Coverage is a combined maximum of $600 per benefit year
Ask your dentist to submit a pre-authorization to Green Shield Canada prior to any dental treatment plan exceeding $500.
These are the different treatments and coverages included:
| Dental Benefits |
Coverage |
| Basic Services |
80% |
- Recalls
Include exams, bitewing X-rays, fluoride treatments and cleanings once every 12 months, based on first paid claim.
- Complete, general or comprehensive oral exams
Full mouth x-rays and panoramic x-rays, once every 3 years based on first paid claim.
- Basic restorations, fillings and inlays.
- Extractions and surgical services.
General anaesthetics and intravenous sedation only when done in conjunction with eligible extraction(s) and/or oral surgery. Sleep dentistry is not eligible.
|
| Comprehensive Basic Services |
80% |
- Endodontic treatment
Including standard root canal therapy, excluding retreatments.
- Periodontal treatment
Including scaling and/or root planning, 3 time units every 12 months based on first paid claim.
- Occlusal equilibration
Selective grinding of tooth surfaces to adjust a bite, 2 time units every 12 months based on first paid claim.
- Standard denture services
Once every 3 years based on first paid claim. Including relining and rebasing of dentures plus denture adjustments after 3 months from installation.
|
Payment of dental benefits is based on the General Practitioners Dental Association suggested fee guide or the Insurance Reimbursement Rate set by the Canadian Life and Health Insurance Association Inc. (CLHIA) when a fee guide is not available. For services provided by a dental specialist, payment is based upon the General Practitioners Dental Association suggested fee guide.
Alternate Benefit - When there are two or more courses of treatment available to adequately correct a dental condition, reimbursement may be based on the cost of the least expensive treatment, which provides adequate care to the Insured.
Laboratory charges must be completed in conjunction with other services and will be limited to the Co-pay of such services. Laboratory charges that are in excess of 40% of the dentist's fee in the current General Practitioners Fee Guide will be reduced accordingly; co-insurance is then applied.
Reimbursement will be made according to standard and/or basic services, supplies or treatment. Related expenses beyond the standard and/or basic services, supplies or treatment will remain your responsibility.
When more than one surgical procedure is performed during the same appointment in the same area of the mouth, only the most comprehensive procedure will be eligible for reimbursement.
Reimbursement will be pro-rated and reduced accordingly, when time spent by the dentist is less than the average time assigned to a dental service procedure code in the General Practitioners Fee Guide.
Reimbursement for root canal therapy will be limited to payment once. The total fee for root canal includes all pulpotomies and pulpectomies performed on the same tooth.
Common surfaces on the same tooth/same day will be assessed as one surface. If individual surfaces are restored on the same tooth/same day, payment will be assessed according to the procedure code representing the combined surface. Payment will be limited to a maximum of 5 surfaces in any 36 month period.
The benefits payable for multiple restorative services in the same quadrant performed at one appointment may be reduced by 20% for all but the most costly service in the quadrant.
Root planing is not eligible if done at the same time as gingival curettage.
In the event of a dental accident, claims should be submitted under the health benefits plan before submitting them under the dental plan.
Limitations and Exclusions to Dental Benefits
An exclusion is a condition or instance that is not covered by the Dental Plan. It's important to review and understand exclusions to the plan before using your benefits.
No benefit is payable for:
- Services or supplies received as a result of disease, illness or Injury due to:
- intentionally self-inflicted Injury while sane or insane;
- an act of war, declared or undeclared;
- participation in a riot or civil commotion; or
- committing a criminal offence;
- Services or supplies provided while serving in the armed forces of any country;
- Failure to keep a scheduled appointment with a legally qualified dental practitioner;
- The completion of any claim forms and/or insurance reports;
- Any dental service that is not contained in the procedure codes developed and maintained by the Canadian Dental Association, adopted by the provincial or territorial dental association of the province or territory in which the service is provided (or your province of residence if any dental service is provided outside Canada) and in effect at the time the service is provided;
- Implants and related services;
- Restorations necessary for wear, acid erosion, vertical dimension and/or restoring occlusion;
- Appliances related to treatment of myofacial pain syndrome including all diagnostic models, gnathological determinants, maintenance, adjustments, repairs and relines;
- Posterior cantilever pontics/teeth and extra pontics/teeth to fill in diastemas/spaces;
- Service and charges for sleep dentistry;
- Diagnostic and/or intraoral repositioning appliances including maintenance, adjustments, repairs and relines related to treatment of temporomandibular joint dysfunction;
- Any specific treatment or drug which:
- does not meet accepted standards of medical, dental or ophthalmic practice, including charges for services or supplies which are experimental in nature, or is not considered to be effective (either medically or from a cost perspective, based on Health Canada's approved indication for use);
- is an adjunctive drug prescribed in connection with any treatment or drug that is not an eligible service;
- will be administered in a hospital;
- is not dispensed by the pharmacist in accordance with the payment method shown under the Health Benefit Plan Prescription Drugs; or
- is not being used and/or administered in accordance with Health Canada's approved indication for use, even though such drug or procedure may customarily be used in the treatment of other illnesses or injuries; or
- Services or supplies that:
- are not recommended, provided by or approved by the attending legally qualified (in the opinion of Green Shield) medical practitioner or dental practitioner as permitted by law;
- are legally prohibited by the government from coverage;
- you are not obligated to pay for or for which no charge would be made in the absence of benefit coverage; or for which payment is made on your behalf by a not-for-profit prepayment association, insurance carrier, third party administrator, like agency or a party other than Green Shield, your plan sponsor or you;
- are provided by a health practitioner whose license by the relevant provincial regulatory and/or professional association has been suspended or revoked;
- are not provided by a designated provider of service in response to a prescription issued by a legally qualified health practitioner;
- are used solely for recreational or sporting activities and which are not medically necessary for regular activities;
- are primarily for cosmetic or aesthetic purposes, or are to correct congenital malformations;
- are provided by an immediate family member related to you by birth, adoption, or by marriage and/or a practitioner who normally resides in your home. An immediate family member includes a parent, spouse, child or sibling;
- are provided by your plan sponsor and/or a practitioner employed by your plan sponsor, other than as part of an employee assistance plan;
- are a replacement of lost, missing or stolen items, or items that are damaged due to negligence (replacements are eligible when required due to natural wear, growth or relevant change in your medical condition but only when the equipment/prostheses cannot be adjusted or repaired at a lesser cost and the item is still medically required);
- are video instructional kits, informational manuals or pamphlets;
- are delivery and transportation charges;
- are a duplicate prosthetic device or appliance;
- are from any governmental agency which are obtained without cost by compliance with laws or regulations enacted by a federal, provincial, municipal or other governmental body;
- would normally be paid through any provincial health insurance plan, Workplace Safety and Insurance Board or tribunal, or any other government agency, or which would have been payable under such a plan had proper application for coverage been made, or had proper and timely claims submission been made;
- relate to treatment of injuries arising out of a motor vehicle accident (Ontario);
Note: Payment of benefits for claims relating to automobile accidents for which coverage is available under a motor vehicle liability policy providing no-fault benefits will be considered only if:
- the service or supplies being claimed is not eligible; or
- the financial commitment is complete (a letter from your automobile insurance carrier will be required); or
- are cognitive or administrative services or other fees charged by a provider of service for services other than those directly relating to the delivery of the service or supply.