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<br />SUNNYISLES <br />5395246 <br /> <br />City of Sunny Isles Beach <br />DENTAL LIMITATIONS & EXCLUSIONS (Continued) <br /> <br />20. charges which do not directly provide treatment for a dental injury or condition, such as: <br />a) the completion of claim forms; <br />b) broken appointments; <br />c) interest or collection charges; <br />d) sales or other taxes or surcharges; <br />e) education, training and supplies used for dietary or nutritional counseling, personal oral hygiene or <br />dental plaque control; <br />f) caries susceptibility tests, bacteriologic studies, histopathologic exams or pulp vitality testing; or <br />g) duplication of x-rays or other dental records. <br /> <br />21. itemized or separated charges for dental services, supplies or materials when those services, supplies <br />and materials may be combined into a single, more comprehensive procedure payable under the policy. <br />This also includes itemized charges which are routinely included in the dentist's charge for the primary <br />service, such as: <br />a) sterilization or asepsis charges; <br />b) a charge for local anesthesia; <br />c) charges for pre- and post-operative care; or <br />d) temporary dental services (for example, a temporary crown), which are considered to be part of the <br />permanent service. If the temporary service is billed separately, benefits for the temporary service <br />will be deducted from the amount payable for the permanent service. <br /> <br />22. duplication of services. <br /> <br />23. charges for which the covered person is not liable, or which would not have been made had no coverage <br />been in force. <br /> <br />24. a covered person, because of a dental injury or condition: <br />a) for which he or she is paid for benefits under Workers' Compensation or any similar law; or <br />b) sustained while performing military service. <br /> <br />25. services received for dental conditions caused directly or indirectly by: <br />a) war or an act of war; <br />b) intentionally self-inflicted injury; <br />c) engaging in an illegal occupation; <br />d) commission or attempt to commit a felony; or <br />e) a covered person's active participation in a riot. <br /> <br />26. for treatment rendered by a Dentist or dental hygienist: <br />a) who ordinarily resides in the covered person's household; or <br />b) who is related to the covered employee or dependent by blood, marriage or legal adoption. <br /> <br />27. root planing; unless the presence of periodontal disease (bone and attachment loss of 4mm or more) is <br />confirmed by x-rays and pocket depth charting of each tooth involved. <br /> <br />FL <br /> <br />The Lincoln National Life Insurance Company <br />12 <br /> <br />2/9/2009 <br />