Dental Plan

If the Plan Administrator issues an Adverse Benefit Determination, you can request to have your claim reviewed and reconsidered. An “Adverse Benefit Determination” includes:

Coverage denial,

Denial because the service is experimental, investigational or not medically necessary, or

Reduction or termination in an ongoing course of treatment (except due to Dental Plan amendment or termination).

The written explanation of the denial will be provided by the Plan Administrator and it will state:

The specific reasons for the denial,

A reference to the specific Plan provision on which the denial is based,

If the Plan Administrator relied on an internal rule, guideline, protocol, or other similar criterion in making its decision, a description of the specific rule, guideline, protocol, scientific or clinical judgment, or other similar criterion or a statement that such a rule, guideline, protocol, or other similar criterion was relied on and that a copy of such rule, guideline, protocol, or other criterion will be provided free of charge to you upon request,

A description of any additional material or information necessary for you to complete your claim and an explanation of why such material or information is necessary, and

Appropriate information as to the steps to be taken if you wish to appeal the Plan Administrator’s determination, including your right to submit written comments and have them considered, your right to review (on request and at no charge) relevant documents and other information, and your right to file suit under ERISA with respect to any adverse determination after appeal of your claim.

While this Summary Plan Description summarizes the major provisions of this plan, it does not provide you with every plan detail. The plan documents, which govern this plan, provide full details. If there are any discrepancies between this Summary Plan Description and the legal plan documents, the legal plan documents control.