Procedures and Services That Are Not Covered

Citi Benefits Handbook

Benefits are not provided for services and supplies not medically necessary for the diagnosis or treatment of dental illness or injury. For example, cosmetic services such as tooth whitening are elective in nature and, therefore, not covered by the Plan.

Exclusions that apply to the MetLife PDP include, but are not limited to, the following:

Dental care received from a dental department maintained by an employer, mutual benefit association or similar group;

Treatment performed for cosmetic purposes;

Use of nitrous oxide;

Treatment by anyone other than a licensed dentist, except for dental prophylaxis performed by a licensed dental hygienist under the supervision of a licensed dentist;

Services in connection with dentures, bridgework, crowns and prosthetics if for:

Prosthetics started before the patient became covered. Benefits are payable if this is completed while covered since payment is based on completion date;

Replacement within five years of a prior placement covered under this Plan;

Extensions of bridges or prosthetics paid for under this Plan, unless into new areas;

Replacement due to loss or theft;

Teeth that are restorable by other means or for the purpose of periodontal splinting; and

Connecting (splinting) teeth, changing or altering the way the teeth meet, restoring the bite (occlusion), or making cosmetic changes;

Any work done or appliance used to increase the distance between nose and chin (vertical dimension);

Facings or veneers on molar crowns or molar false teeth;

Training or supplies used to educate people on the care of teeth;

Any charges incurred for services or supplies not recommended by a licensed dentist;

Any charges incurred due to sickness or injury that is covered by a Workers' Compensation act or other similar legislation or that arise out of or in the course of any employment or occupation whatsoever for wage or profit;

Any charges incurred while confined in a hospital owned or operated by the U.S. government or an agency thereof for treatment of a service-connected disability;

Any charges that, in the absence of this coverage, you would not be legally required to pay;

Any charges incurred that result directly or indirectly from war (whether declared or undeclared);

Any charges due to injuries sustained while committing a felony or assault or during a riot or insurrection;

Any charges for services and supplies furnished for you or your eligible dependent(s) prior to the effective date of coverage or subsequent to the termination date of coverage;

Any charges for services or supplies that are not generally accepted in the United States as being necessary and appropriate for the treatment of dental conditions, including experimental care;

Any charges for nutritional supplements and vitamins;

Services covered by motor vehicle liability insurance;

Services that would be provided free of charge but for coverage;

Broken appointments;

Charges for filing claims or charges for copies of X-rays;

Any charges for services rendered to sound and natural teeth injured in an accident;

Care and treatment that are in excess of the maximum allowed amount; and

Services that, to any extent, are payable under any medical benefits, including HMOs.