Laserfiche WebLink
<br />4.11 <br /> <br />4.12 <br /> <br />---- <br /> <br />---- <br />-------- <br />-_u_- <br />- ------ <br /> <br />- --- -- -- <br /> <br />---------- <br /> <br />GENERAL LIMITATIONS - OPTIONAL SERVICES <br /> <br />(a) <br /> <br />(b) <br /> <br />Only the first two cleanings, or Single Procedures which include <br />cleaning, or combination thereof, provided to a patient in a calendar <br />year while he or she is an Eligible Person under any Delta program <br />are Benefits under this program. <br /> <br />If an Eligible Person selects a more expensive plan of treatment than <br />is customarily provided, or specialized techniques rather than <br />standard procedures, Delta will pay the applicable percentage of the <br />lesser fee and the patient is responsible for the remainder of the <br />Dentist's fee. For example: a crown where a silver filling would <br />restore the tooth or a gold crown where one constructed of semi- <br />precious materials would restore the tooth or a precision denture <br />where a standard denture would suffice. <br /> <br />EXCLUSIONS: The following services are not Benefits: <br /> <br />(a) <br /> <br />(b) <br /> <br />(c) <br /> <br />(d) <br /> <br />Services for injuries or conditions which are covered under <br />Workers' Compensation or Employer's Liability Laws. <br /> <br />Services which are provided to the Eligible Person by any Federal <br />or State Government Agency or are provided without cost to the <br />Eligible Person by any municipality, county or other political <br />subdivision, except as provided in California Health and Safety <br />Code Section 1373(a). <br /> <br />Services with respect to congenital (hereditary) or developmental <br />(following birth) malformations or cosmetic surgery or dentistry for <br />purely cosmetic reasons, including but not limited to: cleft palate, <br />upper and lower jaw malformations, enamel hypoplasia (lack of <br />development), fluorosis (a type of discoloration of the teeth), and <br />anodontia (congenitally missing teeth). <br /> <br />Services for restoring tooth structure lost from wear, for rebuilding <br />or maintaining chewing surfaces due to teeth out of alignment or <br />occlusion, or for stabilizing the teeth. Such services include but are <br />not limited to: equilibration and periodontal splinting. <br /> <br />14 <br /> <br />------- <br /> <br />. . "'-'~" ..... -,--,,-,--'-------" <br />