Individual Dental Plan
The dentists must meet the Plan's standard of
quality and service. All have agreed to provide dental care at an affordable
price to its members. Since there is no waiting period for your dental
services to begin, pre-existing dental conditions are covered and best of
all, the dental plan services starts on the first day of next month if the
application is received by the dental plan on or before the 20th of this
month. Review the sample schedule below and see how easy it is for you or
your entire family to enjoy these quality dental services
Disclosure information for
several of the Assurant dental plans
SECTION I: PLAN DENTIST SERVICES (Subject to
Exclusions and Limitations Listed in Agreement)
Plan Benefits are provided for the dental services listed in this Plan
Dentist Services Section of the Copayment Schedule only when services are
provided by Member's selected Plan Dentist. Benefits for Emergency Services
from other Plan Dentists are provided as specifically stated in the
EMERGENCY SERVICES Article of the Evidence of Coverage. Plan Benefits are
not available for dental services that do not appear on the Copayment
Schedule. To fully understand the benefits, exclusions and limitations of
this plan, Member should consult the Evidence of Coverage.
Member is responsible for paying the amount listed in the Member Copayment
column, plus any additional laboratory (ďlabĒ) fees for certain dental
services. Payment may be due at the time the service is received or in
accordance with Plan Dentist's billing procedures. Lab fees may apply to
asterisked (*) services. For such a service, the lab fee is that Plan
Dentistís normal retail lab fee for that service.
Plan Benefits will be based on the most current dental terminology. Company
reserves the right to update the Copayment Schedule to reflect the most
current dental terminology, with at least thirty (30) days written notice to
The Plan Dentist selected by Member may not perform all listed services. To
fully understand payment responsibility for dental services, Member should
discuss availability of services, the proposed treatment, and cost with
selected Plan Dentist prior to treatment. Company cannot guarantee that any
specific general dentist.
Any Plan Dentist may (but is not required to) charge any Member for any
missed appointment, in accordance with the Plan Dentistís guidelines, if
Member fails to notify the Plan Dentist at least 24 hours before the
scheduled appointment time. However, the charge to the member may not exceed
$25.00 per missed appointment.
Payment for all services received from a Non-Plan Dentist (at the Non-Plan
Dentistís entire normal retail charge) is the responsibility of Member,
except for benefits for Emergency Services as specifically stated in the
EMERGENCY SERVICES Article of Agreement.
SECTION II: PLAN SPECIALTY DENTIST SERVICES (Subject to Exclusions and
Limitations Listed in Agreement)
If Member requires dental specialty services that cannot be provided by
selected Plan Dentist, Member may obtain such services from a Plan Specialty
Dentist. No referral from Memberís selected Plan Dentist is needed. There is
no applicable copayment schedule for Plan Specialty Dentist services.
Instead, the following reductions in charges apply. A 15% reduction from
that Plan Specialty Dentist's normal retail charges applies to services
obtained from a Plan Specialty Dentist whose practice is limited to
endodontics. A 25% reduction from that Plan Specialty Dentist's normal
retail charges applies to services obtained from any other Plan Specialty
Dentist (including, but not limited to, a Plan Specialty Dentist whose
practice is orthodontics). Member is responsible for paying the entire
reduced charge either at the time the service is received or in accordance
with Plan Specialty Dentist's billing procedures.
To fully understand payment responsibility for dental specialty services,
Member should discuss the proposed treatment and its cost with the Plan
Specialty Dentist prior to treatment. Availability of specific types of
specialty services from Plan Specialty Dentists depends on which types of
dentists are Plan Specialty Dentists. Company cannot guarantee that any
specific dentist, or any specific type of dentist, will be a Plan Specialty
Dentist. Types of dentists who are Plan Specialty Dentists may vary from
time to time in different parts of the Service Area.
Payment for all services received from a Non-Plan Specialty Dentist (at the
Non-Plan Specialty Dentistís entire normal retail charge) is the
responsibility of Member, except for benefits for Emergency Services as
specifically stated in the EMERGENCY SERVICES Article of Agreement.
Limitations and exclusions
1.Any services not specifically described in the Copayment Schedule
(including but not limited to any hospital or outpatient care facility cost
associated with any dental service)
2.Any part of any dental service for which a charge is incurred before the
effective date of member's enrollment ends.
3.Any dental service initiated after Memberís enrollment ends.
4.Services provided by Non-Plan Providers unless for Emergency Services for
temporary pain relief (with limited benefits) as specifically provided in
the EMERGENCY SERVICES Article of the Individual Dental Service Agreement.
5.Replacement of bridgework, dentures or other fixed or removable appliances
unless (a) at least five years have elapsed since such appliance was
provided as a Plan Benefit, or (b) during that five year period, appliance
becomes unusable and cannot be made usable due to Memberís illness or an
accident involving damage to the appliance while it is in use.
6.Replacement of dentures or other removable appliances due to (a) damage
while not in use or (b) loss or theft.
7.Oral reconstruction using fixed bridgework or other fixed appliances if
the overall treatment plan to achieve complete oral reconstruction involves
the replacement of six or more teeth (whether those teeth are missing before
treatment begins or are extracted as part of the overall treatment plan).
8.Implants or any related implant appliances, or surgery for the insertion
of implants or any related implant appliances, whether fixed or removable.
9.Surgical removal of implants or implant appliances, or any surgical or
non-surgical services to adjust, repair, replace, or treat any problem
related to an existing implant or implant appliance, whether fixed or
10.Restorations or splints used to increase vertical dimension, restore
occlusion, or replace or stabilize tooth structure lost by attrition.
11.Orthodontic treatment involving therapy for myofunctional problems, TMJ (temporomandibular
joint) dysfunctions, micrognathia, macroglossia, cleft palate or other
growth and developmental abnormalities.
12.Orthodontic treatment associated with orthognathic surgery, whether the
treatment precedes or follows the surgery.
13.Extractions of third molars (wisdom teeth) that are not symptomatic,
whether or not the extractions follow the completion of orthodontic
treatment. Examples of symptomatic conditions include decay, odontogenic
cysts, chronic pericoronitis and infection.
14.Treatment of malignancies, neoplasms or cysts, including but not limited
Renewal at option of Company.
The Secure Choice individual plan provides dental benefits with attractive
prepayment fees. To receive the benefits of the Secure Choice Plan you will
need to select a Plan Dentist for you and your family members from the list
of Plan Dentists. Please note that you may choose a different dentist for
each family member.
The Plan Dentist you select may not perform all procedures listed. The
copayments shown apply to those Plan Dentists who perform those services.
Therefore, you are encouraged to discuss availability of the scheduled
services with your Plan Dentist. Charges for procedures not listed on the
Copayment Schedule that are performed by your Plan Dentist are not covered
under the Secure Choice Plan. Should you require dental services that your
selected Plan Dentist is unable to provide, you may obtain those services
from a Plan Specialty Dentist at a reduced rate. No referral is needed from
your Plan Dentist in order for you to obtain services from a Plan Specialty
Dentist. There is no applicable copayment schedule for specialty services.
Instead, the following reductions off the Plan Specialty Dentistís normal
retail charges apply to all services received. A 15% reduction applies if
the Plan Specialty Dentist is an endodontic specialty dentist. A 25%
reduction applies if the Plan Specialty Dentist is any other type of
specialty, including but not limited to an orthodontic specialty dentist.
You are responsible for paying the entire reduced charge at the time the
service is received, or in accordance with the Plan Specialty Dentistís
Payment for each service of a Non-Plan Dentist or Non- Plan Specialty
Dentist (at that providerís normal retail charge) is your responsibility,
except for limited Plan Benefits for covered dental Emergency Services as
stated in the Individual Dental Service Agreement.
Availability and participation of Plan Dentists and Plan Specialty Dentist(s)
are subject to change.
What are copayments? Copayments are reduced fees that you pay directly to
the dentist for some dental treatments. A partial list of some frequently
used dental treatments is included on the back of this brochure. This list
shows you the potential savings with United Dental Care of Texas, Inc.
versus what you would pay without this Plan.
Cosmetic dentistry: United Dental Care of Texas, Inc. understands the
importance of your appearance. Thatís why we have included cosmetic
services, such as bleaching and bonding procedures, in your plan benefits.
Orthodontic benefits: The Secure Choice Plan includes reduced fees on
Orthodontic procedures for children and adults. Plan Orthodontic Specialty
Dentist provide reduced fees of 25% off his or her normal retail charge.
Orthodontic services are available only in areas where United Dental Care of
Texas, Inc. has Plan Orthodontist(s) who provide those services. Orthodontic
treatment begun prior to your plan effective date is not eligible for this
Specialty benefits: Should the services of a Specialty Dentist be necessary
you may seek treatment from any Plan Specialty Dentist listed in our printed
or online directory. If an oral specialty dentist, orthodontic specialty
dentist, periodontic specialty dentist or pedodontic specialty dentist
provides treatment you will receive 25% off that specialistís normal retail
charges. For treatment by an endodontic specialty dentist you will receive
15% off that Specialty Dentistís normal retail charges. Specialty Dentist
services are available only in areas where United Dental Care of Texas, Inc.
has Plan Specialty Dentist(s). Please note that payment for a service
performed by a Non-Plan Specialty Dentist is your responsibility.
When will I receive a membership card? Once your application has been
processed, you will receive a membership card, the Individual Dental Service
Agreement, and a complete list of copayments. Your effective date will be
provided with your membership materials.
What if I need to change my dentist? You may change dentists by simply
calling the Customer Service Department.
How do I receive care? After your effective date, phone the dentist you
selected, and tell the office that you have United Dental Care of Texas,
Inc. prepaid coverage. They will schedule your appointment to see the
Who is eligible? You, your spouse and dependent children as defined by state
When do I renew my dental plan? If you select the annual prepayment method,
a renewal notification and billing statement will be mailed to your home in
advance of your anniversary date. If you select the monthly bank draft
method for payment, no action is required to renew your dental plan.
Renewal/Cancellation/Termination: This Plan renews at each yearly
anniversary of the effective date. Company and Subscriber each have the
right to terminate the Plan with prior written notice. Please consult the
Individual Dental Service Agreement for details concerning renewability,
cancellation and termination.
* Refer to the detailed plan document.
** Members are responsible for additional lab fees for these services.
1 The Average Retail Charges were determined by "Company" claims analysis
for the year 2006 for the state of Texas. The Retail Charges represent a
mean average rounded to the nearest dollar representing what you may pay
without the plan services.
If you purchase this plan you must agreed to these terms and conditions:
Products are marketed by Assurant Employee Benefits, administered by Union
Security Insurance Company and provided United Dental Care of Texas, Inc. I
affirmatively consent to completing the Data Collection Form (the "Form")
electronically. I understand that the option to receive and complete a paper
version of the Form is available by printing the Form and completing and
submitting the Form. I acknowledge that by clicking the "Submit Form" box
above, I have consented to the transmittal of the information contained
therein to Union Security Insurance Company and its legal affiliates
(hereafter "Company") and that Company may use this information in
connection with processing any associated enrollment application. I
understand that the Company may be required to retain records of all
relevant communications pertaining to the transaction. I also acknowledge
that those records may be kept so that the Company may show that the records
are authentic, were reliably created by me, and were created and linked to
the electronic transaction to which they relate in a manner, such that if
the record or the signature is intentionally or unintentionally changed
after signing, the electronic signature is invalidated. I understand that I
may withdraw this consent to completing the Form electronically by providing
notice of my intent to do so to the Company or its agent(s) and that I have
an opportunity to review this consent, as well as the Form, in written form
as soon as practicable upon my request. I agree that all of the foregoing
statements are true and I agree with the terms of this consent.
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Dr. David Blunt