HomeMy WebLinkAbout89-0501 Dental denti National Dental Health Insurance Company 85-o`°\
Southwick Office Centre'
1300 Woodfield Drive,South 308 National
care Schaumburg,Illinois 60173 Dental
(312)330-0900 Health
INSUANCCON�sl;
GROUP DENTAL CONTRACT OF COVERAGE
This Agreement is made by and between NATIONAL DENTAL HEALTH INSURANCE COMPANY, hereinafter referred
to as"PLAN,"and
Name CITY OF ELGIN Phone (312)695-6500
Address 150 DEXTER CT
City ELGIN State I LL I NO I S 4,60120 , hereinafter referred to as"GROUP."
Group#f 5258 Plan# 89—vi Effective Date MAY 1,1989 Time 12:01 A.M.
Monthly Dues:
$ 10. 50 Subscriber Portion of dues paid by employer: % (S
$ 18, 50 Subscriber and one dependent Portion of dues paid by employee: % ($
$ 26. 50 Subscriber and two or three dependents $ 15. 00 Monthly Group Administrative Fee
$ 31 . 50 Subscriber and four or more dependents
I. GENERAL PURPOSE: PLAN, a licensed health insurer, was established to provide a wide range of dental care services on
an indemnity and prepaid basis to Members participating in its Programs.
II. DEFINITIONS:
A. "Group" shall mean the organization or employing unit with which the Subscriber is associated and which has executed
this Dental Membership Agreement.
B. "Subscriber"shall mean individual in whose name the family unit is enrolled.
C. "Member" shall mean any individual subscriber or eligible family dependent entitled to receive services by reason of this
Agreement with Plan and the payment of appropriate membership dues.
D. "Participating Dentist"shall mean those licensed dentists contracting with the Plan to provide dental services for members.
E. "Dental Centers"shall mean those Centers selected by Plan to provide dental services for Members.
F. "Membership Dues" shall mean amounts payable on a regular prepayment basis by or for the Member to Plan as set
forth in this Agreement.
G. "Co-Payments" shall mean those amounts payable by Members directly to the Participating Dentist at the time services
are rendered as set forth in the Schedule of Benefits and Co-Payments attached as an exhibit or addendum to this Agreement.
III. ELIGIBILITY AND MEMBERSHIP: Following the effective date of this Agreement, membership is open to full-time employees
(if group agreement). Eligible dependents include spouse unless legally separated, and unmarried children from birth to 19
years of age. Children from 19 to 23 years of age are also eligible as dependents if their time is principally devoted to attending
school and their primary support comes from Subscriber. At the attainment of limiting age, coverage as a dependent shall
be extended if the child is and continues to be both (a) incapable of self-sustaining employment by reason of mental retardation
or physical handicap and (b) chiefly dependent upon the Subscriber for support and maintenance, provided proof of such
incapacity and dependency is furnished to Plan by the Subscriber within 31 days of the child's attainment of limiting age
and subsequently as may be required by the Plan, but not more frequently than annually after the two year period following
the child's attainment of the limiting age. Enrollment is normally on a family basis. When a Subscriber enrolls in Plan, he
must apply for all eligible dependents in his family,unless dependent has existing dental coverage.
IV. TERM OF AGREEMENT: Individual and family coverage under this Agreement shall be for a period of one year from effective
date. Group coverage under this Agreement shall be for a period of year(s)from the effective
date.
V. EFFECTIVE DATE OF AGREEMENT: All individuals or groups who have applied for membership and paid the appropriate
membership dues therefore prior to the 10th day of the month, shall be eligible for benefits commencing on the first day of
the following month. Applications and membership dues received between the 10th day of the month and the last day of the
month shall be eligible for benefits commencing the 1st day of the second month thereafter.
VI. DUES AND CO-PAYMENTS: All dues are payable on or before the 10th day of the month preceeding the month in which
services may be rendered. Co-Payments are payable to the Participating Dentist at the time services are rendered.
VII. CHANGE IN SERVICE: Plan reserves the right to change the service or membership charges to Members. No benefit or
rate change will be made without giving Member thirty(30)days written notice.
VIII. SERVICES PROVIDED: Plan provides for services to Members as described in the Schedule of Benefits and Co-Payments,
following and incorporated herein by reference. Dentist services provided by this Agreement are limited to those licensed dentists
working in Plan Dental Centers, or those outside dentists designated by Plan when a referral is made for definitive treatment
or consultation. No service of any other dentist will be provided or paid for unless duly authorized by Plan. Members will
be assigned to a specific Center, selected by Member, and Plan reserves the right to re-assign Member at any time to a different
Plan Dental Center of Member's choice.
FORM P IO9
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IX. DENTAL RECORDS: The dental records of the Member concerning services performed herein shall remain the property of
the Participating Dentist.
X. OUT-OF-AREA EMERGENCY CARE: Eligible members, when more than 50 miles from the nearest Plan Dental Center,•
may have emergency services rendered by any licensed dentist. Emergency care is defined as "care of any injury or accident
requiring the attention of a dentist which occurs under circumstances where it is medically contraindicated for the member
to present himself to a designated Plan Dental Center for care." Plan pays for emergency out-of-area care up to $50.00. Plan
will reimburse Member upon presentation of bona fide documentation thereof.
XI. TERMINATION: Benefits shall cease upon any of the following events:
(A) On the date of the expiration of the period for which the last payment was made.
(B) Upon the date of entry into full-time military service.
(C) Plan reserves the right, if after reasonable effort to establish and maintain a satisfactory dentist-patient relationship with
any Member and are unable to do so, then the rights of such Member and other members of his family under this
Agreement may be terminated effective the last day of the month during which termination notice occurs.
(D) In the event membership dues are delinquent, services and benefits under the Plan shall be suspended effective on the
last day of the month during which the delinquency occurred.
(E) On the date of contract expiration, if not renewed.
XII. CONTINUATION OF SERVICES: Plan coverage will terminate for group Subscribers and their dependents when Subscriber
is no longer eligible for group benefits. Thereafter, he may continue his membership benefits by re-enrolling with Plan on
an individual basis;in the event of same,payment shall be on an annual basis only.
XIII. SERVICES NOT RENDERED:Services for injuries or conditions which are covered under Worker's compensation or Employer's
Liability Laws. Services which are provided without cost to the member by any municipality,county,or other Political subdivision.
Oral surgery requiring the setting of fractures or dislocations. Treatment of malignancies, cysts or neoplasms. Dispensing of
drugs not normally supplied in a dental office. Hospital benefits for any dental procedure. Loss or theft of dentures or bridgework.
Any dental procedure of implantation or experimental procedures. General anesthesia. Services that cannot be performed because
of the general health of the patient. Cost of dental care which is covered under automobile medical, no-fault or similar type
insurance. Any dental procedure requiring the services of a specialist. Restorations necessary to increase vertical dimension
or restore occlusion. Cosmetic, elective, or aesthetic dentistry. Services, which in the opinion of the attending dentist, are not
necessary for the patient's dental health. Temporomandibular joint treatment.
XIV. COORDINATION OF BENEFITS: In the event the Member is entitled to UCD benefits or other benefits from another dental
care plan or health and accident insurance policy in addition to Plan, there will be coordination of benefits in that Member
will only be eligible to receive from Plan those services incurred over and above the benefits provided by other plan to the
extent of the benefits provided under this policy. Member is required to assign all benefits to Plan.
XV. THIRD PARTY RESPONSIBILITY: When a Member's dental injury or illness is the liability of an insurance company that
covers the Member as a part of his auto and casualty policy, or is the result of an act or omission of a third party and
said third party is responsible, Plan shall be entitled to bill the Member for the usual and customary charges for such care,
including all legal and dental expenses provided, but shall forego collection until such time as financial responsibility has been
established. The members shall furnish any assignment which may be necessary to protect the Plan's rights in regard to payment
for dental and laboratory expenses furnished.
XVI. GENERAL PROVISIONS:
(A) This Agreement,including any amendments or exhibits thereto,constitutes the entire contract between the parties.
(B) Any provision of this Agreement, which on its effective date is in conflict with the statutes of the State of Illinois is
hereby amended to conform to the minimum requirements of such statute.
(C) In the event of any controversy between Group, Member, or the heirs-at-law or personal representatives of Group or
Member, as the case may be, and the Plan, its agents and its employees as participants of the Plan, as individuals or
otherwise, whether involving a claim or tort, contract or otherwise, the same shall be submitted to arbitration. Said
arbitration shall be conducted and governed by the provisions of Illinois Code of Civil Procedure shall be binding upon
parties thereto.
GROUP CONSENT AND AGREEMENT: •
XVII. EXHIBITS: Service benefits, Co-Payments, designated care centers;-exclusions and limitations, in-area emergency care and
out-of-area emergency care. r
XVIII. IN WITNESS THERETO,the parties have caused this Agreement to beexecuted this S day of
I
19 � at � .,Illinois.
/s/ /s/ I
Plan Representative(Agent/Broker) • Gro•p ' epresentative
•
/s/
National Dental Health Insurance Company