAW TO INCLUDE THE NOTICE(S)WHICH APPEAR ON THIS PAGE
AND IN THE NOTICE(S) SECTION WHICH FOLLOWS THIS PAGE. PLEASE READ THE(SE) NOTICE(S)
CAREFULLY.
GCERT2000
fp as amended by GEND16-NM-DSC
2
IMPORTANT NOTICE AVISO IMPORTANTE
To obtain information or make a complaint: Para obtener informacion o para presentar una queja:
You may call MetLife's toll free telephone number Usted puede Ilamar al numero de telefono gratuito de
for information or to make a complaint at: MetLife's para obtener informacion o para presentar
una queja al:
1-800-942-0854
1-800-942-0854
You may contact the Texas Department of Usted puede comunicarse con el Departamento de
Insurance to obtain information on companies, Seguros de Texas para obtener informacion sobre
coverages, rights, or complaints at: companias, coberturas, derechos, o quejas al:
1-800-252-3439 1-800-252-3439
You may write the Texas Department of Insurance: Usted puede escribir al Departamento de Seguros de
Texas a:
P.O. Box 149104
Austin, TX 78714-9104 P.O. Box 149104
Fax: (512)490-1007 Austin, TX 78714-9104
Fax: (512)490-1007
Web:www.tdi.texas.gov
Sitio Web:www.tdi.texas.gov
Email: ConsumerProtection@tdi.texas.gov
Email: ConsumerProtection@tdi.texas.gov
DISPUTAS POR PRIMAS DE SEGUROS 0
PREMIUM OR CLAIM DISPUTES: Should you RECLAMACIONES: Si tiene una disputa relacionada
have a dispute concerning your premium or about a con su prima de seguro o con una reclamaciOn, usted
claim, you should contact MetLife first. If the debe comunicarse con MetLife primero. Si la disputa
dispute is not resolved, you may contact the Texas no es resuelta, usted puede comunicarse con el
Department of Insurance. Departamento de Seguros de Texas.
ADJUNTE ESTE AVISO A SU CERTIFICADO:
ATTACH THIS NOTICE TO YOUR CERTIFICATE: Este aviso es solamente para propositos informativos
This notice is for information only and does not y no se convierte en parte o en condicion del
become a part or condition of the attached documento adjunto.
document.
GCERT2000 For Texas Residents
notice/tx 11/14 3
NOTICE FOR RESIDENTS OF ALASKA, LOUISIANA, MINNESOTA, MONTANA, NEW
HAMPSHIRE, NEW MEXICO, TEXAS, UTAH AND WASHINGTON
The Definition Of Child Is Modified For The Coverages Listed Below:
For Alaska Residents(Dental Insurance):
The term also includes newborns.
For Louisiana Residents(Dental Insurance):
The term also includes Your grandchildren residing with You. The age limit for children and grandchildren will not
be less than 21, regardless of the child's or grandchild's student status or full-time employment status. In addition,
the age limit for students will not be less than 24. Your natural child, adopted child, stepchild or grandchild under
age 21 will not need to be supported by You to qualify as a Child under this insurance.
For Minnesota Residents(Dental Insurance):
The term also includes:
• Your grandchildren who are financially dependent upon You and reside with You continuously from birth;
• children for whom You or Your Spouse is the legally appointed guardian; and
• children for whom You have initiated an application for adoption.
The age limit for children and grandchildren will not be less than 25 regardless of the child's or grandchild's
student status or full-time employment status. Your natural child, adopted child stepchild or children for whom
You or Your Spouse is the legally appointed guardian under age 25 will not need to be supported by You to
qualify as a Child under this insurance.
For Montana Residents(Dental Insurance):
The term also includes newborn infants of any person insured under this certificate. The age limit for children will
not be less than 25, regardless of the child's student status or full-time employment status. Your natural child,
adopted child or stepchild under age 25 will not need to be supported by You to qualify as a child under this
insurance.
For New Hampshire Residents(Dental Insurance):
The age limit for children will not be less than 26, regardless of the child's marital status, student status, or
full-time employment status. Your natural child, adopted child or stepchild under age 26 will not need to be
supported by You to qualify as a Child under this insurance.
For New Mexico Residents (Dental Insurance):
The age limit for children will not be less than 25, regardless of the child's student status or full-time employment
status. Your natural child, adopted child or stepchild will not be denied dental insurance coverage under this
certificate because:
• that child was born out of wedlock;
• that child is not claimed as Your dependent on Your federal income tax return; or
• that child does not reside with You.
For Texas Residents(Dental Insurance):
The term also includes Your grandchildren. The age limit for children and grandchildren will not be less than 25,
regardless of the child's or grandchild's student status, full-time employment status or military service status.
Your natural child, adopted child or stepchild under age 25 will not need to be supported by You to qualify as a
Child under this insurance. A child will be considered Your adopted child during the period You are party to a suit
in which You are seeking the adoption of the child. In addition, grandchildren must be able to be claimed by You
as a dependent for Federal Income Tax purposes at the time You applied for Insurance.
GCERT2000 4
notice/childdef
NOTICE FOR RESIDENTS OF ALASKA, LOUISIANA, MINNESOTA, MONTANA, NEW
HAMPSHIRE, NEW MEXICO, TEXAS, UTAH AND WASHINGTON (continued)
For Utah Residents(Dental Insurance):
The age limit for children will not be less than 26, regardless of the child's student status or full-time employment
status. Your natural child, adopted child or stepchild under age 26 will not need to be supported by You to qualify
as a Child under this insurance. The term includes an unmarried child who is incapable of self-sustaining
employment because of a mental or physical handicap as defined by applicable law and who has been
continuously covered under a Dental plan since reaching age 26,with no break in coverage of more than 63 days,
and who otherwise qualifies as a Child except for the age limit. Proof of such handicap must be sent to Us within
31 days after:
• the date the Child attains the limiting age in order to continue coverage; or
• You enroll a Child to be covered under this provision;
and at reasonable intervals after such date, but no more often than annually after the two-year period immediately
following the date the Child qualifies for coverage under this provision.
For Washington Residents(Dental Insurance):
The age limit for children will not be less than 26, regardless of the child's marital status, student status, or full-
time employment status. Your natural child, adopted child or stepchild under age 26 will not need to be supported
by You to qualify as a Child under this insurance.
GCERT2000 5
notice/childdef
NOTICE FOR RESIDENTS OF ALL STATES WHO ARE INSURED FOR DENTAL
INSURANCE
Notice Regarding Your Rights and Responsibilities
Rights:
• We will treat communications,financial records and records pertaining to Your care in accordance with all
applicable laws relating to privacy.
• Decisions with respect to dental treatment are the responsibility of You and the Dentist. We neither
require nor prohibit any specified treatment. However, only certain specified services are covered for
benefits. Please see the Dental Insurance sections of this certificate for more details.
• You may request a pre-treatment estimate of benefits for the dental services to be provided. However,
actual benefits will be determined after treatment has been performed.
• You may request a written response from MetLife to any written concern or complaint.
• You have the right to receive an explanation of benefits which describes the benefit determinations for
Your dental insurance.
Responsibilities:
• You are responsible for the prompt payment of any charges for services performed by the Dentist. If the
dentist agrees to accept part of the payment directly from MetLife, You are responsible for prompt
payment of the remaining part of the dentist's charge.
• You should consult with the Dentist about treatment options, proposed and potential procedures,
anticipated outcomes, potential risks, anticipated benefits and alternatives. You should share with the
Dentist the most current, complete and accurate information about Your medical and dental history and
current conditions and medications.
• You should follow the treatment plans and health care recommendations agreed upon by You and the
Dentist.
GCERT2000 6
notice/denrights
NOTICE FOR RESIDENTS OF ALASKA
Reasonable and Customary Charges
Reasonable and Customary Charges for Out-of-Network services will not be based less than an 80th percentile of the
dental charges.
Reasonable Access to an In-Network Dentist
If You do not have an In-Network Dentist within 50 miles of Your legal residence, We will reimburse You for the cost of
Covered Services and materials provided by an Out-of-Network Dentist at the same benefit level as an In-Network
Dentist.
Exclusions
The exclusion of services which are primarily cosmetic will not apply to the treatment or correction of a congenital
defect of a newborn child.
Coordination of Benefits or Non-Duplication of Benefits with a Secondary Plan:
If This Plan is Secondary, This Plan will determine benefits as if the services were obtained from This Plan's In-Network
provider under the following circumstances:
• the Primary Plan does not provide benefits through a provider network;
• both the Primary Plan and This Plan provide benefits through provider networks but the covered person obtains
services through a provider in the Primary plan's network who is not in This Plan's network; or
• both the Primary Plan and This Plan provide benefits through provider networks but the covered person obtains
services from a provider that is not part of the provider network of the Primary Plan or This Plan because no
provider in the Primary Plan's provider network or This Plan's network is able to meet the particular health need of
the covered person.
Procedures For Dental Claims
Procedures for Presenting Claims for Dental Insurance Benefits
All claim forms needed to file for Dental Insurance benefits under the group insurance program can be obtained from
the Employer who can also answer questions about the insurance benefits and to assist You or, if applicable, Your
beneficiary in filing claims. Dental claim forms can also be downloaded from www.metlife.com/dental. The instructions
on the claim form should be followed carefully. This will expedite the processing of the claim. Be sure all questions are
answered fully.
Routine Questions on Dental Insurance Claims
If there is any question about a claim payment, an explanation may be requested from MetLife by dialing
1-800-942-0854.
Claim Submission
For claims for Dental Insurance benefits, the claimant must complete the appropriate claim form and submit the
required proof as described in the FILING A CLAIM section of the certificate.
Claim forms must be submitted in accordance with the instructions on the claim form.
GCERT2000
notice/ak 7
NOTICE FOR RESIDENTS OF ALASKA
Procedures For Dental Claims(Continued)
Initial Determination
After You submit a claim for Dental Insurance benefits to MetLife, MetLife will review Your claim and notify You of its
decision to approve or deny Your claim.
Such notification will be provided to You within a 30 day period from the date You submitted Your claim; except for
situations requiring an extension of time of up to 15 days because of matters beyond the control of MetLife. If MetLife
needs such an extension, MetLife will notify You prior to the expiration of the initial 30 day period, state the reason why
the extension is needed, and state when it will make its determination. If an extension is needed because You did not
provide sufficient information or filed an incomplete claim, the time from the date of MetLife's notice requesting further
information and an extension until MetLife receives the requested information does not count toward the time period
MetLife is allowed to notify You as to its claim decision. You will have 45 days to provide the requested information
from the date You receive the notice requesting further information from MetLife.
If MetLife denies Your claim in whole or in part, the notification of the claims decision will state the reason why Your
claim was denied and reference the specific Plan provision(s)on which the denial is based. If the claim is denied
because MetLife did not receive sufficient information, the claims decision will describe the additional information
needed and explain why such information is needed. Further, if an internal rule, protocol, guideline or other criterion
was relied upon in making the denial, the claims decision will state the rule, protocol, guideline or other criteria or
indicate that such rule, protocol, guideline or other criteria was relied upon and that You may request a copy free of
charge.
Within 30 days after We receive Proof of Your claim,We will approve and pay the claim or We will deny the claim. If
We deny the claim,We will provide You with the basis of Our denial or the specific additional information that We need
to adjudicate Your claim. If We request additional information,We will approve and pay the claim or We will deny the
claim within 15 days after We receive the additional information. If the claim is approved and not paid within the time
period provided, the claim will accrue at an interest rate of 15 percent per year until the claim is paid.
Appealing the Initial Determination
If MetLife denies Your claim,You may appeal the denial. Upon Your written request, MetLife will provide You free of
charge with copies of documents, records and other information relevant to Your claim. You must submit Your appeal
to MetLife at the address indicated on the claim form within 180 days of receiving MetLife's decision, or as soon as
reasonably possible for situations in which You cannot reasonably meet the deadline. Appeals must be in writing and
must include at least the following information:
• Name of Employee
• Name of the Plan
• Reference to the initial decision
• Whether the appeal is the first or second appeal of the initial determination
• An explanation why You are appealing the initial determination.
As part of each appeal,You may submit any written comments, documents, records, or other information relating to
Your claim.
After MetLife receives Your written request, MetLife will conduct a full and fair review of Your claim. Deference will not
be given to initial denials, and MetLife's review will look at the claim anew. The review on appeal will take into account
all comments, documents, records, and other information that You submit relating to Your claim without regard to
whether such information was submitted or considered in the initial determination. Your appeal will be reviewed by a
person holding the same professional license as the treating Dental provider. The person who will review Your appeal
will not be the same person as the person who made the initial decision to deny Your claim. In addition, the person
who is reviewing the appeal will not be a subordinate of the person who made the initial decision to deny Your claim.
GCERT2000
notice/ak 8
NOTICE FOR RESIDENTS OF ALASKA
Procedures For Dental Claims(Continued)
MetLife will notify You in writing of its final decision within 18 days after MetLife's receipt of Your written request for
review.
If MetLife denies the claim on appeal, MetLife will send You a final written decision that states the reason(s)why the
claim You appealed is being denied and references any specific Plan provision(s)on which the denial is based. If an
internal rule, protocol, guideline or other criterion was relied upon in denying the claim on appeal, the final written
decision will state the rule, protocol, guideline or other criteria or indicate that such rule, protocol, guideline or other
criteria was relied upon and that You may request a copy free of charge. Upon written request, MetLife will provide You
free of charge with copies of documents, records and other information relevant to Your claim.
Second Level Appeal
If You disagree with the response to the initial appeal of the denied claim, You have the right to a second level appeal.
We shall communicate Our final determination to You within 18 calendar days from receipt of the request, or as
required by any applicable state or federal laws or regulations. Our communication to You shall include the specific
reasons for the determination.
External Appeal
If You disagree with the response to the second appeal of the denied claim, You have the right to an external appeal.
We will communicate the decision of the external appear agency in Writing. The decision will be made in accordance
with the medical exigencies of the case involved, but in no event later than 21 working days after the appeal is filed, or,
in the case of an expedited appeal, 72 hours after the time of requesting an external appeal of the health care insurer's
decision. Decisions made by an external appeal agency are binding on Us and You unless the aggrieved party files suit
in superior court within 6 months from the decision of the external appeal agency. All costs of the external appeal
process, except those incurred by You or the treating professional in support of the appeal,will be paid by Us.
Overpayments
Recovery of Overpayments
We have the right to recover any amount that is determined to be an overpayment, within 180 days from
the date of service,whether for services received by You or Your Dependents.
An overpayment occurs if it is determined that:
• the total amount paid by Us on a claim for Dental Insurance benefits is more than the total of the benefits due to
You under this certificate; or
• payment We made should have been made by another group plan.
If such overpayment occurs,You have an obligation to reimburse Us.
GCERT2000
notice/ak 9
NOTICE FOR RESIDENTS OF ALASKA
Overpayments(Continued)
How We Recover Overpayments
We may recover the overpayment, within 180 days from the date of service,from You by:
• stopping or reducing any future benefits payable for Dental Insurance;
• demanding an immediate refund of the overpayment from You; and
• taking legal action.
If the overpayment results from Our having made a payment to You that should have been made under another group
plan,We may recover such overpayment within 180 days from the date of service, from one or more of the following:
• any other insurance company;
• any other organization; or
• any person to or for whom payment was made.
GCERT2000
notice/ak 10
NOTICE FOR RESIDENTS OF ARKANSAS
If You have a question concerning Your coverage or a claim,first contact the Policyholder or group account
administrator. If, after doing so, You still have a concern, You may call the toll free telephone number shown
on the Certificate Face Page.
If You are still concerned after contacting both the Policyholder and MetLife, You should feel free to contact:
Arkansas Insurance Department
Consumer Services Division
1200 West Third Street
Little Rock,Arkansas 72201
(501)371-2640 or(800)852-5494
GCERT2000
notice/ar 11
NOTICE FOR RESIDENTS OF CALIFORNIA
IMPORTANT NOTICE
TO OBTAIN ADDITIONAL INFORMATION, OR TO MAKE A COMPLAINT, CONTACT THE
POLICYHOLDER OR METLIFE AT:
METROPOLITAN LIFE INSURANCE COMPANY
ATTN: CONSUMER RELATIONS DEPARTMENT
500 SCHOOLHOUSE ROAD
JOHNSTOWN, PA 15904
1-800-438-6388
IF,AFTER CONTACTING THE POLICYHOLDER AND/OR METLIFE,YOU FEEL THAT A SATISFACTORY
SOLUTION HAS NOT BEEN REACHED,YOU MAY FILE A COMPLAINT WITH THE CALIFORNIA
DEPARTMENT OF INSURANCE DEPARTMENT AT:
DEPARTMENT OF INSURANCE
CONSUMER SERVICES
300 SOUTH SPRING STREET
LOS ANGELES, CA 90013
WEBSITE: http://www.insurance.ca.gov/
1-800-927-4357 (within California)
1-213-897-8921 (outside California)
GCERT2000 12
notice/ca
NOTICE FOR RESIDENTS OF THE STATE OF CALIFORNIA
California law provides that for dental insurance, domestic partners of California's residents must be treated
the same as spouses. If the certificate does not already have a definition of domestic partner, then the
following definition applies:
"Domestic Partner means each of two people, one of whom is an employee of the Policyholder, a
resident of California and who have registered as domestic partners or members of a civil union with
the California government or another government recognized by California as having similar
requirements."
If the certificate already has a definition of domestic partner, that definition will apply to California residents, as
long as it recognizes as a domestic partner any person registered as the employee's domestic partner with
the California government or another government recognized by California as having similar requirements.
Wherever the term "Spouse"appears in this certificate it shall, unless otherwise specified, be read to include
Your Domestic Partner.
Wherever the term step-child appears, it is replaced by step-child or child of Your Domestic Partner.
GCERT2000 13
notice/dp/ca
NOTICE FOR RESIDENTS OF GEORGIA
IMPORTANT NOTICE
The laws of the state of Georgia prohibit insurers from unfairly discriminating against any person based upon
his or her status as a victim of family violence.
GCERT2000
notice/ga 14
NOTICE FOR RESIDENTS OF IDAHO
If You have a question concerning Your coverage or a claim,first contact the Policyholder. If, after doing so,
You still have a concern, You may call the toll free telephone number shown on the Certificate Face Page.
If You are still concerned after contacting both the Policyholder and MetLife,You should feel free to contact:
Idaho Department of Insurance
Consumer Affairs
700 West State Street, 3rd Floor
PO Box 83720
Boise, Idaho 83720-0043
1-800-721-3272(for calls placed within Idaho)or 208-334-4250 or www.DOI.Idaho.gov
GCERT2000
notice/id 15
NOTICE FOR RESIDENTS OF ILLINOIS
IMPORTANT NOTICE
To make a complaint to MetLife, You may write to:
MetLife
200 Park Avenue
New York, New York 10166
The address of the Illinois Department of Insurance is:
Illinois Department of Insurance
Public Services Division
Springfield, Illinois 62767
GCERT2000
notice/iI 16
NOTICE FOR RESIDENTS OF INDIANA
Questions regarding your policy or coverage should be directed to:
Metropolitan Life Insurance Company
1-800-438-6388
If you(a)need the assistance of the government agency that regulates insurance; or(b)have a
complaint you have been unable to resolve with your insurer you may contact the Department
of Insurance by mail,telephone or email:
State of Indiana Department of Insurance
Consumer Services Division
311 West Washington Street, Suite 300
Indianapolis, Indiana 46204
Consumer Hotline: (800)622-4461; (317)232-2395
Complaint can be filed electronically at www.in.gov/idoi
GCERT2000
notice/in 17
NOTICE FOR RESIDENTS OF MAINE
You have the right to designate a third party to receive notice if Your insurance is in danger of lapsing due to
a default on Your part, such as for nonpayment of a contribution that is due. The intent is to allow
reinstatements where the default is due to the insured person's suffering from cognitive impairment or
functional incapacity. You may make this designation by completing a"Third-Party Notice Request Form"and
sending it to MetLife. Once You have made a designation, You may cancel or change it by filling out a new
Third-Party Notice Request Form and sending it to MetLife. The designation will be effective as of the date
MetLife receives the form. Call MetLife at the toll-free telephone number shown on the face page of this
certificate to obtain a Third-Party Notice Request Form. Within 90 days after cancellation of coverage for
nonpayment of premium, You, any person authorized to act on Your behalf, or any covered Dependent may
request reinstatement of the certificate on the basis that You suffered from cognitive impairment or functional
incapacity at the time of cancellation.
GCERT2000
notice/me 18
NOTICE FOR MASSACHUSETTS RESIDENTS
CONTINUATION OF DENTAL INSURANCE
1. If Your Dental Insurance ends due to a Plant Closing or Covered Partial Closing, such insurance will be
continued for 90 days after the date it ends.
2. If Your Dental Insurance ends because:
• You cease to be in an Eligible Class; or
• Your employment terminates;
for any reason other than a Plant Closing or Covered Partial Closing, such insurance will continue for 31 days
after the date it ends.
Continuation of Your Dental Insurance under the CONTINUATION OF INSURANCE WITH PREMIUM
PAYMENT subsection will end before the end of continuation periods shown above if You become covered
for similar benefits under another plan.
Plant Closing and Covered Partial Closing have the meaning set forth in Massachusetts Annotated Laws,
Chapter 151A, Section 71A.
CONTINUATION OF DENTAL INSURANCE FOR YOUR FORMER SPOUSE
If the judgment of divorce dissolving Your marriage provides for continuation of insurance for Your former
Spouse when You remarry, Dental Insurance for Your former Spouse that would otherwise end may be
continued.
To continue Dental insurance under this provision:
1. You must make a written request to the employer to continue such insurance;
2. You must make any required premium to the employer for the cost of such insurance.
The request form will be furnished by the Employer.
Such insurance may be continued from the date Your marriage is dissolved until the earliest of the following:
• the date Your former Spouse remarries;
• the date of expiration of the period of time specified in the divorce judgment during which You are
required to provide Dental Insurance for Your former Spouse;
• the date coverage is provided under any other group health plan;
• the date Your former Spouse becomes entitled to Medicare;
• the date Dental Insurance under the policy ends for all active employees, or for the class of active
employees to which You belonged before Your employment terminated;
• the date of expiration of the last period for which the required premium payment was made; or
• the date such insurance would otherwise terminate under the policy.
If Your former Spouse is eligible to continue Dental Insurance under this provision and any other provision of
this Policy, all such continuation periods will be deemed to run concurrently with each other and shall not be
deemed to run consecutively.
GCERT2000
notice/ma 19
NOTICE FOR RESIDENTS OF MISSISSIPPI
DENTAL INSURANCE: PROCEDURES FOR DENTAL CLAIMS
Procedures for Presenting Claims for Dental Insurance Benefits
All claim forms needed to file for Dental Insurance benefits under the group insurance program can be obtained
from the Employer who can also answer questions about the insurance benefits and to assist You or, if
applicable,Your beneficiary in filing claims. Dental claim forms can also be downloaded from
www.metlife.com/dental. The instructions on the claim form should be followed carefully. This will expedite the
processing of the claim. Be sure all questions are answered fully.
Routine Questions on Dental Insurance Claims
If there is any question about a claim payment, an explanation may be requested from MetLife by dialing
1-800-942-0854.
Claim Submission
For claims for Dental Insurance benefits,the claimant must complete the appropriate claim form and submit the
required proof as described in the FILING A CLAIM section of the certificate.
Claim forms must be submitted in accordance with the instructions on the claim form.
Initial Determination
After You submit a claim for Dental Insurance benefits to MetLife, MetLife will review Your claim and notify You of
its decision to approve or deny Your claim.
If Your claim is a Clean Claim and it is approved by MetLife, benefits will be paid within 25 days after MetLife
receives due written proof in electronic form of a covered loss, or within 35 days after receipt of due written proof
in paper form of a covered loss. Due written proof includes, but is not limited to, information essential for Us to
administer coordination of benefits.
"Clean Claim"means a claim that:
• does not require further information, adjustment or alteration by You or the provider of the services in
order for MetLife to process and pay it;
• does not have any defects;
• does not have any impropriety, including any lack of supporting documentation; and
• does not involve a particular circumstance required special treatment that substantially prevents timely
payments from being made on the claim.
A Clean Claim does not include a claim submitted by a provider more than 30 days after the date of service,
or if the provider does not submit the claim on Your behalf, a claim submitted more than 30 days after the
date the provider bills You.
If MetLife is unable to pay a claim for Dental Insurance benefits because MetLife needs additional information
or documentation, or there is a particular circumstance requiring special treatment,within 25 days after the
date MetLife receives the claim if it is submitted in electronic form, or within 35 days after the date MetLife
receives the claim if it is submitted in paper form, MetLife will send You notice of what supporting
documentation or information MetLife needs. Any claim or portion of a claim for Dental Insurance benefits
that is resubmitted with all of the supporting documentation requested in Our notice and becomes payable will
be paid to You within 20 days after MetLife receives it.
GCERT2000 20
notice/ms
NOTICE FOR RESIDENTS OF MISSISSIPPI (continued)
Clean Claim (Continued)
If MetLife does not deny payment of such benefits to You by the end of the 25 day period for clean claims
submitted in electronic form, or 35 day period for clean claims submitted in paper form, and such benefits
remain due and payable to You, interest will accrue on the amount of such benefits at the rate of 1% percent
per month until such benefits are finally settled. If MetLife does not pay benefits to You when due and
payable, You may bring action to recover such benefits, any interest which has accrued with respect to such
benefits and any other damages which may be allowed by law. MetLife will pay benefits when MetLife
receives satisfactory Written proof of Your claim.
Proof must be given to MetLife not later than 90 days after the end of the Dental Expense Period in which the
Covered Dental Expenses were incurred. If proof is not given on time, the delay will not cause a claim to be
denied or reduced as long as the proof is given as soon as possible.
Appealing the Initial Determination
If MetLife denies Your claim, You may take two appeals of the initial determination. Upon Your written
request, MetLife will provide You free of charge with copies of documents, records and other information
relevant to Your claim. You must submit Your appeal to MetLife at the address indicated on the claim form
within 180 days of receiving MetLife's decision.Appeals must be in writing and must include at least the
following information:
• Name of Employee
• Name of the Plan
• Reference to the initial decision
• Whether the appeal is the first or second appeal of the initial determination
• An explanation why You are appealing the initial determination.
As part of each appeal, You may submit any written comments, documents, records, or other information
relating to Your claim.
After MetLife receives Your written request appealing the initial determination or determination on the first
appeal, MetLife will conduct a full and fair review of Your claim. Deference will not be given to initial denials,
and MetLife's review will look at the claim anew. The review on appeal will take into account all comments,
documents, records, and other information that You submit relating to Your claim without regard to whether
such information was submitted or considered in the initial determination. The person who will review Your
appeal will not be the same person as the person who made the initial decision to deny Your claim. In
addition, the person who is reviewing the appeal will not be a subordinate of the person who made the initial
decision to deny Your claim. If the initial denial is based in whole or in part on a medical judgment, MetLife
will consult with a health care professional with appropriate training and experience in the field of dentistry
involved in the judgment. This health care professional will not have consulted on the initial determination,
and will not be a subordinate of any person who was consulted on the initial determination.
MetLife will notify You in writing of its final decision within 30 days after MetLife's receipt of Your written
request for review, except that under special circumstances MetLife may have up to an additional 30 days to
provide written notification of the final decision. If such an extension is required, MetLife will notify You prior
to the expiration of the initial 30 day period, state the reason(s)why such an extension is needed, and state
when it will make its determination.
If MetLife denies the claim on appeal, MetLife will send You a final written decision that states the reason(s)
why the claim You appealed is being denied and references any specific Plan provision(s)on which the denial
is based. If an internal rule, protocol, guideline or other criterion was relied upon in denying the claim on
appeal, the final written decision will state the rule, protocol, guideline or other criteria or indicate that such
rule, protocol, guideline or other criteria was relied upon and that You may request a copy free of charge.
Upon written request, MetLife will provide You free of charge with copies of documents, records and other
information relevant to Your claim.
GCERT2000 21
notice/ms
NOTICE FOR NEW HAMPSHIRE RESIDENTS
CONTINUATION OF YOUR DENTAL INSURANCE
If You are a resident of New Hampshire, Your Dental Insurance may be continued if it ends because Your
employment ends unless:
• Your employment ends due to Your gross misconduct;
• this Dental Insurance ends for all employees;
• this Dental Insurance is changed to end Dental Insurance for the class of employees to which You
belong;
• You are entitled to enroll in Medicare; or
• Your Dental Insurance ends because You failed to pay the required premium.
The Employer must give You written notice of:
• Your right to continue Your Dental Insurance;
• the amount of premium payment that is required to continue Your Dental Insurance;
• the manner in which You must request to continue Your Dental Insurance and pay premiums; and
• the date by which premium payments will be due.
The premium that You must pay for Your continued Dental Insurance may include:
• any amount that You contributed for Your Dental Insurance before it ended;
• any amount the Employer paid; and
• an administrative charge which will not to exceed two percent of the rest of the premium.
To continue Your Dental Insurance, You must:
• send a written request to continue Your Dental Insurance; and
• pay the first premium within 30 days after the date Your employment ends.
The maximum continuation period will be the longest of:
• 36 months if Your employment ends because You retire, and within 12 months of retirement You have a
substantial loss of coverage because the employer files for bankruptcy protection under Title 11 of the
United States Code;
• 29 months if You become entitled to disability benefits under Social Security within 60 days of the date
Your Employment ends; or
• 18 months.
Your continued Dental Insurance will end on the earliest of the following to occur:
• the end of the maximum continuation period;
• the date this Dental Insurance ends;
• the date this Dental Insurance is changed to end Dental Insurance for the class of employees to which
You belong;
• the date You are entitled to enroll for Medicare;
• if You do not pay the required premium to continue Your Dental Insurance; or
• the date You become eligible for coverage under any other group Dental coverage.
GCERT2000
notice/coi/nh 22
NOTICE FOR NEW HAMPSHIRE RESIDENTS (continued)
CONTINUATION OF YOUR DEPENDENT'S DENTAL INSURANCE
If You are a resident of New Hampshire, Your Dental Insurance for Your Dependents may be continued if it
ends because Your employment ends, Your marriage ends in divorce or separation, or You die, unless:
• Your employment ends due to Your gross misconduct;
• this Dental Insurance ends for all Dependents;
• this Dental Insurance is changed,for the class of employees to which You belong, to end Dental
Insurance for Dependents;
• the Dependent is entitled to enroll in Medicare; or
• Your Dental Insurance for Your Dependents ends because You fail to pay a required premium.
If Dental Insurance for Your Dependents ends because Your marriage ends in divorce or separation, the party
responsible under the divorce decree or separation agreement for payment of premium for continued Dental
Insurance must notify the employer, in writing,within 30 days of the date of the divorce decree or separation
agreement that the divorce or separation has occurred. If You and Your divorced or separated Spouse share
responsibility for payment of the premium for continued Dental Insurance, both You and Your divorced or
separated Spouse must provide the notification.
The Employer must give You, or Your former Spouse if You have died or Your marriage has ended,written
notice of:
• Your right to continue Your Dental Insurance for Your Dependents;
• the amount of premium payment that is required to continue Your Dental Insurance for Your Dependents;
• the manner in which You or Your former Spouse must request to continue Your Dental Insurance for Your
Dependents and pay premiums; and
• the date by which premium payments will be due.
The premium that You or Your former Spouse must pay for continued Dental Insurance for Your Dependents
may include:
• any amount that You contributed for Your Dental Insurance before it ended; and
• any amount the Employer paid.
To continue Dental Insurance for Your Dependents, You or Your former Spouse must:
• send a written request to continue Dental Insurance for Your Dependents; and
• must pay the first premium within 30 days of the date Dental Insurance for Your Dependents ends.
If You, and Your former Spouse, if applicable, fail to provide any required notification, or fail to request to
continue Dental Insurance for Your Dependents and pay the first premium within the time limits stated in this
section,Your right to continue Dental Insurance for Your Dependents will end.
GCERT2000
notice/coi/nh 23
NOTICE FOR NEW HAMPSHIRE RESIDENTS (continued)
CONTINUATION OF YOUR DEPENDENT'S DENTAL INSURANCE(Continued)
The maximum continuation period will be the longest of the following that applies:
• 36 months if Dental Insurance for Your Dependents ends because Your marriage ends in divorce or
separation, except that with respect to a Spouse who is age 55 or older when your marriage ends in
divorce or separation the maximum continuation period will end when the divorced or separated Spouse
becomes eligible for Medicare or eligible for participation in another employer's group plan;
• 36 months if Dental Insurance for Your Dependents ends because You die, except that with respect to a
Spouse who is age 55 or older when You die, the maximum continuation period will end when Your
surviving Spouse becomes eligible for Medicare or eligible for participation in another employer's group
dental coverage;
• 36 months if Dental Insurance for Your Dependents ends because You become entitled to benefits under
Title XVIII of Social Security, except that with respect to a Spouse who is age 55 or older when You
become entitled to benefits under Title XVIII of Social Security, the maximum continuation period will end
when the divorced or separated Spouse becomes eligible for Medicare or eligible for participation in
another employer's group dental coverage;
• 36 months if You become entitled to benefits under Title XVIII of Social Security while You are already
receiving continued benefits under this section, except that with respect to a Spouse who is age 55 or
older when You first become entitled to continue Your Dental Insurance the maximum continuation period
will end when the divorced or separated Spouse becomes eligible for Medicare or eligible for participation
in another employer's group dental coverage;
• 36 months with respect to a Dependent Child if Dental Insurance ends because the Child ceases to be a
Dependent Child;
• 36 months if Your employment ends because You retire, and within 12 months of retirement You have a
substantial loss of coverage because the employer files for bankruptcy protection under Title 11 of the
United States Code;
• 29 months if Dental Insurance for Your Dependents ends because Your employment ends, and within 60
days of the date Your employment ends you become entitled to disability benefits under Social Security;
or
• 18 months if Dental Insurance for Your Dependents ends because Your employment ends.
A Dependent's continued Dental Insurance will end on the earliest of the following to occur:
• the end of the maximum continuation period;
• the date this Dental Insurance ends;
• the date this Dental Insurance is changed to end Dental Insurance for Dependents for the class of
employees to which You belong;
• the date the Dependent becomes entitled to enroll for Medicare;
• if You do not pay a required premium to continue Dental Insurance for Your Dependents; or
• the date the Dependent becomes eligible for coverage under any other group dental coverage.
GCERT2000
notice/coi/nh 24
NOTICE FOR NEW HAMPSHIRE RESIDENTS
The following service will be a Covered Service for New Hampshire residents whether or not general
anesthesia or intravenous sedation is already specified elsewhere as covered:
General anesthesia or intravenous sedation in connection with oral surgery, extractions or other Covered
Services,when
• the covered person is a Child under the age of 6 who is determined by a licensed Dentist in
conjunction with a licensed Physician to have a dental condition of significant complexity which
requires the Child to receive general anesthesia for the treatment of such condition;
• the covered person has exceptional medical circumstances or a developmental disability as
determined by a licensed Physician which place the person at serious risk; or
• We determine such anesthesia is necessary in accordance with generally accepted dental standards.
GCERT2000
notice/den/nh 25
NOTICE FOR RESIDENTS OF PENNSYLVANIA
Dental Insurance for a Dependent Child may be continued past the age limit if that Child is a full-time student
and insurance ends due to the Child being ordered to active duty(other than active duty for training)for 30 or
more consecutive days as a member of the Pennsylvania National Guard or a Reserve Component of the
Armed Forces of the United States.
Insurance will continue if such Child:
• re-enrolls as a full-time student at an accredited school, college or university that is licensed in the
jurisdiction where it is located;
• re-enrolls for the first term or semester, beginning 60 or more days from the child's release from active
duty;
• continues to qualify as a Child, except for the age limit; and
• submits the required Proof of the child's active duty in the National Guard or a Reserve Component of the
United States Armed Forces.
Subject to the Date Insurance For Your Dependents Ends subsection of the section entitled ELIGIBILITY
PROVISIONS: INSURANCE FOR YOUR DEPENDENTS, this continuation will continue until the earliest of
the date:
• the insurance has been continued for a period of time equal to the duration of the child's service on active
duty; or
• the child is no longer a full-time student.
GCERT2000 26
notice/pa
NOTICE FOR RESIDENTS OF TEXAS
THE INSURANCE POLICY UNDER WHICH THIS CERTIFICATE IS ISSUED IS NOT A POLICY OF
WORKERS'COMPENSATION INSURANCE. YOU SHOULD CONSULT YOUR EMPLOYER TO
DETERMINE WHETHER YOUR EMPLOYER IS A SUBSCRIBER TO THE WORKERS'COMPENSATION
SYSTEM.
GCERT2000
notice/tx/wc 27
DENTAL INSURANCE: PROCEDURES FOR DENTAL CLAIMS
NOTICE FOR RESIDENTS OF TEXAS
If You reside in Texas, note the following Procedures for Dental Claims will be followed:
Procedures for Presenting Claims for Dental Insurance Benefits
All claim forms needed to file for Dental Insurance benefits under the group insurance program can be obtained
from the Employer who can also answer questions about the insurance benefits and to assist You or, if
applicable,Your beneficiary in filing claims. Dental claim forms can also be downloaded from
www.metlife.com/dental. The instructions on the claim form should be followed carefully. This will expedite the
processing of the claim. Be sure all questions are answered fully.
Routine Questions on Dental Insurance Claims
If there is any question about a claim payment,an explanation may be requested from MetLife by dialing 1-800-
942-0854.
Claim Submission
For claims for Dental Insurance benefits, the claimant must complete the appropriate claim form and submit
the required proof as described in the FILING A CLAIM section of the certificate.
Claim forms must be submitted in accordance with the instructions on the claim form.
Initial Determination
After You submit a claim for Dental Insurance benefits to MetLife, MetLife will notify You acknowledging
receipt of Your claim, commence with any investigation, and request any additional information within 15 days
of receipt of Your claim.
MetLife will notify You in writing of the acceptance or rejection of Your claim within 15 business days of
receipt of all information needed to process Your claim.
If MetLife cannot accept or reject Your claim within 15 business days after receipt of all information, MetLife
will notify You within 15 business days stating the reason why we require an extension. If an extension is
requested, We will notify You of our decision to approve or deny Your claim within 45 days. Upon notification
of approval, Your claim will be paid within 5 business days.
If MetLife denies Your claim in whole or in part, the notification of the claims decision will state the reason why
Your claim was denied and reference the specific Plan provision(s)on which the denial is based. If the claim
is denied because MetLife did not receive sufficient information, the claims decision will describe the
additional information needed and explain why such information is needed. Further, if an internal rule,
protocol, guideline or other criterion was relied upon in making the denial, the claims decision will state the
rule, protocol, guideline or other criteria or indicate that such rule, protocol, guideline or other criteria was
relied upon and that You may request a copy free of charge.
Appealing the Initial Determination
If MetLife denies Your claim, You may take two appeals of the initial determination. Upon Your written
request, MetLife will provide You free of charge with copies of documents, records and other information
relevant to Your claim. You must submit Your appeal to MetLife at the address indicated on the claim form
within 180 days of receiving MetLife's decision. Appeals must be in writing and must include at least the
following information:
• Name of Employee;
• Name of the Plan;
• Reference to the initial decision;
• Whether the appeal is the first or second appeal of the initial determination;
• An explanation why You are appealing the initial determination.
GCERT2000 28
notice/denc/tx
DENTAL INSURANCE: PROCEDURES FOR DENTAL CLAIMS (continued)
As part of each appeal,You may submit any written comments, documents, records, or other information
relating to Your claim.
After MetLife receives Your written request appealing the initial determination or determination on the first
appeal, MetLife will conduct a full and fair review of Your claim. Deference will not be given to initial denials,
and MetLife's review will look at the claim anew. The review on appeal will take into account all comments,
documents, records, and other information that You submit relating to Your claim without regard to whether
such information was submitted or considered in the initial determination. The person who will review Your
appeal will not be the same person as the person who made the initial decision to deny Your claim. In
addition, the person who is reviewing the appeal will not be a subordinate of the person who made the initial
decision to deny Your claim. If the initial denial is based in whole or in part on a medical judgment, MetLife
will consult with a health care professional with appropriate training and experience in the field of dentistry
involved in the judgment. This health care professional will not have consulted on the initial determination,
and will not be a subordinate of any person who was consulted on the initial determination.
MetLife will notify You in writing of its final decision within 30 days after MetLife's receipt of Your written
request for review, except that under special circumstances MetLife may have up to an additional 30 days to
provide written notification of the final decision. If such an extension is required, MetLife will notify You prior
to the expiration of the initial 30 day period, state the reason(s)why such an extension is needed, and state
when it will make its determination.
If MetLife denies the claim on appeal, MetLife will send You a final written decision that states the reason(s)
why the claim You appealed is being denied and references any specific Plan provision(s)on which the denial
is based. If an internal rule, protocol, guideline or other criterion was relied upon in denying the claim on
appeal, the final written decision will state the rule, protocol, guideline or other criteria or indicate that such
rule, protocol, guideline or other criteria was relied upon and that You may request a copy free of charge.
Upon written request, MetLife will provide You free of charge with copies of documents, records and other
information relevant to Your claim.
GCERT2000 29
notice/denc/tx
NOTICE FOR RESIDENTS OF UTAH
Notice of Protection Provided by
Utah Life and Health Insurance Guaranty Association
This notice provides a brief summary of the Utah Life and Health Insurance Guaranty Association("the
Association")and the protection it provides for policyholders. This safety net was created under Utah law,
which determines who and what is covered and the amounts of coverage.
The Association was established to provide protection in the unlikely event that your life, health, or annuity
insurance company becomes financially unable to meet its obligations and is taken over by its insurance
regulatory agency. If this should happen, the Association will typically arrange to continue coverage and pay
claims, in accordance with Utah law,with funding from assessments paid by other insurance companies.
The basic protections provided by the Association are:
• Life Insurance
o$500,000 in death benefits
o$200,000 in cash surrender or withdrawal values
• Health Insurance
o$500,000 in hospital, medical and surgical insurance benefits
o$500,000 in long-term care insurance benefits
o$500,000 in disability income insurance benefits
o$500,000 in other types of health insurance benefits
• Annuities
o$250,000 in withdrawal and cash values
The maximum amount of protection for each individual, regardless of the number of policies or contracts, is
$500,000. Special rules may apply with regard to hospital, medical and surgical insurance benefits.
Note: Certain policies and contracts may not be covered or fully covered. For example, coverage does
not extend to any portion of a policy or contract that the insurer does not guarantee, such as certain
investment additions to the account value of a variable life insurance policy or a variable annuity contract.
Coverage is conditioned on residency in this state and there are substantial limitations and exclusions. For a
complete description of coverage, consult Utah Code, Title 3 IA, Chapter 28.
Insurance companies and agents are prohibited by Utah law to use the existence of the Association
or its coverage to encourage you to purchase insurance.When selecting an insurance company,you
should not rely on Association coverage. If there is any inconsistency between Utah law and this
notice, Utah law will control.
To learn more about the above protections, as well as protections relating to group contracts or retirement
plans, please visit the Association's website at www.utlifega.org or contact:
Utah Life and Health Insurance Guaranty Assoc. Utah Insurance Department
60 East South Temple, Suite 500 3110 State Office Building
Salt Lake City UT 84111 Salt Lake City UT 84114-6901
(801)320-9955 (801)538-3800
A written complaint about misuse of this Notice or the improper use of the existence of the Association may
be filed with the Utah Insurance Department at the above address.
GTY-NOTICE-UT-0710 30
NOTICE FOR RESIDENTS OF THE STATE OF VERMONT
Vermont law provides that the following apply to Your certificate:
Domestic Partner means each of two people, one of whom is an Employee of the Policyholder,who have
registered as each other's domestic partner, civil union partner or reciprocal beneficiary with a government
agency where such registration is available.
Wherever the term "Spouse"appears in this certificate it shall, unless otherwise specified, be read to include
Your Domestic Partner.
Wherever the term "step-child"appears in this certificate it shall be read to include the children of Your Domestic
Partner.
GCERT2000 31
notice/vt
NOTICE TO RESIDENTS OF VIRGINIA
IMPORTANT INFORMATION REGARDING YOUR INSURANCE
In the event You need to contact someone about this insurance for any reason please contact Your agent. If no
agent was involved in the sale of this insurance,or if You have additional questions You may contact the
insurance company issuing this insurance at the following address and telephone number:
MetLife
200 Park Avenue
New York, New York 10166
Attn: Corporate Consumer Relations Department
To phone in a claim related question, You may call Claims Customer Service at:
1-800-275-4638
If You have any questions regarding an appeal or grievance concerning the dental services that You have been
provided that have not been satisfactorily addressed by this Dental Insurance,You may contact the Virginia
Office of the Managed Care Ombudsman for assistance.
The Office of the Managed Care Ombudsman
Bureau of Insurance
P.O. Box 1157
Richmond,VA 23218
1-877-310-6560-toll-free
1-804-371-9944-fax
www.scc.virainia.gov-web address
ombudsman anscc.virainia.gov-email
Or:
Office of Licensure and Certification
Division of Acute Care Services
Virginia Department of Health
9960 Mayland Drive
Suite 401
Henrico, Virginia 23233-1463
Phone number: 1-800-955-1819/local: 804-367-2106
Fax: (804)527-4503
MCHIP@vdh.virginia.gov
Written correspondence is preferable so that a record of Your inquiry is maintained. When contacting Your
agent, company or the Bureau of Insurance, have Your policy number available.
DENTAL INSURANCE: PROCEDURES FOR DENTAL CLAIMS
Claim Submission
For claims for Dental Insurance benefits, the claimant must complete the appropriate claim form and submit
the required proof as described in the FILING A CLAIM section of the certificate.
Claim forms must be submitted in accordance with the instructions on the claim form.
GCERT2000
notice/vat 32
NOTICE TO RESIDENTS OF VIRGINIA(continued)
Appealing the Initial Determination
If MetLife denies Your claim, You may take two appeals of the initial determination. Upon your written
request, MetLife will provide You free of charge with copies of documents, records and other information
relevant to your claim. You must submit Your appeal to MetLife at the address indicated on the claim form
within 180 days of receiving MetLife's decision.Appeals must be in writing and must include at least the
following information:
• Name of Employee;
• Name of the Plan;
• Reference to the initial decision;
• Whether the appeal is the first or second appeal of the initial determination;
• An explanation why You are appealing the initial determination.
As part of each appeal You may submit any written comments, documents, records or other information
relating to Your claim.
After MetLife receives Your written request appealing the initial determination or determination on the first
appeal, MetLife will conduct a full and fair review of Your claim. Deference will not be given to initial denials,
and MetLife's review will look at the claim anew. The review on appeal will take into account all comments,
documents, records, and other information that You submit relating to Your claim without regard to whether
such information was submitted or considered in the initial determination. The person who will review Your
appeal will not be the same person as the person who made the initial decision to deny Your claim. In
addition,the person who is reviewing the appeal will not be a subordinate of the person who made the initial
decision to deny Your claim. If the initial denial is based in whole or in part on a medical judgment, MetLife
will consult with a health care professional with appropriate training and experience in the field of dentistry
involved in the judgment. This health care professional will not have consulted on the initial determination,
and will not be a subordinate of any person who was consulted on the initial determination.
MetLife will notify You in writing of its final determination within 30 days after MetLife's receipt of Your written
request for review, except that under special circumstances MetLife may have up to an additional 30 days to
provide written notification of the final decision. If such an extension is required, MetLife will notify You prior to
the expiration of the 30 day period, state the reason(s)why an extension is needed, and state when it will
make its determination.
If MetLife denies the claim on appeal, MetLife will send You a final written decision that states the reason(s)
why the claim You appealed is being denied and references any specific Plan provision(s)on which the
denial is based. If an internal rule, protocol, guideline or other criterion was relied upon in denying the claim
on appeal, the final written decision will state the rule, protocol, guideline or other criteria or indicate that
such rule, protocol, guideline or other criteria was relied upon and that You may request a copy free of
charge. Upon written request, MetLife will provide You free of charge with copies of documents, records and
other information relevant to Your claim.
Policies and Procedures for Emergency and Urgent Care
Urgent care and Emergency services:All member dentists of the MetLife Preferred Dentist Program are
required to have 24-hour emergency coverage or have alternate arrangements for emergency care for their
patients. Since the MetLife Preferred Dentist Program is a freedom-of-choice PPO program, there is no
primary care physician. No authorization of a service is necessary by a Primary Care Physician, nor is it
necessary to obtain a pre-authorization of services. The patient is free to use the dentist of their choice.
An important distinction to be made for this section is the difference between Urgent Care in a dental situation
versus that found in medical. Urgent care is defined more narrowly in dental to mean the alleviation of severe
pain(as there are no life-threatening situations in dental). Additionally, the alleviation of pain in dental is a
simple palliative treatment,which is not subject to claim review.
The benefit amount will be consistent with the terms contained in the insured's contract.
GCERT2000
notice/vat 33
NOTICE TO RESIDENTS OF VIRGINIA(continued)
Urgent Care Submission:
A small number of claims for dental expense benefits may be urgent care claims. Urgent care claims for
dental expense benefits are claims for reimbursement of dental expenses for services which a dentist familiar
with the dental condition determines would subject the patient to severe pain that cannot be adequately
managed without the care or treatment that is the subject of the claim. Of course any such claim may always
be submitted in accordance with the normal claim procedures. However your dentist may also submit such a
claim to MetLife by telephoning MetLife and informing MetLife that the claim is an Urgent Care Claim. Urgent
Care Claims are processed according to the procedures set out above, however once a claim for urgent care
is submitted MetLife will notify you of the determination on the claim as soon as possible, but no later than 72
hours after the claim is filed. If you or your covered dependent does not provide the claims administrator with
enough information to decide the claim, MetLife will notify you within 24 hours after it receives the claim of the
further information that is needed. You will have 48 hours to provide the information. If the needed information
is provided, MetLife will then notify you of the claim decision within 48 hours after MetLife received the
information. If the needed information is not provided, MetLife will notify you or your covered dependent of its
decision within 120 hours after the claim was received.
If your urgent care claim is denied but you receive the care, you may appeal the denial using the normal claim
procedures. If your urgent care claim is denied and you do not receive the care, you can request an expedited
appeal of your claim denial by phone or in writing. MetLife will provide you any necessary information to assist
you in your appeal. MetLife will then notify you of its decision within 72 hours of your request in writing.
However, MetLife may notify you by phone within the same time frames above and then mail you a written
notice.
GCERT2000
notice/vat 34
NOTICE FOR RESIDENTS OF THE STATE OF WASHINGTON
Washington law provides that the following apply to Your certificate:
Wherever the term "Spouse" appears in this certificate it shall, unless otherwise specified, be read to include
Your Domestic Partner.
Domestic Partner means each of two people, one of whom is an Employee of the Policyholder, who have
registered as each other's domestic partner, civil union partner or reciprocal beneficiary with a government
agency where such registration is available.
Wherever the term "step-child" appears in this certificate it shall be read to include the children of Your
Domestic Partner.
GCERT2000 35
notice/wa
NOTICE FOR RESIDENTS OF WISCONSIN
KEEP THIS NOTICE WITH YOUR INSURANCE PAPERS
PROBLEMS WITH YOUR INSURANCE?- If You are having problems with Your insurance company or
agent, do not hesitate to contact the insurance company or agent to resolve Your problem.
MetLife
Attn: Corporate Consumer Relations Department
200 Park Avenue
New York, New York 10166
1-800-438-6388
You can also contact the OFFICE OF THE COMMISSIONER OF INSURANCE, a state agency which
enforces Wisconsin's insurance laws, and file a complaint. You can contact the OFFICE OF THE
COMMISSIONER OF INSURANCE by contacting:
Office of the Commissioner of Insurance
Complaints Department
P.O. Box 7873
Madison,WI 53707-7873
1-800-236-8517 outside of Madison or 608-266-0103 in Madison.
GCERT2000
notice/wi 36
TABLE OF CONTENTS
Section Page
CERTIFICATE FACE PAGE 1
NOTICES 3
SCHEDULE OF BENEFITS 39
DEFINITIONS 41
ELIGIBILITY PROVISIONS: INSURANCE FOR YOU 45
Eligible Classes 45
Date You Are Eligible for Insurance 45
Enrollment Process For Dental Insurance 45
Date Your Insurance Takes Effect 45
Date Your Insurance Ends 47
ELIGIBILITY PROVISIONS: INSURANCE FOR YOUR DEPENDENTS 48
Eligible Classes For Dependent Insurance 48
Date You Are Eligible For Dependent Insurance 48
Enrollment Process For Dependent Dental Insurance 48
Date Dental Insurance Takes Effect For Your Dependents 48
Date Your Insurance For Your Dependents Ends 50
SPECIAL RULES FOR GROUPS PREVIOUSLY COVERED UNDER OTHER GROUP DENTAL
COVERAGE 51
CONTINUATION OF INSURANCE WITH PREMIUM PAYMENT 52
For Mentally or Physically Handicapped Children 52
For Family And Medical Leave 52
COBRA Continuation For Dental Insurance 52
At The Policyholder's Option 52
DENTAL INSURANCE 53
DENTAL INSURANCE: DESCRIPTION OF COVERED SERVICES 57
Type A Covered Services 57
Type B Covered Services 57
GCERT2000
toc 37
TABLE OF CONTENTS (continued)
Section Page
Type C Covered Services 58
Orthodontic Covered Services 59
DENTAL INSURANCE: EXCLUSIONS 60
DENTAL INSURANCE: COORDINATION OF BENEFITS 62
FILING A CLAIM 67
DENTAL INSURANCE: PROCEDURES FOR DENTAL CLAIMS 68
GENERAL PROVISIONS 70
Assignment 70
Dental Insurance:Who We Will Pay 70
Entire Contract 70
Incontestability: Statements Made by You 70
Conformity with Law 70
Overpayments 70
GCERT2000
toc 38
SCHEDULE OF BENEFITS
This schedule shows the benefits that are available under the Group Policy. You and Your Dependents will
only be insured for the benefits:
• for which You and Your Dependents become and remain eligible;
• which You elect, if subject to election; and
• which are in effect.
BENEFIT BENEFIT AMOUNT AND HIGHLIGHTS
Dental Insurance For You and Your Dependents
In-Network Out-of-Network
Covered Percentage for: based on the based on the
Maximum Allowed Charge Reasonable and Customary
Charge
Type A Services 100% 100%
Type B Services 80% 80%
Type C Services 50% 50%
Orthodontic Covered Services 50% 50%
Deductibles for:
Yearly Individual Deductible $50 for the following Covered $50 for the following Covered
Services Combined: Type B; Services Combined: Type B;
Type C Type C
Yearly Family Deductible $150 for the following Covered $150 for the following Covered
Services Combined: Type B; Services Combined: Type B;
Type C Type C
Maximum Benefit:
Yearly Individual Maximum $1,000 for the following Covered $1,000 for the following Covered
Services: Type A;Type B; Type C Services: Type A;Type B; Type C
Lifetime Individual Maximum $1,000 $1,000
Benefit Amount for Orthodontic
Covered Services
GCERT2000 39
sch
SCHEDULE OF BENEFITS
Benefit Waiting Periods
Type A Services No waiting period
Type B Services No waiting period
Type C Services(See Note) 12 month waiting period
Type D Services(Orthodontic) 12 month waiting period
Note: Oral Surgery, surgical extractions and general anesthesia or intravenous sedation in
connection with oral surgery or extractions are not subject to the 12 month waiting period.
GCERT2000 40
sch
DEFINITIONS
As used in this certificate,the terms listed below will have the meanings set forth below. When defined terms
are used in this certificate, they will appear with initial capitalization. The plural use of a term defined in the
singular will share the same meaning.
Actively at Work or Active Work means that You are performing all of the usual and customary duties of
Your job on a Full-Time basis. This must be done at:
• the Policyholder's place of business;
• an alternate place approved by the Policyholder; or
• a place to which the Policyholder's business requires You to travel.
You will be deemed to be Actively at Work during weekends or Policyholder approved vacations, holidays or
business closures if You were Actively at Work on the last scheduled work day preceding such time off.
Cast Restoration means an inlay, onlay, or crown.
Child means the following: (for residents of Alaska, Louisiana, Minnesota, Montana, New Hampshire, New
Mexico, Texas, Utah and Washington, the Child Definition is modified as explained in the Notice pages of this
certificate-please consult the Notice)
Your natural or adopted child; Your stepchild; Your foster child; or a child who resides with and is fully
supported by You; and who, in each case, is under age 26 and unmarried.
The definition of Child includes newborns.
An adopted child includes a child placed in Your physical custody for purpose of adoption. If prior to
completion of the legal adoption the child is removed from Your custody, the child's status as an adopted child
will end.
If You provide Us notice, a Child also includes a child for whom You must provide Dental Insurance due to a
Qualified Medical Child Support Order as defined in the United States Employee Retirement Income Security
Act of 1974 as amended.
For the purposes of determining who may become covered for insurance,the term does not include any
person who:
• is on active duty in the military of any country or international authority; however, active duty for this
purpose does not include weekend or summer training for the reserve forces of the United States,
including the National Guard; or
• is insured under the Group Policy as an employee.
Contributory Insurance means insurance for which the Policyholder requires You to pay any part of the
premium.
Contributory Insurance includes: Dental Insurance.
Covered Percentage means:
• for a Covered Service performed by an In-Network Dentist, the percentage of the Maximum Allowed
Charge that We will pay for such services after any required Deductible is satisfied; and
• for a Covered Service performed by an Out-of-Network Dentist, the percentage of the Reasonable and
Customary Charge that We will pay for such services after any required Deductible is satisfied.
GCERT2000
def 41
DEFINITIONS (continued)
Covered Service means a dental service used to treat Your or Your Dependent's dental condition which is:
• prescribed or performed by a Dentist while such person is insured for Dental Insurance;
• Dentally Necessary to treat the condition; and
• described in the SCHEDULE OF BENEFITS or DENTAL INSURANCE sections of this certificate.
Deductible means the amount You or Your Dependents must pay before We will pay for Covered Services.
Dental Hygienist means a person trained to:
• remove calcareous deposits and stains from the surfaces of teeth; and
• provide information on the prevention of oral disease.
Dentally Necessary means that a dental service or treatment is performed in accordance with generally
accepted dental standards as determined by Us and is:
• necessary to treat decay, disease or injury of the teeth; or
• essential for the care of the teeth and supporting tissues of the teeth.
Dentist means:
• a person licensed to practice dentistry in the jurisdiction where such services are performed; or
• any other person whose services, according to applicable law, must be treated as Dentist's services for
purposes of the Group Policy. Each such person must be licensed in the jurisdiction where the services
are performed and must act within the scope of that license. The person must also be certified and/or
registered if required by such jurisdiction.
For purposes of Dental Insurance, the term will include a Physician who performs a Covered Service.
Dentures means fixed partial dentures(bridgework), removable partial dentures and removable full dentures.
Dependent(s)means Your Spouse and/or Child.
Full-Time means Active Work of at least 30 hours per week on the Policyholder's regular work schedule for
the eligible class of employees to which You belong.
In-Network Dentist means a Dentist who participates in the Preferred Dentist Program and has a contractual
agreement with Us to accept the Maximum Allowed Charge as payment in full for a dental service.
Maximum Allowed Charge means the lesser of:
• the amount charged by the Dentist; or
• the maximum amount which the In-Network Dentist has agreed with Us to accept as payment in full for
the dental service.
Out-of-Network Dentist means a Dentist who does not participate in the Preferred Dentist Program.
GCERT2000
def 42
DEFINITIONS (continued)
Physician means:
• a person licensed to practice medicine in the jurisdiction where such services are performed; or
• any other person whose services, according to applicable law, must be treated as Physician's services for
purposes of the Group Policy. Each such person must be licensed in the jurisdiction where he performs
the service and must act within the scope of that license. He must also be certified and/or registered if
required by such jurisdiction.
Proof means Written evidence satisfactory to Us that a person has satisfied the conditions and requirements
for any benefit described in this certificate. When a claim is made for any benefit described in this certificate,
Proof must establish:
• the nature and extent of the loss or condition;
• Our obligation to pay the claim; and
• the claimant's right to receive payment.
Proof must be provided at the claimant's expense.
Reasonable and Customary Charge is the lowest of:
• the Dentist's actual charge for the services or supplies(or, if the provider of the service or supplies is not
a Dentist, such other provider's actual charge for the services or supplies)(the'Actual Charge'); or
• the usual charge by the Dentist or other provider of the services or supplies for the same or similar
services or supplies(the'Usual Charge'); or
• the usual charge of other Dentists or other providers in the same geographic area equal to the 90th
percentile of charges as determined by MetLife based on charge information for the same or similar
services or supplies maintained in MetLife's Reasonable and Customary Charge records(the'Customary
Charge'). Where MetLife determines that there is inadequate charge information maintained in MetLife's
Reasonable and Customary Charge records for the geographic area in question, the Customary Charge
will be determined based on actuarially sound principles.
An example of how the 90th percentile is calculated is to assume one hundred(100)charges for the
same service are contained in MetLife's Reasonable and Customary charge records. These one hundred
(100)charges would be sorted from lowest to highest charged amount and numbered 1 through 100. The
90th percentile of charges is the charge that is equal to the charge numbered 90.
Signed means any symbol or method executed or adopted by a person with the present intention to
authenticate a record,which is on or transmitted by paper or electronic media which is acceptable to Us and
consistent with applicable law.
Spouse means Your lawful spouse.
For the purposes of determining who may become covered for insurance, the term does not include any
person who:
• is on active duty in the military of any country or international authority; however, active duty for this
purpose does not include weekend or summer training for the reserve forces of the United States,
including the National Guard; or
• is insured under the Group Policy as an employee.
GCERT2000
def 43
DEFINITIONS (continued)
We, Us and Our mean MetLife.
Written or Writing means a record which is on or transmitted by paper or electronic media which is
acceptable to Us and consistent with applicable law.
Year or Yearly, for Dental Insurance, means the 12 month period that begins January 1.
You and Your mean an employee who is insured under the Group Policy for the insurance described in this
certificate.
GCERT2000
def 44
ELIGIBILITY PROVISIONS: INSURANCE FOR YOU
ELIGIBLE CLASS(ES)
All Full-Time and retired employees of the Policyholder.
You are eligible for insurance if You were Actively at Work and covered for insurance on the day immediately
preceding the date of Your retirement and have retired in accord with the Policyholder's retirement plan.
Please be aware that:
• references to Active Work and Actively at Work will not apply; and
• end of employment will mean the end of the person's status as a retiree, as stated in the Policyholder's
retirement plan.
DATE YOU ARE ELIGIBLE FOR INSURANCE
You may only become eligible for the insurance available for Your eligible class as shown in the SCHEDULE
OF BENEFITS.
You will be eligible for insurance described in this certificate on the later of:
1. January 1, 2017; and
2. the first day of the calendar month following the date You complete the Waiting Period of 30 days.
Waiting Period means the period of continuous membership in an eligible class that You must wait before You
become eligible for insurance. This period begins on the date You enter an eligible class and ends on the date
You complete the period(s)specified.
ENROLLMENT PROCESS FOR DENTAL INSURANCE
If You are eligible for insurance, You may enroll for such insurance by completing the required form in Writing.
If You enroll for Contributory Insurance, You must also give the Policyholder Written permission to deduct
premiums from Your pay for such insurance. You will be notified by the Policyholder how much You will be
required to contribute.
The Dental Insurance has a regular enrollment period established by the Policyholder. Subject to the rules of
the Group Policy, You may enroll for Dental Insurance only when You are first eligible, during an annual
enrollment period or if You have a Qualifying Event. You should contact the Policyholder for more information
regarding the flexible benefits plan.
DATE YOUR INSURANCE TAKES EFFECT
Enrollment When First Eligible
If You complete the enrollment process within 31 days of becoming eligible for insurance, such insurance will
take effect on the date You become eligible, provided You are Actively at Work on that date.
If You are not Actively at Work on the date the insurance would otherwise take effect, the insurance will take
effect on the day You resume Active Work.
If You Do Not Enroll When First Eligible
If You do not complete the enrollment process within 31 days of becoming eligible, You will not be able to
enroll for insurance until the next annual enrollment period for Dental Insurance, as determined by the
Policyholder,following the date You first become eligible. At that time You will be able to enroll for insurance
for which You are then eligible.
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ELIGIBILITY PROVISIONS: INSURANCE FOR YOU (continued)
Enrollment During an Annual Enrollment Period
During any annual enrollment period as determined by the Policyholder, You may enroll for insurance for
which You are eligible or choose a different option than the one for which You are currently enrolled. The
changes to Your insurance made during an enrollment period will take effect on the first day of the calendar
year following the enrollment period, if You are Actively at Work on that date.
If You are not Actively at Work on the date the insurance would otherwise take effect, insurance will take
effect on the date You resume Active Work.
Enrollment Due to a Qualifying Event
You may enroll for insurance,for which You are eligible, or change the amount of Your insurance between
annual enrollment periods only if You have a Qualifying Event.
If You have a Qualifying Event, You will have 31 days from the date of that change to make a request. This
request must be consistent with the nature of the Qualifying Event. The insurance enrolled for, or changes to
Your insurance made as a result of a Qualifying Event,will take effect on the first day of the month following
the date of Your request, if You are Actively at Work on that date.
If You are not Actively at Work on the date the insurance would otherwise take effect, insurance will take
effect on the day You resume Active Work.
Qualifying Event includes:
• marriage;
• the birth, adoption or placement for adoption of a dependent child;
• divorce, legal separation or annulment;
• the death of a dependent;
• a change in Your or Your dependent's employment status, such as beginning or ending employment,
strike, lockout, taking or ending a leave of absence, changes in worksite or work schedule, if it causes
You or Your dependent to gain or lose eligibility for group coverage;
• You previously did not enroll for Dental Insurance for You or Your dependent because You had other
group coverage, but that coverage has ceased due to one or more of the following reasons:
1. loss of eligibility for the other group coverage;
2. termination of employer contributions for the other group coverage; or
3. COBRA Continuation of the other group coverage was exhausted; or
• Your or Your dependent's loss of coverage under any group health coverage sponsored by a
governmental or educational institution.
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ELIGIBILITY PROVISIONS: INSURANCE FOR YOU (continued)
DATE YOUR INSURANCE ENDS
Your insurance will end on the earliest of:
1. the date the Group Policy ends;
2. the date insurance ends for Your class;
3. the date You cease to be in an eligible class;
4. the end of the period for which the last premium has been paid for You;
5. the last day of the calendar month in which Your employment ends; Your employment will end if You
cease to be Actively at Work in any eligible class, except as stated in the section entitled
CONTINUATION OF INSURANCE WITH PREMIUM PAYMENT.
In certain cases insurance may be continued as stated in the section entitled CONTINUATION OF
INSURANCE WITH PREMIUM PAYMENT.
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ELIGIBILITY PROVISIONS: INSURANCE FOR YOUR DEPENDENTS
ELIGIBLE CLASS(ES) FOR DEPENDENT INSURANCE
All Full-Time and retired employees of the Policyholder.
DATE YOU ARE ELIGIBLE FOR DEPENDENT INSURANCE
You may only become eligible for the Dependent insurance available for Your eligible class as shown in
the SCHEDULE OF BENEFITS.
You will be eligible for Dependent insurance described in this certificate on the latest of:
1. January 1, 2017;
2. the date You enter a class eligible for insurance;
3. the date You obtain a Dependent; and
4. the first day of the calendar month following the date You complete the Waiting Period of 30 days.
Waiting Period means the period of continuous membership in an eligible class that You must wait before
You become eligible for insurance. This period begins on the date You enter an eligible class and ends on
the date You complete the period(s)specified.
No person may be insured as a Dependent of more than one employee.
ENROLLMENT PROCESS FOR DEPENDENT DENTAL INSURANCE
If You are eligible for Dependent Insurance, You may enroll for such insurance by completing the required
form in Writing for each Dependent to be insured. If You enroll for Contributory Insurance, You must also
give the Policyholder Written permission to deduct premiums from Your pay for such insurance. You will
be notified by the Policyholder how much You will be required to contribute.
In order to enroll for Dental Insurance for Your Dependents, You must either(a)already be enrolled for
Dental Insurance for You or(b)enroll at the same time for Dental Insurance for You.
The Dental Insurance has a regular enrollment period established by the Policyholder. Subject to the
rules of the Group Policy, You may enroll for Dependent Dental Insurance only when You are first eligible,
during an annual enrollment period or if You have a Qualifying Event. You should contact the
Policyholder for more information regarding the flexible benefits plan.
DATE DENTAL INSURANCE TAKES EFFECT FOR YOUR DEPENDENTS
Enrollment When First Eligible
If You complete the enrollment process within 31 days of becoming eligible for Dependent Insurance,
such insurance will take effect on the date You become eligible, provided You are Actively at Work on
that date.
If You are not Actively at Work on the date the insurance would otherwise take effect, the insurance will
take effect on the day You resume Active Work.
If You Do Not Enroll When First Eligible
If You do not complete the enrollment process within 31 days of becoming eligible, You will not be able to
enroll for Dependent Insurance until the next annual enrollment period for Dental Insurance, as
determined by the Policyholder,following the date You first become eligible. At that time You will be able
to enroll for insurance for which You are then eligible.
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ELIGIBILITY PROVISIONS: INSURANCE FOR YOUR DEPENDENTS (continued)
Enrollment During an Annual Enrollment Period
During any annual enrollment period as determined by the Policyholder, You may enroll for Dependent
Insurance for which You are eligible or choose a different option than the one for which Your Dependents
are currently enrolled. The changes to Your Dependent Insurance made during an enrollment period will
take effect on the first day of the calendar year following the enrollment period, if You are Actively at Work
on that date.
If You are not Actively at Work on the date the insurance would otherwise take effect, insurance will take
effect on the date You resume Active Work.
Enrollment Due to a Qualifying Event
You may enroll for Dependent Insurance for which You are eligible or change the amount of Your
Dependent Insurance between annual enrollment periods only if You have a Qualifying Event.
If You have a Qualifying Event, You will have 31 days from the date of that change to make a request.
This request must be consistent with the nature of the Qualifying Event.The insurance enrolled for or
changes to Your insurance made as a result of a Qualifying Event will take effect on the first day of the
month following the date of Your request, if You are Actively at Work on that date.
If You are not Actively at Work on the date the insurance would otherwise take effect, insurance will take
effect on the day You resume Active Work.
Qualifying Event includes:
• marriage;
• the birth, adoption or placement for adoption of a dependent child;
• divorce, legal separation or annulment;
• the death of a dependent;
• a change in Your or Your dependent's employment status, such as beginning or ending employment,
strike, lockout, taking or ending a leave of absence, changes in worksite or work schedule, if it causes
You or Your dependent to gain or lose eligibility for group coverage;
• You previously did not enroll for Dental Insurance for You or Your dependent because You had other
group coverage, but that coverage has ceased due to one or more of the following reasons:
1. loss of eligibility for the other group coverage;
2. termination of employer contributions for the other group coverage;
3. COBRA Continuation of the other group coverage was exhausted; or
• Your or Your dependent's loss of coverage under any group health coverage sponsored by a
governmental or educational institution.
Once You have enrolled one Child for Dependent Insurance, each succeeding Child will automatically be
insured for such insurance on the date the Child qualifies as a Dependent.
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ELIGIBILITY PROVISIONS: INSURANCE FOR YOUR DEPENDENTS (continued)
DATE YOUR INSURANCE FOR YOUR DEPENDENTS ENDS
A Dependent's insurance will end on the earliest of:
1. the date You die;
2. the date Dental Insurance for You ends;
3. the date You cease to be in an eligible class;
4. the date the Group Policy ends;
5. the date insurance for Your Dependents ends under the Group Policy;
6. the date insurance for Your Dependents ends for Your class;
7. the last day of the calendar month in which Your employment ends;Your employment will end if You
cease to be Actively at Work in any eligible class, except as stated in the section entitled
CONTINUATION OF INSURANCE WITH PREMIUM PAYMENT;
8. the end of the period for which the last premium has been paid; or
9. the last day of the calendar month the person ceases to be a Dependent.
In certain cases insurance may be continued as stated in the section entitled CONTINUATION OF
INSURANCE WITH PREMIUM PAYMENT.
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SPECIAL RULES FOR GROUPS PREVIOUSLY COVERED UNDER OTHER GROUP
DENTAL COVERAGE
The following rules will apply if this Dental Insurance replaces other group dental coverage provided to
You by the Policyholder.
Prior Plan means the group dental coverage provided to You by the Policyholder on the day before the
Replacement Date.
Replacement Date means the effective date of this Dental Insurance under the Group Policy.
Rules if You or You and Your Dependents were Covered Under the Prior Plan on the Day Before
the Replacement Date:
1. if You and Your Dependents were covered under the Prior Plan on the day before the Replacement
Date, You will be eligible for this Dental Insurance on the Replacement Date if You are in an eligible
class on such date;
2. if any of the following conditions occurred while coverage was in effect under the Prior Plan, We will
treat such conditions as though they occurred while this Dental Insurance is in effect:
• the loss of a tooth; and
• the accumulation of amounts toward:
a) Annual Deductibles;
b) Annual Maximum Benefits;
c) Lifetime Maximum Benefits;
3. if a dental service was received while the Prior Plan was in effect and such service would be a
Covered Service subject to frequency and/or time limitations if performed while this Dental Insurance
is in effect, the receipt of such prior service will be counted toward the time and frequency limitations
under this Dental Insurance;
4. if a government mandated continuation of coverage under the Prior Plan was in effect on the
Replacement Date, such coverage may be continued under this Dental Insurance if the required
payment is made for the cost of such coverage. In such case, benefits will be available under this
Dental Insurance until the earlier of:
• the date the continued coverage ends as set forth in the provisions of the government-mandated
requirements; or
• the date this Dental Insurance ends.
Rules if You or You and Your Dependents were NOT covered under the Prior Plan on the Day
Before the Replacement Date:
1. You will be eligible for this Dental Insurance when You meet the eligibility requirements for such
insurance as described in ELIGIBILITY PROVISIONS:INSURANCE FOR YOU;
2. Your Dependents will be eligible for this Dental Insurance when they meet the eligibility requirements
for such insurance as described in ELIGIBILITY PROVISIONS: INSURANCE FOR YOUR
DEPENDENTS; and
3. We will credit any time accumulated toward any eligibility waiting period under the Prior Plan to the
satisfaction of any eligibility waiting period required to be met under this Dental Insurance.
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CONTINUATION OF INSURANCE WITH PREMIUM PAYMENT
FOR MENTALLY OR PHYSICALLY HANDICAPPED CHILDREN
Insurance for a Dependent Child may be continued past the age limit if the child is incapable of self-
sustaining employment because of a mental or physical handicap as defined by applicable law. Proof of
such handicap must be sent to Us within 31 days after the date the Child attains the age limit and at
reasonable intervals after such date.
Subject to the DATE YOUR INSURANCE FOR YOUR DEPENDENTS ENDS subsection of the section
entitled ELIGIBILITY PROVISIONS: INSURANCE FOR YOUR DEPENDENTS, insurance will continue
while such Child:
• remains incapable of self-sustaining employment because of a mental or physical handicap; and
• continues to qualify as a Child, except for the age limit.
FOR FAMILY AND MEDICAL LEAVE
Certain leaves of absence may qualify for continuation of insurance under the Family and Medical Leave
Act of 1993(FMLA), or other legally mandated leave of absence or similar laws. Please contact the
Policyholder for information regarding such legally mandated leave of absence laws.
COBRA CONTINUATION FOR DENTAL INSURANCE
If Dental Insurance for You or a Dependent ends, You or Your Dependent may qualify for continuation of
such insurance under the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended
(COBRA). Please refer to the COBRA section of Your summary plan description or contact the
Policyholder for information regarding continuation of insurance under COBRA.
AT THE POLICYHOLDER'S OPTION
The Policyholder has elected to continue insurance by paying premiums for employees who cease Active
Work in an eligible class for any of the reasons specified below. If Your insurance is continued, insurance
for Your Dependents may also be continued.
Insurance will continue for the following periods:
1. if You cease Active Work due to injury or sickness,for a period in accordance with the Policyholder's
general practice for an employee in Your job class.
The Policyholder's general practice for employees in a job class determines which employees with the
above types of absences are to be considered as still insured and for how long among persons in like
situations.
At the end of any of the continuation periods listed above, Your insurance will be affected as follows:
• if You resume Active Work in an eligible class at this time, You will continue to be insured under the
Group Policy;
• if You do not resume Active Work in an eligible class at this time,Your employment will be considered
to end and Your insurance will end in accordance with the DATE YOUR INSURANCE ENDS
subsection of the section entitled ELIGIBILITY PROVISIONS: INSURANCE FOR YOU.
If Your insurance ends, Your Dependents' insurance will also end in accordance with the DATE YOUR
INSURANCE FOR YOUR DEPENDENTS ENDS subsection of the section entitled ELIGIBILITY
PROVISIONS: INSURANCE FOR YOUR DEPENDENTS.
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DENTAL INSURANCE
If You or a Dependent incur a charge for a Covered Service, Proof of such service must be sent to Us. When
We receive such Proof,We will review the claim and if We approve it, will pay the insurance in effect on the
date that service was completed.
This Dental Insurance gives You access to Dentists through the MetLife Preferred Dentist Program. Dentists
participating in the MetLife Preferred Dentist Program have agreed to limit their charge for a dental service to
the Maximum Allowed Charge for such service. Under the MetLife Preferred Dentist Program,We pay
benefits for Covered Services performed by either In-Network Dentists,or Out-of-Network Dentists. However,
You may be able to reduce Your out-of-pocket costs by using an In-Network Dentist because Out-of-Network
Dentists have not entered into an agreement with Us to limit their charges. You are always free to receive
services from any Dentist. You do not need any authorization from Us to choose a Dentist.
The MetLife Preferred Dentist Program does not provide dental services. Whether or not benefits are
available for a particular service, does not mean You should or should not receive the service.You and Your
Dentist have the right and are responsible at all times for choosing the course of treatment and services to be
performed.After services have been performed,We will determine the extent to which benefits, if any, are
payable.
When requesting a Covered Service from an In-Network Dentist,We recommend that You:
• identify Yourself as an insured in the Preferred Dentist Program; and
• confirm that the Dentist is currently an In-Network Dentist at the time that the Covered Service is
performed.
The amount of the benefit will not be affected by whether or not You identify Yourself as a member in the
Preferred Dentist Program.
You can obtain a customized listing of MetLife's In-Network Dentists either by calling 1-800-942-0854 or by
visiting Our website at www.metlife.com/dental.
BENEFIT AMOUNTS
We will pay benefits in an amount equal to the Covered Percentage for charges incurred by You or a
Dependent for a Covered Service as shown in the SCHEDULE OF BENEFITS, subject to the conditions set
forth in this certificate.
In-Network
If a Covered Service is performed by an In-Network Dentist,We will base the benefit on the Covered
Percentage of the Maximum Allowed Charge.
If an In-Network Dentist performs a Covered Service, You will be responsible for paying:
• the Deductible; and
• any other part of the Maximum Allowed Charge for which We do not pay benefits.
Out-of-Network
If a Covered Service is performed by an Out-of-Network Dentist,We will base the benefit on the Covered
Percentage of the Reasonable and Customary Charge.
Out-of-Network Dentists may charge You more than the Reasonable and Customary Charge. If an Out-of-
Network Dentist performs a Covered Service, You will be responsible for paying:
• the Deductible; and
• any other part of the Reasonable and Customary Charge for which We do not pay benefits; and
• any amount in excess of the Reasonable and Customary Charge charged by the Out-of-Network Dentist.
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DENTAL INSURANCE (continued)
Maximum Benefit Amounts
The SCHEDULE OF BENEFITS sets forth Maximum Benefit Amounts We will pay for Covered Services
received In-Network and Out-of-Network. We will never pay more than the greater of the In-Network
Maximum Benefit Amount or the Out-of-Network Maximum Benefit Amount.
For example, if a Covered Service is received Out-of-Network and We pay$300 in benefits for such service,
$300 will be applied toward both the In-Network and the Out-of-Network Maximum Benefit Amounts
applicable to such service.
Deductibles
The Deductible amounts are shown in the SCHEDULE OF BENEFITS.
The Yearly Individual Deductible is the amount that You and each Dependent must pay for Covered Services
to which such Deductible applies each Year before We will pay benefits for such Covered Services.
We apply amounts used to satisfy Yearly Individual Deductibles to the Yearly Family Deductible. Once the
Yearly Family Deductible is satisfied, no further Yearly Individual Deductibles are required to be met.
The amount We apply toward satisfaction of a Deductible for a Covered Service is the amount We use to
determine benefits for such service. The Deductible Amount will be applied based on when Dental Insurance
claims for Covered Services are processed by Us. The Deductible Amount will be applied to Covered
Services in the order that Dental Insurance claims for Covered Services are processed by Us regardless of
when a Covered Service is"incurred". When several Covered Services are incurred on the same date and
Dental Insurance benefits are claimed as part of the same claim, the Deductible Amount is applied based on
the Covered Percentage applicable to each Covered Service. The Deductible Amount will be applied in the
order of highest Covered Percentage to lowest Covered Percentage.
Alternate Benefit
If We determine that a service, less costly than the Covered Service the Dentist performed, could have been
performed to treat a dental condition,We will pay benefits based upon the less costly service if such service:
• would produce a professionally acceptable result under generally accepted dental standards; and
• would qualify as a Covered Service.
For example:
• when an amalgam filling and a composite filling are both professionally acceptable methods for filling a
molar,We may base Our benefit determination upon the amalgam filling which is the less costly service;
• when a filling and an inlay are both professionally acceptable methods for treating tooth decay or
breakdown,We may base Our benefit determination upon the filling which is the less costly service;
• when a filling and a crown are both professionally acceptable methods for treating tooth decay or
breakdown,We may base Our benefit determination upon the filling which is the less costly service; and
• when a partial denture and fixed bridgework are both professionally acceptable methods for replacing
multiple missing teeth in an arch,We may base Our benefit determination upon the partial denture which
is the less costly service.
If We pay benefits based upon a less costly service in accordance with this subsection, the Dentist may
charge You or Your Dependent for the difference between the service that was performed and the less costly
service. This is the case even if the service is performed by an In-Network Dentist.
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DENTAL INSURANCE (continued)
Certain comprehensive dental services have multiple steps associated with them. These steps can be
completed at one time or during multiple sessions. For benefit purposes under this certificate,these separate
steps of one service are considered to be part of the more comprehensive service. Even if the dentist
submits separate bills, the total benefit payable for all related charges will be limited by the maximum benefit
payable for the more comprehensive service. For example, root canal therapy includes x-rays, opening of the
pulp chamber, additional x-rays, and filling of the chamber.Although these services may be performed in
multiple sessions,they all constitute root canal therapy. Therefore,We will only pay benefits for the root
canal therapy.
Orthodontic Covered Services
Orthodontic treatment generally consists of initial placement of an appliance and periodic follow-up visits.
The benefit payable for the initial placement will not exceed 20% of the Lifetime Maximum Benefit Amount for
Orthodontia in effect when the course of treatment begins.
The benefit payable for the periodic follow-up visits will also be based on the Lifetime Maximum Benefit
Amount for Orthodontia in effect when the course of treatment begins. It will be payable on a quarterly basis
during the course of the orthodontic treatment if:
• Dental Insurance is in effect for the person receiving the orthodontic treatment; and
• Proof is given to Us that the orthodontic treatment is continuing.
Benefits for Orthodontic Services Begun Prior to this Dental Insurance
If the initial placement was made prior to this Dental Insurance being in effect, the benefit payable will be
reduced by the portion attributable to the initial placement.
If the periodic follow-up visits commenced prior to this Dental Insurance being in effect:
• the number of months for which benefits are payable will be reduced by the number of months of
treatment performed before this Dental Insurance was in effect; and
• the total amount of the benefit payable for the periodic visits will be reduced proportionately.
Pretreatment Estimate of Benefits
If a planned dental service is expected to cost more than$300, You have the option of requesting a
pretreatment estimate of benefits. The Dentist should submit a claim detailing the services to be performed
and the amount to be charged. After We receive this information,We will provide You with an estimate of the
Dental Insurance benefits available for the service. The estimate is not a guarantee of the amount We will
pay. Under the Alternate Benefit provision, benefits may be based on the cost of a service other than the
service that You choose. You are required to submit Proof on or after the date the dental service is
completed in order for Us to pay a benefit for such service.
The pretreatment estimate of benefits is only an estimate of benefits available for proposed dental services.
You are not required to obtain a pretreatment estimate of benefits. As always, You or Your Dependent and
the Dentist are responsible for choosing the services to be performed.
Benefits We Will Pay After Insurance Ends
We will pay benefits for a 31 day period after Your insurance ends for the completion of installation of a
prosthetic device if:
• the Dentist prepared the abutment teeth or made impressions before Your insurance ends; and
• the device is installed within 31 days after the date the insurance ends.
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DENTAL INSURANCE (continued)
We will pay benefits for a 31 day period after Your insurance ends for the completion of installation of a Cast
Restoration if:
• the Dentist prepared the tooth for the Cast Restoration before Your insurance ends; and
• the Cast Restoration is installed within 31 days after the date the insurance ends.
We will pay benefits for a 31 day period after Your insurance ends for completion of root canal therapy if:
• the Dentist opened into the pulp chamber before Your insurance ends; and
• the treatment is finished within 31 days after the date the insurance ends.
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DENTAL INSURANCE: DESCRIPTION OF COVERED SERVICES
Type A Covered Services
1. Oral exams and problem-focused exams, but no more than two exams(whether these exams are oral
exams or problem-focused exams)every 12 months.
2. Screenings, including state or federally mandated screenings, to determine an individual's need to be
seen by a dentist for diagnosis, but no more than twice every 12 months.
3. Patient assessments(limited clinical inspection that is performed to identify possible signs of oral or
systemic disease, malformation, or injury, and the potential need for referral for diagnosis and treatment),
but no more than twice every 12 months.
4. Bitewing x-rays:
• 2 sets every 12 months for a Child.
• 1 set every 12 months for everyone else.
5. Pulp vitality tests and bacteriological studies for determination of bacteriologic agents.
6. Collection and preparation of genetic sample material for laboratory analysis and report, but no more than
once per lifetime.
7. Cleaning of teeth also referred to as oral prophylaxis(including full mouth scaling in presence of
generalized moderate or severe gingival inflammation after oral evaluation)twice in 12 months.
8. Topical fluoride treatment for a Child under age 19 twice in a 12 month period.
9. Space maintainers for a Child under age 14 once per lifetime per tooth area.
Type B Covered Services
1. Full mouth or panoramic x-rays once every 5 Years.
2. Intraoral-periapical x-rays.
3. X-rays, except as mentioned elsewhere.
4. Diagnostic casts.
5. Emergency palliative treatment to relieve tooth pain.
6. Initial placement of amalgam fillings.
7. Replacement of an existing amalgam filling, but only if:
• at least 24 months have passed since the existing filling was placed; or
• a new surface of decay is identified on that tooth.
8. Initial placement of resin-based composite fillings.
9. Replacement of an existing resin-based composite filling, but only if:
• at least 24 months have passed since the existing filling was placed; or
• a new surface of decay is identified on that tooth.
10. Protective(sedative)fillings.
11. Injections of therapeutic drugs.
12. Sealants or sealant repairs for a Child under age 16, which are applied to non-restored, non-decayed first
and second permanent molars, once per tooth every 2 Years.
13. Preventive resin restorations,which are applied to non-restored first and second permanent molars, once
per tooth every 2 Years.
14. Interim caries arresting medicament application applied to permanent bicuspids and 1st and 2nd molar
teeth, once per tooth every 2 Years.
15. Prefabricated crown, but no more than one replacement for the same tooth within 24 consecutive months.
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DENTAL INSURANCE: DESCRIPTION OF COVERED SERVICES (continued)
16. Application of desensitizing medicaments where periodontal treatment(including scaling, root planing,
and periodontal surgery, such as osseous surgery) has been performed.
Type C Covered Services
Certain benefit waiting periods may need to be satisfied before expenses for these services are
payable. Refer to the SCHEDULE OF BENEFITS for the benefit waiting period that applies.
1. Pulp capping(excluding final restoration).
2. Therapeutic pulpotomy(excluding final restoration).
3. Pulp therapy.
4. Apexification/recalcification.
5. Pulpal regeneration, but not more than once per lifetime.
6. General anesthesia or intravenous sedation in connection with oral surgery,extractions or other Covered
Services, when We determine such anesthesia is necessary in accordance with generally accepted
dental standards.
7. Local chemotherapeutic agents.
8. Initial installation of full or partial Dentures(other than implant supported prosthetics):
• when needed to replace congenitally missing teeth; or
• when needed to replace teeth that are lost while the person receiving such benefits was insured for
Dental Insurance.
9. Addition of teeth to a partial removable Denture to replace teeth removed while this Dental Insurance was
in effect for the person receiving such services.
10. Replacement of a non-serviceable fixed Denture if such Denture was installed more than 5 Years prior to
replacement.
11. Replacement of a non-serviceable removable Denture if such Denture was installed more than 5 Years
prior to replacement.
12. Replacement of an immediate, temporary, full Denture with a permanent,full Denture, if the immediate,
temporary,full Denture cannot be made permanent and such replacement is done within 12 months of
the installation of the immediate, temporary,full Denture.
13. Relinings and rebasings of existing removable Dentures, if at least 6 months have passed since the
installation of the existing removable Denture.
14. Re-cementing of Cast Restorations or Dentures, but not more than once in a 12 month period.
15. Adjustments of Dentures, if at least 6 months have passed since the installation of the Denture.
16. Initial installation of Cast Restorations(except implant supported Cast Restorations).
17. Replacement of Cast Restorations(except an implant supported Cast Restoration)but only if at least a 5
Year period have passed since the most recent time that:
• a Cast Restoration was installed for the same tooth; or
• a Cast Restoration for the same tooth was replaced.
18. Core buildup, but no more than once per tooth in a period of 5 Years.
19. Posts and cores, but no more than once per tooth in a period of 5 Years.
20. Labial veneers, but no more than once per tooth in a period of 10 Years.
21. Oral surgery, except as mentioned elsewhere in this certificate.
22. Consultations for interpretation of diagnostic image by a Dentist not associated with the capture of the
image, but not more than twice in a 12 month period.
23. Other consultations, but not more than twice in a 12 month period.
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DENTAL INSURANCE: DESCRIPTION OF COVERED SERVICES (continued)
24. Root canal treatment, including bone grafts and tissue regeneration procedures in conjunction with
periradicular surgery.
25. Other endodontic procedures, such as apicoectomy, retrograde fillings, root amputation, and hemisection.
26. Periodontal scaling and root planing, but no more than once per quadrant in any 24 month period.
27. Full mouth debridements, but not more than once in any 36 month period.
28. Periodontal surgery, including gingivectomy, gingivoplasty and osseous surgery.
29. Periodontal maintenance,where periodontal treatment(including scaling, root planing, and periodontal
surgery, such as gingivectomy, gingivoplasty and osseous surgery)has been performed. Periodontal
maintenance is limited to twice in 12 months, less the number of teeth cleanings received during such 12
month period.
30. Simple extractions. Extractions of primary teeth or adult teeth solely for orthodontic purposes will be
treated as orthodontic services.
31. Surgical extractions. Extractions of primary teeth or adult teeth solely for orthodontic purposes will be
treated as orthodontic services.
32. Implant supported Cast Restorations, but no more than once for the same tooth position in a 5 Year
period:
• when needed to replace congenitally missing teeth; or
• when needed to replace teeth that are lost while the person receiving such benefits was insured for
Dental Insurance.
33. Implant supported fixed Dentures, but no more than once for the same tooth position in a 5 Year period:
• when needed to replace congenitally missing teeth; or
• when needed to replace teeth that are lost while the person receiving such benefits was insured for
Dental Insurance.
34. Implant supported removable Dentures, but no more than once for the same tooth position in a 5 Year
period:
• when needed to replace congenitally missing teeth; or
• when needed to replace teeth that are lost while the person receiving such benefits was insured for
Dental Insurance.
35. Tissue conditioning, but not more than once in a 36 month period.
36. Simple repair of Cast Restorations or Dentures other than recementing, but not more than once in a 12
month period.
Orthodontic Covered Services
Certain benefit waiting periods may need to be satisfied before expenses for these services are
payable. Refer to the SCHEDULE OF BENEFITS for the benefit waiting period that applies.
Orthodontia, for a Child under 19.
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DENTAL INSURANCE: EXCLUSIONS
We will not pay Dental Insurance benefits for charges incurred for:
1. services which are not Dentally Necessary, or those which do not meet generally accepted standards
of care for treating the particular dental condition;
2. services for which You would not be required to pay in the absence of Dental Insurance;
3. services or supplies received by You or Your Dependent before the Dental Insurance starts for that
person;
4. services which are neither performed nor prescribed by a Dentist, except for those services of a
licensed Dental Hygienist which are supervised and billed by a Dentist, and which are for:
• scaling and polishing of teeth; or
• fluoride treatments;
5. services which are primarily cosmetic, unless required for the treatment or correction of a congenital
defect of a newborn Child;
6. services or appliances which restore or alter occlusion or vertical dimension;
7. restoration of tooth structure damaged by attrition, abrasion or erosion, unless caused by disease;
8. restorations or appliances used for the purpose of periodontal splinting;
9. counseling or instruction about oral hygiene, plaque control, nutrition and tobacco;
10. personal supplies or devices including, but not limited to: water piks,toothbrushes, or dental floss;
11. decoration or inscription of any tooth, device, appliance, crown or other dental work;
12. missed appointments;
13. services:
• covered under any workers'compensation or occupational disease law;
• covered under any employer liability law;
• for which the Employer of the person receiving such services is required to pay; or
• received at a facility maintained by the Policyholder, labor union, mutual benefit association, or
VA hospital;
14. services covered under other coverage provided by the Policyholder;
15. biopsies of hard or soft oral tissue;
16. temporary or provisional restorations;
17. temporary or provisional appliances;
18. prescription drugs;
19. services for which the submitted documentation indicates a poor prognosis;
20. the following, when charged by the Dentist on a separate basis:
• claim form completion;
• infection control, such as gloves, masks, and sterilization of supplies; or
• local anesthesia, non-intravenous conscious sedation or analgesia, such as nitrous oxide;
21. dental services arising out of accidental injury to the teeth and supporting structures, except for
injuries to the teeth due to chewing or biting of food;
22. caries susceptibility tests;
23. modification of removable prosthodontic and other removable prosthetic services;
24. implants including, but not limited to any related surgery, placement, maintenance, and removal;
25. repair of implants;
26. occlusal adjustments;
27. fixed and removable appliances for correction of harmful habits;
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DENTAL INSURANCE: EXCLUSIONS (continued)
28. appliances or treatment for bruxism (grinding teeth);
29. initial installation of a Denture or implant supported prosthetic to replace one or more teeth which
were missing before such person was insured for Dental Insurance, except for congenitally missing
teeth;
30. precision attachments associated with fixed and removable prostheses;
31. adjustment of a Denture made within 6 months after installation by the same Dentist who installed it;
32. duplicate prosthetic devices or appliances;
33. replacement of a lost or stolen appliance, Cast Restoration or Denture;
34. replacement of an orthodontic device;
35. diagnosis and treatment of temporomandibular joint disorders and cone beam imaging associated
with the treatment of temporomandibular joint disorders;
36. intra and extraoral photographic images.
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DENTAL INSURANCE: COORDINATION OF BENEFITS
When You or a Dependent incur charges for Covered Services, there may be other Plans, as defined below,
that also provide benefits for those same charges. In that case, We may reduce what We pay based on what
the other Plans pay. This Coordination of Benefits section explains how and when We do this.
DEFINITIONS
In this section, the terms set forth below have the following meanings:
Allowable Expense means a necessary dental expense for which both of the following are true:
• a covered person must pay it; and
• it is at least partly covered by one or more of the Plans that provide benefits to the covered person.
If a Plan provides fixed benefits for specified events or conditions(instead of benefits based on expenses
incurred), such benefits are Allowable Expenses.
If a Plan provides benefits in the form of services,We treat the reasonable cash value of each service
performed as both an Allowable Expense and a benefit paid by that Plan.
The term does not include:
• expenses for services performed because of a Job-Related Injury or Sickness;
• any amount of expenses in excess of the higher reasonable and customary fee for a service, if two or
more Plans compute their benefit payments on the basis of reasonable and customary fees;
• any amount of expenses in excess of the higher negotiated fee for a service, if two or more Plans
compute their benefit payments on the basis of negotiated fees; and
• any amount of benefits that a Primary Plan does not pay because the covered person fails to comply with
the Primary Plan's managed care or utilization review provisions, these include provisions requiring:
• second surgical opinions;
• pre-certification of services;
• use of providers in a Plan's network of providers; or
• any other similar provisions.
We won't use this provision to refuse to pay benefits because an HMO member has elected to have dental
services provided by a non-HMO provider and the HMO's contract does not require the HMO to pay for
providing those services.
Claim Determination Period means a period that starts on any January 1 and ends on the next
December 31. A Claim Determination Period for any covered person will not include periods of time during
which that person is not covered under This Plan.
Custodial Parent means a Parent awarded custody, other than joint custody, by a court decree. In the
absence of a court decree, it means the Parent with whom the child resides more than half of the Year without
regard to any temporary visitation.
HMO means a Health Maintenance Organization or Dental Health Maintenance Organization.
Job-Related Injury or Sickness means any injury or sickness:
• for which You are entitled to benefits under a workers'compensation or similar law, or any
arrangement that provides for similar compensation; or
• arising out of employment for wage or profit.
Parent means a person who covers a child as a dependent under a Plan.
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DENTAL INSURANCE: COORDINATION OF BENEFITS (continued)
Plan means any of the following, if it provides benefits or services for an Allowable Expense:
• a group insurance plan;
• an HMO;
• a blanket plan;
• uninsured arrangements of group or group type coverage;
• a group practice plan;
• a group service plan;
• a group prepayment plan;
• any other plan that covers people as a group;
• motor vehicle No Fault coverage if the coverage is required by law; and
• any other coverage required or provided by any law or any governmental program, except Medicaid.
The term does not include any of the following:
• individual or family insurance or subscriber contracts;
• individual or family coverage through closed panel Plans or other prepayment, group practice or individual
practice Plans;
• hospital indemnity coverage;
• a school blanket plan that only provides accident-type coverage on a 24 hour basis, or a "to and from
school basis,"to students in a grammar school, high school or college;
• disability income protection coverage;
• accident only coverage;
• specified disease or specified accident coverage;
• nursing home or long term care coverage; or
• any government program or coverage if, by state or Federal law, its benefits are excess to those of any
private insurance plan or other non-government plan.
The provisions of This Plan,which limit benefits based on benefits or services provided under plans which the
Policyholder(or an affiliate)contributes to or sponsors will not be affected by these Coordination of Benefits
provisions.
Each policy, contract or other arrangement for benefits is a separate Plan. If part of a Plan reserves the right
to reduce what it pays based on benefits or services provided by other Plans, that part will be treated
separately from any parts which do not.
This Plan means the dental benefits described in this certificate, except for any provisions in this certificate
that limit insurance based on benefits for services provided under plans which the Policyholder(or an affiliate)
contributes to or sponsors.
Primary Plan means a Plan that pays its benefits first under the"Rules to Decide Which Plan Is Primary"
section. A Primary Plan pays benefits as if the Secondary Plans do not exist.
Secondary Plan means a Plan that is not a Primary Plan. A Secondary Plan may reduce its benefits by
amounts payable by the Primary Plan. If there are more than two Plans that provide coverage, a Plan may be
Primary to some plans, and Secondary to others.
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DENTAL INSURANCE: COORDINATION OF BENEFITS (continued)
RULES TO DECIDE WHICH PLAN IS PRIMARY
When more than one Plan covers the person for whom Allowable Expenses were incurred,We determine
which plan is primary by applying the rules in this section.
When there is a basis for claim under This Plan and another Plan, This Plan is Secondary unless:
• the other Plan has rules coordinating its benefits with those of This Plan; and
• this Plan is primary under This Plan's rules.
The first rule below, which will allow Us to determine which Plan is Primary, is the rule that We will use.
Dependent or Non-Dependent: A Plan that covers a person other than as a dependent(for example, as an
employee, member, subscriber, or retiree)is Primary and shall pay its benefits before a Plan that covers the
person as a dependent; except that if the person is a Medicare beneficiary and, as a result of federal law or
regulations, Medicare is:
• Secondary to the Plan covering the person as a dependent; and
• Primary to the Plan covering the person as other than a dependent(e.g., a retired employee);
then the order of benefits between the two Plans is reversed and the Plan that covers the person as a
dependent is Primary.
Child Covered Under More Than One Plan—Court Decree:When This Plan and another Plan cover the
same Child as the Dependent of two or more Parents, and the specific terms of a court decree state that one
of the Parents must provide health coverage or pay for the Child's health care expenses, that Parent's Plan is
Primary, if the Plan has actual knowledge of those terms. This rule applies to Claim Determination Periods
that start after the Plan is given notice of the court decree.
Child Covered Under More Than One Plan—The Birthday Rule:When This Plan and another Plan cover
the same Child as the Dependent of two or more Parents,the Primary Plan is the Plan of the Parent whose
birthday falls earlier in the Year if:
• the Parents are married; or
• the Parents are not separated(whether or not they have ever married); or
• a court decree awards joint custody without specifying which Parent must provide health coverage.
If both Parents have the same birthday, the Plan that covered either of the Parents longer is the Primary Plan.
However, if the other Plan does not have this rule, but instead has a rule based on the gender of the parent,
and if, as a result,the Plans do not agree on the order of benefits, the rule in the other Plan will determine the
order of benefits.
Child Covered Under More than One Plan—Custodial Parent:When This Plan and another Plan cover the
same Child as the Dependent of two or more Parents, if the Parents are not married, or are separated
(whether or not they ever married), or are divorced,the Primary Plan is:
• the Plan of the Custodial Parent; then
• the Plan of the spouse of the Custodial Parent; then
• the Plan of the non-custodial Parent; and then
• the Plan of the spouse of the non-custodial Parent.
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DENTAL INSURANCE: COORDINATION OF BENEFITS (continued)
Active or Inactive Employee: A Plan that covers a person as an employee who is neither laid off nor retired
is Primary to a Plan that covers the person as a laid-off or retired employee(or as that person's Dependent).
If the other Plan does not have this rule and, if as a result, the Plans do not agree on the order of benefits, this
rule is ignored.
Continuation Coverage: The Plan that covers a person as an active employee, member or subscriber(or as
that employee's Dependent)is Primary to a Plan that covers that person under a right of continuation
pursuant to federal law(e.g., COBRA)or state law. If the Plan that covers the person has not adopted this
rule, and if, as a result, the Plans do not agree on the order of benefits,this rule shall not apply.
Longer/Shorter Time Covered: If none of the above rules determine which Plan is Primary, the Plan that
has covered the person for the longer time shall be Primary to a Plan that has covered the person for a
shorter time.
No Rules Apply: If none of the above rules determine which Plan is Primary, the Allowable Expenses shall
be shared equally between all the Plans. In no event will This Plan pay more than it would if it were Primary.
EFFECT ON BENEFITS OF THIS PLAN
If This Plan is Secondary,when the total Allowable Expenses incurred by a covered person in any Claim
Determination Period are less than the sum of:
• the benefits that would be payable under This Plan without applying this Coordination of Benefits
provision; and
• the benefits that would be payable under all other Plans without applying Coordination of Benefits or
similar provisions;
then We will reduce the benefits that would otherwise be payable under This Plan. The sum of these reduced
benefits, plus all benefits payable for such Allowable Expenses under all other Plans, will not exceed the total
of the Allowable Expenses. Benefits payable under all other Plans include all benefits that would be payable
if the proper claims had been made on time.
RIGHT TO RECEIVE AND RELEASE NEEDED INFORMATION
We need certain information to apply the Coordination of Benefits rules. We have the right to decide which
facts We need. We may get facts from or give them to any other organization or person. We do not need to
tell, or get the consent of, any person or organization to do this. To obtain all benefits available, a covered
person who incurs Allowable Expenses should file a claim under each Plan which covers the person. Each
person claiming benefits under This Plan must give Us any facts We need to pay the claim.
FACILITY OF PAYMENT
A payment made under another Plan may include an amount which should have been paid under This Plan.
If it does,We may pay that amount to the organization which made that payment. That amount will then be
treated as though it were a benefit paid under This Plan. We will not have to pay that amount again. The
term "payment made" includes benefits provided in the form of services, in which case We may pay the
reasonable cash value of the benefits provided in the form of services.
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DENTAL INSURANCE: COORDINATION OF BENEFITS (continued)
RIGHT OF RECOVERY
If the amount We pay is more than We should have paid under this Coordination of Benefits provision,We
may recover the excess from one or more of:
• the person We have paid or for whom We have paid;
• insurance companies; or
• other organizations.
The amount of the payment includes the reasonable cash value of any benefits provided in the form of
services.
GCERT2000 66
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FILING A CLAIM
The Policyholder should have a supply of claim forms. Obtain a claim form from the Policyholder and fill it out
carefully. Return the completed claim form with the required Proof to the Policyholder. The Policyholder will
certify Your insurance under the Group Policy and send the certified claim form and Proof to Us.
For Dental Insurance, all claim forms needed to file for benefits under the group insurance program can be
obtained by calling MetLife at 1-800-942-0854. Dental claim forms can also be downloaded from
www.metlife.com/dental. The instructions on the claim form should be followed carefully. This will expedite
the processing of the claim.
When We receive the claim form and Proof,We will review the claim and, if We approve it,We will pay
benefits subject to the terms and provisions of this certificate and the Group Policy.
CLAIMS FOR DENTAL INSURANCE BENEFITS
When a claimant files a claim for Dental Insurance benefits described in this certificate, both the
notice of claim and the required Proof should be sent to Us within 90 days of the date of a loss.
Claim and Proof may be given to Us by following the steps set forth below:
Step 1
A claimant can request a claim form by calling Us at 1-800-942-0854.
Step 2
We will send a claim form to the claimant within 15 days of the request. The instructions on the
claim form should be followed carefully. This will expedite the processing of the claim.
Step 3
When the claimant receives the claim form,the claimant should fill it out as instructed and return
it with the required Proof described in the claim form.
Step 4
The claimant must give Us Proof not later than 90 days after the date of the loss.
If notice of claim or Proof is not given within the time limits described in this section,the delay will not
cause a claim to be denied or reduced if such notice and Proof are given as soon as is reasonably
possible.
Time Limit on Legal Actions. A legal action on a claim may only be brought against Us during a certain
period. This period begins 60 days after the date Proof is filed and ends 3 years after the date such Proof is
required.
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DENTAL INSURANCE: PROCEDURES FOR DENTAL CLAIMS
Procedures for Presenting Claims for Dental Insurance Benefits
All claim forms needed to file for Dental Insurance benefits under the group insurance program can be obtained
from the Employer who can also answer questions about the insurance benefits and to assist You or, if
applicable,Your beneficiary in filing claims. Dental claim forms can also be downloaded from
www.metlife.com/dental. The instructions on the claim form should be followed carefully. This will expedite the
processing of the claim. Be sure all questions are answered fully.
Routine Questions on Dental Insurance Claims
If there is any question about a claim payment, an explanation may be requested from MetLife by dialing 1-800-
942-0854.
Claim Submission
For claims for Dental Insurance benefits, the claimant must complete the appropriate claim form and submit
the required Proof as described in the FILING A CLAIM section of the certificate.
Claim forms must be submitted in accordance with the instructions on the claim form.
Initial Determination
After You submit a claim for Dental Insurance benefits to MetLife, MetLife will review Your claim and notify
You of its decision to approve or deny Your claim.
Such notification will be provided to You within a 30 day period from the date You submitted Your claim;
except for situations requiring an extension of time of up to 15 days because of matters beyond the control of
MetLife. If MetLife needs such an extension, MetLife will notify You prior to the expiration of the initial 30 day
period, state the reason why the extension is needed, and state when it will make its determination. If an
extension is needed because You did not provide sufficient information or filed an incomplete claim, the time
from the date of MetLife's notice requesting further information and an extension until MetLife receives the
requested information does not count toward the time period MetLife is allowed to notify You as to its claim
decision. You will have 45 days to provide the requested information from the date You receive the notice
requesting further information from MetLife.
If MetLife denies Your claim in whole or in part,the notification of the claims decision will state the reason why
Your claim was denied and reference the specific Plan provision(s)on which the denial is based. If the claim
is denied because MetLife did not receive sufficient information,the claims decision will describe the
additional information needed and explain why such information is needed. Further, if an internal rule,
protocol, guideline or other criterion was relied upon in making the denial, the claims decision will state the
rule, protocol, guideline or other criteria or indicate that such rule, protocol, guideline or other criteria was
relied upon and that You may request a copy free of charge.
Appealing the Initial Determination
If MetLife denies Your claim, You may take two appeals of the initial determination. Upon Your written
request, MetLife will provide You free of charge with copies of documents, records and other information
relevant to Your claim. You must submit Your appeal to MetLife at the address indicated on the claim form
within 180 days of receiving MetLife's decision. Appeals must be in writing and must include at least the
following information:
• Name of Employee
• Name of the Plan
• Reference to the initial decision
• Whether the appeal is the first or second appeal of the initial determination
• An explanation why You are appealing the initial determination.
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DENTAL INSURANCE: PROCEDURES FOR DENTAL CLAIMS (continued)
As part of each appeal, You may submit any written comments, documents, records, or other information
relating to Your claim.
After MetLife receives Your written request appealing the initial determination or determination on the first
appeal, MetLife will conduct a full and fair review of Your claim. Deference will not be given to initial denials,
and MetLife's review will look at the claim anew. The review on appeal will take into account all comments,
documents, records, and other information that You submit relating to Your claim without regard to whether
such information was submitted or considered in the initial determination. The person who will review Your
appeal will not be the same person as the person who made the initial decision to deny Your claim. In
addition, the person who is reviewing the appeal will not be a subordinate of the person who made the initial
decision to deny Your claim. If the initial denial is based in whole or in part on a medical judgment, MetLife
will consult with a health care professional with appropriate training and experience in the field of dentistry
involved in the judgment. This health care professional will not have consulted on the initial determination,
and will not be a subordinate of any person who was consulted on the initial determination.
MetLife will notify You in writing of its final decision within 30 days after MetLife's receipt of Your written
request for review, except that under special circumstances MetLife may have up to an additional 30 days to
provide written notification of the final decision. If such an extension is required, MetLife will notify You prior
to the expiration of the initial 30 day period, state the reason(s)why such an extension is needed, and state
when it will make its determination.
If MetLife denies the claim on appeal, MetLife will send You a final written decision that states the reason(s)
why the claim You appealed is being denied and references any specific Plan provision(s)on which the denial
is based. If an internal rule, protocol, guideline or other criterion was relied upon in denying the claim on
appeal, the final written decision will state the rule, protocol, guideline or other criteria or indicate that such
rule, protocol, guideline or other criteria was relied upon and that You may request a copy free of charge.
Upon written request, MetLife will provide You free of charge with copies of documents, records and other
information relevant to Your claim.
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GENERAL PROVISIONS
Assignment
The rights and benefits under the Group Policy are not assignable prior to a claim for benefits, except as
required by law. We are not responsible for the validity of an assignment.
Upon receipt of a Covered Service,You may assign Dental Insurance benefits to the Dentist providing such
service.
Dental Insurance: Who We Will Pay
If You assign payment of Dental Insurance benefits to Your or Your Dependent's Dentist,We will pay benefits
directly to the Dentist. Otherwise,We will pay Dental Insurance benefits to You.
Entire Contract
Your insurance is provided under a contract of group insurance with the Policyholder. The entire contract with
the Policyholder is made up of the following:
1. the Group Policy and its Exhibits,which include the certificate(s);
2. the Policyholder's application;and
3. any amendments and/or endorsements to the Group Policy.
Incontestability: Statements Made by You
Any statement made by You will be considered a representation and not a warranty.
Evidence of insurability will not be required nor will any statement made by You, which relates to insurability,
be used:
1. to contest the validity of the insurance benefits; or
2. to reduce the insurance benefits.
Conformity with Law
If the terms and provisions of this certificate do not conform to any applicable law, this certificate shall be
interpreted to so conform.
Overpayments
Recovery of Dental Insurance Overpayments
We have the right to recover any amount that We determine to be an overpayment,whether for services
received by You or Your Dependents.
An overpayment occurs if We determine that:
• the total amount paid by Us on a claim for Dental Insurance is more than the total of the benefits due
to You under this certificate; or
• payment We made should have been made by another group plan.
If such overpayment occurs, You have an obligation to reimburse Us.
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GENERAL PROVISIONS (continued)
How We Recover Overpayments
We may recover the overpayment from You by:
• stopping or reducing any future benefits payable for Dental Insurance;
• demanding an immediate refund of the overpayment from You; and
• taking legal action.
If the overpayment results from Our having made a payment to You that should have been made under
another group plan,We may recover such overpayment from one or more of the following:
• any other insurance company;
• any other organization; or
• any person to or for whom payment was made.
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THIS IS THE END OF THE CERTIFICATE
THE FOLLOWING IS ADDITIONAL INFORMATION
PLAN PRIVACY INFORMATION
Notwithstanding any other Plan provision in this or other sections of this Plan,the Plan will operate in
accordance with the HIPAA privacy laws and regulations as set forth in 45 CFR Parts 160 and 164,and
as they may be amended ("HIPAA")with respect to protected health information("PHI")as that term
is defined therein.The Plan Administrator and/or his or her designee retains full discretion in
interpreting these rules and applying them to specific situations.All such decisions shall be given full
deference unless the decision is determined to be arbitrary and capricious.
The term "Plan Sponsor"means Augusta Georgia.
The term "Plan Administrator"means the entity designated as Plan Administrator by the Plan
documents pursuant to which the plan is operated. If a Plan Administrator is not designated by the
plan documents,the Plan Sponsor shall be deemed to the Plan Administrator.
I. Permitted Uses and Disclosures of PHI by
the Plan and the Plan Sponsor
The Plan and the Plan Sponsor are permitted to use and disclose PHI for the following purposes, to the extent
they are not inconsistent with HIPAA:
• For general plan administration, including policyholder service functions, enrollment and eligibility
functions, reporting functions, auditing functions,financial and billing functions, to assist in the
administration of a consumer dispute or inquiry, and any other authorized insurance or benefit function.
• As required for computer programming, consulting or other work done in respect to the computer
programs or systems utilized by the Plan.
• Other uses relating to plan administration which are approved in writing by the Plan Administrator.
• At the request of an individual, to assist in resolving an individual's benefit or claim issues.
II. Uses and Disclosures of PHI by the Plan and
the Plan Sponsor for Required Purposes
The Plan and Plan Sponsor may use or disclose PHI for the following required purposes:
• Judicial and administrative proceedings, in response to lawfully executed process such as a court order
or subpoena.
• For public health and health oversight activities and other governmental activities accompanied by
lawfully executed process.
• As otherwise may be required by law.
III. Sharing of PHI With the Plan Sponsor
As a condition of the Plan Sponsor receiving PHI from the Plan, the Plan Documents have been amended to
incorporate the following provisions, under which the Plan Sponsor agrees to:
• Not use or further disclose PHI other than as permitted or required by the plan documents in Sections I
and II above;
• Ensure that any agents to whom it provides PHI received from the Plan agree to the same restrictions
and conditions that apply to the Plan Sponsor;
• Not use or disclose PHI for employment-related actions or decisions or in connection with any other
benefit or employee benefit plan of the Plan Sponsor;
• Report to the Plan any use or disclosure of PHI that is inconsistent with the permitted uses or disclosures
of which it becomes aware;
• Make PHI available to Plan participants for the purposes of the rights of access and inspection,
amendment, and accounting of disclosures required by HIPAA;
• Make its internal practices, books and records relating to the use and disclosure of PHI received from the
Plan available to the Secretary of the U.S. Department of Health and Human Services for purposes of
determining compliance by the Plan with HIPAA;
• If feasible, return or destroy all PHI received from the Plan that the sponsor still maintains in any form and
retain no copies when no longer needed for the purpose for which disclosure was made,except that, if
return or destruction is not feasible, limit further uses and disclosures to those purposes that make the
return or destruction of the information infeasible;
• Ensure adequate separation between the Plan and Plan Sponsor in accordance with the following
requirements:
(A)Employees to be Given Access to PHI: The following employees(or class of employees)of the
Plan Sponsor are the only individuals that may access PHI provided by the Plan:
Compensation& Benefits Manager
(B)Restriction to Plan Administration Functions:The access to and use of PHI by the employees of
the Plan Sponsor designated above will be limited to plan administration functions that the Plan
Sponsor performs for the Plan.
(C)Mechanism for Resolving issues of Noncompliance: If the Plan Administrator determines that an
employee of the Plan Sponsor designated above has acted in noncompliance with the plan document
provisions outlined above, then the Plan Administrator shall take or seek to have taken appropriate
disciplinary action with respect to that employee, up to and including termination of employment as
appropriate. The Plan Administrator shall also document the facts of the violation, actions that have
been taken to discipline the offending party, and the steps taken to prevent future violations.
• Certify to the Plan, prior to the Plan permitting disclosure of PHI to the Plan Sponsor, that the Plan
Documents have been amended to incorporate the provisions of this Section III.
IV. Security
As a condition of the Plan Sponsor receiving electronic PHI ("ePHI")from the Plan, the Plan Documents have
been amended to incorporate the following provisions, under which the Plan Sponsor agrees to:
• Implement administrative, physical, and technical safeguards that reasonably and appropriately protect
the confidentiality, integrity, and availability of the ePHI that it creates, receives, maintains, or transmits on
behalf of the Plan;
• Ensure that the adequate separation between the Plan and the Plan Sponsor,which is required by the
applicable section(s)of the Plan relating to the sharing of PHI with the Plan Sponsor, is supported by
reasonable and appropriate security measures;
• Ensure that any agent to whom it provides ePHI agrees to implement reasonable and appropriate security
measures to protect the information; and
• Report to the Plan any security incident of which it becomes aware. In this context, the term "security
incident" means the attempted or successful unauthorized access, use, disclosure, modification, or
destruction of information or interference with system operations in information systems such as
hardware, software, information, data, applications, communications, and people.
Uniformed Services Employment And Reemployment Rights Act
This section describes the right that you may have to continue coverage for yourself and your covered
dependents under the Uniformed Services Employment and Reemployment Rights Act of 1994(USERRA).
Continuation of Group Dental Insurance:
If you take a leave from employment for"service in the uniformed services,"as that term is defined in
USERRA, and as a consequence your dental insurance coverage under your employer's group dental
insurance policy ends, you may elect to continue dental insurance for yourself and your covered dependents,
for a limited period of time, as described below.
The law requires that your employer notify you of your rights, benefits and obligations under USERRA
including instructions on how to elect to continue insurance, the amount and procedure for payment of
premium. If permitted by USERRA, your employer may require that you elect to continue coverage within a
period of time specified by your employer.
You may be responsible for payment of the required premium to continue insurance. If your leave from
employment for service in the uniformed services lasts less than 31 days, your required premium will be no
more than the amount you were required to pay for dental insurance before the leave began;for a leave
lasting 31 or more days, you may be required to pay up to 102% of the total dental insurance premium,
including any amount that your employer was paying before the leave began.
Your and your covered dependents' insurance that is continued pursuant to USERRA will end on the earliest
of the following:
• the end of 24 consecutive months from the date your leave from employment for service in the uniformed
services begins; or
• the day after the date on which you fail to apply for, or return to employment, in accordance with
USERRA.
You and your covered dependent may become entitled to continuation of coverage under the Consolidated
Omnibus Budget Reconciliation Act("COBRA")while you have dental insurance coverage under your
employer's group dental insurance policy pursuant to USERRA. Contact your employer for more information.