Other Important Information
Benefits are payable only for expenses incurred while your insurance is in-force. Your insurance begins on the first of the month following the date we receive your application and initial premium. Your insurance ends on the earliest of (1) the date you cease to be eligible, (2) (for any covered dependents) the day your dependent ceases to be a dependent, as defined in your Certificate, (3) the last day of the month for which a premium has been paid, subject to the grace period, or (4) the date the policy ends. You may terminate this policy on any premium due date by giving written notice to us prior to any premium due date. We may terminate this policy on any premium due date by giving you written notice at least 31 days prior to such premium.
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Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
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Coverage provided under Group Policy AM3200, issued to the Voluntary Supplementary Benefits Trust.
EXPENSES NOT COVERED: No benefits will be paid for expenses incurred for:
• overdentures and associated procedures • orthodontics • charges in excess of those considered reasonable and customary • cosmetic procedures • the replacement of dentures, bridges, inlays, onlays or crowns that can be repaired or restored to normal function • implants, and for: replacement of lost or stolen appliances; replacement of retainers; athletic mouthguards; precision or semi-precision attachments; denture duplication; or sealants • oral hygiene instructions, and for: plaque control; completion of a claim form; acid etch; broken appointments; prescription or take-home fluoride; or diagnostic photographs • services not completed by the end of the month in which coverage ends, unless continuation of coverage has been requested and accepted by World Insurance • procedures that are begun, but not completed • services and treatment provided without charge or for which there would be no charge in the absence of insurance • services in connection with war or any act of war, whether declared or undeclared, or condition contracted or accident occurring while on full-time active duty in the armed forces of any country or combination of countries • a condition covered under any Worker‘s Compensation Act or similar law • the treatment of cleft palate and anodontia • services or supplies payable under any medical expense plan • orthodontia, unless included in the Coverage Schedule • the diagnosis or treatment of TMJ • hospital services • any unmarried child age 19 years of age and over unless he is dependent upon you for support, while a full-time student. A full-time student is one who is enrolled for 12 semester hours for credit in an accredited junior college, college or university. Any exception for a full-time student will end at age 23.
No benefits will be paid for expenses incurred:
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that are applied toward satisfaction of a
deductible, if any • that are generally
considered by the dental profession as
experimental or investigational • prior to the
date the insured is covered under the
Certificate • during any waiting period
required, when you voluntarily end your
insurance and reenroll at a later date. Your
waiting period is two years and begins on the
date your coverage first ended.
World Insurance Company
c/o James Stafford Insurance Agency
1562 NW Access Rd.
Mount Vernon, TX 75457
Phone: (903) 537-2819
Toll-Free 1-888-869-4904
email: sales@insurance-online-texas.com
Policy Form AM3200 Certificate AC3200 F3202 (02-04) Rider Form R3199
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