Terms and Conditions

Dental And Vision Insurance Terms and Conditions

Authorization Agreement

Payment Options

I authorize Ameritas Life Insurance Corp. ("Ameritas") to initiate electronic debit entries to my account chosen above for payment of my insurance premium. I certify that I am an authorized user on the above listed account. I acknowledge that debits to my account for premium due will occur on a regular recurring basis based on the payment frequency indicated above until such time as coverage terminates or until I notify Ameritas to terminate these transactions. I understand that it may take up to two weeks to process a request to discontinue recurring payments. In order to make changes to this authorization (such as change in bank account, method of payment, or termination of payment) I must provide Ameritas at least two weeks notice in advance of the next scheduled payment date.

Payment Information:

1. Initial premium will be withdrawn within 3 days of your policy effective date, subsequent premiums are due on the day of the month in which the policy was effective.
2. For initial payments I acknowledge that Ameritas may debit my account upon acceptance and approval of my application. Based upon my authorization, Ameritas will process reoccurring payments on or within three business days of the date of the month in which my policy was first effective.

If any authorized payment is returned or dishonored by my bank, I acknowledge that I am responsible for any fees my bank may charge. I understand also that I may incur a return payment fee of $25 charged by Ameritas if the return is due to insufficient funds. I acknowledge that such a fee, if charged, may be automatically debited from my authorized account on the next payment date. I am responsible for remitting payment within the policy grace period. If payment is not received by Ameritas within the defined grace period I acknowledge that my coverage may be cancelled in accordance with the terms of the insurance contract.

I also acknowledge that I have read the following information from Ameritas regarding this electronic signature.

• I may return my policy within the right-to-cancel period as described in my policy;
• I acknowledge receipt of the Outline of Coverage (in states where required by law);
• I understand the policy I am applying for provides dental and (if chosen) vision benefits only and is not a Medicare supplement;
• I acknowledge that the agent of record, if applicable, is my insurance agent for purposes of the Ameritas Privacy Policy; and
• I understand that it is my responsibility to give notice to Ameritas of changes in my email address or any information above, as well as my status and my family's status that affect coverage, such as marriage, births, or death of someone covered under the policy. I will provide notice via email at cs@ameritas.com, fax at 402-309-2598 or in writing to Ameritas or its designee: PO Box 82607, Lincoln, NE 68501-2607.

You are encouraged to print a copy of your electronic forms to retain for your own records.

Dental Limitations and Exclusions

Dental Limitations and Exclusions

Covered expenses will not include and benefits will not be payable for expenses incurred:

• for any treatment which is for cosmetic purposes, except as specifically listed in the Table of Dental Procedures.
• to replace any crowns, inlays, onlays, veneers, complete or partial dentures within five years of the date of the last placement of these items. But if a replacement is required because of an accidental bodily injury sustained while the Insured person is covered under this contract, it will be a covered expense.
• for initial placement of any dental prosthesis or prosthetic crown unless such placement is needed because of the extraction of one or more teeth while the insured person is covered under this contract. But the extraction of a third molar (wisdom tooth) will not qualify under the above. Any such appliance or fixed partial denture must include the replacement of the extracted tooth or teeth.
• for any procedure begun before the insured person was covered under the policy.
• for any procedure begun after the insured person's insurance under the policy terminates; or for any prosthetic dental appliances installed or delivered more than 90 days after the insured's insurance under the policy terminates.
• to replace lost or stolen appliances.
• for appliances, restorations, or procedures to:
  • alter vertical dimension;
  • restore or maintain occlusion; or
  • splint or replace tooth structure lost as a result of abrasion or attrition.
• for any procedure which is not shown on the Table of Dental Procedures. (There may be additional frequencies and limitations that apply, please see the Table of Dental Procedures in the policy.)
• for which the insured person is entitled to benefits under any workmen's compensation or similar law, or charges for services or supplies received as a result of any dental condition caused or contributed to by an injury or sickness arising out of or in the course of any employment for wage or profit (except in CA & KY) .
• for charges for which the insured person is not liable or which would not have been made had no insurance been in force.
• for services which are not required for necessary care and treatment or are not within the generally accepted parameters of care.
• because of war or any act of war, declared or not.
• if two or more procedures are considered adequate and appropriate treatment to correct a certain condition under generally accepted standards of dental care, the amount of the covered expense will be equal to the charge for the least expensive procedure.

Orthodontia Limitations and Exclusions

• for a Program begun on or after the Insured's 19th birthday.
• for a Program which uses a material other than metal brackets for treatment. The benefit will be considered as though metal brackets were applied.
• for a Program begun before the Insured became covered under this section,
• in any quarter of a Program if the Insured was not covered under this section for the entire quarter.
• for a Program more than once in a lifetime.
• if the Insured's insurance under this section terminates.
• for which the Insured is entitled to benefits under any workmen's compensation or similar law, or for charges for services or supplies received as a result of any dental condition caused or contributed to by an injury or sickness arising out of or in the course of any employment for wage or profit.
• for charges the Insured is not legally required to pay or would not have been made had no insurance been in force.
• for services not required for necessary care and treatment or not within the generally accepted parameters of care.
• because of war or any act of war, declared or not.
• to fix or repair broken or damaged orthodontic appliances.
• to replace lost, missing or stolen orthodontic appliances.
• for expenses incurred as a result of the Insured not being compliant with the Treatment Program.
• for services to alter vertical dimension and/or restore or maintain the occlusion due to, but not limited to the following: equilibration, periodontal splinting, full mouth rehabilitation, and restoration for misalignment of teeth.

Hearing Limitations and Exclusions

Covered Expenses will not include and no benefits will be payable for expenses incurred for:

• examinations performed before the Insured was covered under this section.
• any examination performed after the Insured's coverage under this section ceases.
• any hearing examination required by an employer as a condition of employment, including but not limited to, any mandatory worksite programs designed to satisfy OSHA hearing conservation programs.
• medical or surgical treatment of any part of the ear, including but not limited to, cochlear implants, or tubes in the ears.
• which the Insured person is entitled to benefits under any workers' compensation or similar law, or charges for services or supplies received as a result of any hearing loss caused or contributed to by an injury or sickness arising out of or in the course of any employment for wage or profit, including an occupational hearing loss.
• charges for which the Insured person is not liable or which would not have been made had no insurance been in force.
• any procedure not shown in the Schedule of Hearing Care Services.
• any treatment which is for cosmetic purposes.
• assistive hearing devices not listed in the Schedule of Hearing Care Services, such as phone amplification, cellular phone amplifier, hearing aid dehumidifier, loop system, etc.
• charges for services not provided by a licensed provider, such as an audiologist, hearing aid specialist, otolaryngologist (ENT) or otologist (ear doctor), within the scope of that license.
• services which are not related to a conductive or sensorineural hearing loss, such as any nonorganic hearing loss or occupational hearing loss.
• charges for a hearing screening performed as a part of or in the course of any non-hearing routine examination.
• because of war or any act of war, declared or not.

Vision Limitations and Exclusions

VSP Vision Limitations and Exclusions

This plan does not cover:

• Services and/or materials not specifically included in this Schedule as covered Plan Benefits,
• Plano lenses (lenses with refractive correction of less than plus or minus .50 diopter) except as specifically allowed in the frames benefit section below,
• Services or materials that are cosmetic, including Plano contact lenses to change eye color and artistically painted Contact Lenses,
• Two pairs of glasses in lieu of Bifocals,
• Replacement of Spectacle Lenses, Frames, and/or contact lenses furnished under this plan that are lost or damaged, except at the normal intervals when services are otherwise available,
• Orthoptics or vision training and any associated supplemental testing,
• Medical or surgical treatment of the eyes,
• Contact lens modification, polishing or cleaning,
• The refitting of Contact Lenses after the initial 90-day filing period.
• Contact Lens insurance policies or service contracts.
• Additional office visits associated with contact lens pathology,
• Local, state and/or federal taxes, except where law requires us to pay,
• Membership fees for any retail center in which an Affiliate or Open Access provider office may be located. Covered persons may be required to purchase a membership in such entities as a condition of accessing Plan Benefits.

EyeMed Vision Limitations and Exclusions

This plan has the following limitations.

• Vision examinations, lenses and frames more than the frequency as indicated on the plan summary page.
• This plan does not cover Medically Necessary Contact Lenses more than once in any 24-month period. The treating provider determines if an Insured meets the coverage criteria for this benefit as listed below. This benefit is in lieu of Elective Contact Lenses.
  • For Keratoconus where the patient is not correctable to 20/30 in either or both eyes using standard spectacle lenses.
  • Patients whose vision can be corrected two lines of improvement on the visual acuity chart when compared to best standard spectacle lens correction.
  • Anisometropia of 3D or more.
  • High Ametropia exceeding -10D or +10D in meridian powers.
• This plan does not cover Orthoptics or vision training and any associated testing.
• This plan does not cover Plano Lenses.
• This plan does not cover non-prescribed Lenses or sunglasses.
• This plan does not cover two pairs of glasses in lieu of Bifocals.
• This plan does not cover replacement of Lenses and Frames that are lost or broken outside of the normal coverage intervals.
• This plan does not cover medical or surgical treatment of the eyes or supporting structures.
• This plan does not cover services for claims filed more than one year after completion of the service. An exception is if the Insured shows it was not possible to submit the proof of loss within this period.
• This plan does not cover any procedure not listed on the Schedule of Eye Care Services.

Indemnity Vision Limitations

Covered expenses will not include and no benefits will be payable for:

• Vision examinations, lenses and frames more than the frequency as indicated on the plan summary page.
• Examinations performed or frames or lenses ordered before the Insured was covered under this section.
• Any examination performed or frame or lens ordered after the Insured's coverage under this section ceases, subject to Extension of Benefits.
• Sub-normal vision aids; orthoptic or vision training or any associated testing.
• Non-prescription lenses.
• Replacement or repair of lost or broken lenses or frames except at normal intervals.
• Any eye examination or corrective eyewear required by an employer as a condition of employment.
• Medical or surgical treatment of the eyes.
• Any service or supply not shown on the Schedule of Eye Care Services.
• Coated lenses; oversize lenses (exceeding 71 mm); photo-gray lenses; polished edges; UV-400 coating and facets, and tints other than solid.
• Lenses and frames during the first twelve months that a person is insured under this section, when the person is a Late Entrant, as defined.

Important State Notices

Fraud Notices

Any person who knowingly, and with intent to injure, defraud or deceive any insurer or insurance company, files a statement of claim containing any materially false, incomplete, or misleading information or conceals any fact material thereto, may be guilty of a fraudulent act, may be prosecuted under state law and may be subject to civil and criminal penalties. In addition, any insurer or insurance company may deny benefits.

If you live in a state other than mentioned above, the following statement applies to you: Any person who knowingly, and with intent to injure, defraud or deceive any insurer or insurance company, files a statement of claim containing any materially false, incomplete, or misleading information or conceals any fact material thereto, may be guilty of a fraudulent act, may be prosecuted under state law and may be subject to civil and criminal penalties. In addition, any insurer or insurance company may deny benefits if false information materially related to a claim is provided by the claimant.