2012-038 Human Resources - Delta Dental Claims & Administrative fees

Browse Search

claimant to file the claim within that time, provided that the claim is submitted as soon as possible and in no event, except in the absence of legal capacity of the claimant, later than one year from the time submittal of the claim is otherwise required. Dentist- Patient Relationship Eligible Persons are free to choose any Dentist. Each Dentist maintains the dentist- patient relationship with the patient and is solely responsible to the patient for dental advice and treatment and any resulting liability. Loss of Eligibility During Treatment If an Eligible Person loses eligibility while receiving dental treatrnent, only Covered Services received while that person was covered under the Plan will be payable. Certain services begun before the loss of eligibility may be covered if they are completed within a 60-day period measured from the date of termination. In those cases, Delta Dental evaluates those services in progress to determine what portion may be paid by Delta Dental. Entire Contract/Chan4es This Certificate, along with your Summary of Dental Plan Benefits, constitutes the entire contract of your Delta Dental program. No agent has the authority to change any provisions in this Certificate or the provisions of the contract on which it is based. No changes to this Certificate or the underlying contract are valid unless Delta Dental approves them in writing. Note: This Certificate and your Plan are subject to change if, in the future, federal or state laws or regulations require Delta Dental or your employer or organization to comply with such laws or regulations. Leaal Actions No action on a legal claim arising out of or related to this Certificate will be brought unti160 days after the time written proof of loss is required to be given. In addition, no action can be brought more than three years after the legal claim first arose. Any person seeking to do so will be deemed to have waived his or her right to bring suit on such legal claim. Governinq Law The group contract and/or Certificate will be governed by and interpreted under the laws of the state of North Carolina. Ri4ht of Recoverv Due to Fraud If Delta Dental pays for dental services that were sought or received under fraudulent, false, or misleading pretenses or circumstances, pays a claim that contains false or misrepresented inforn~ation, or pays a claim that is determined to be fraudulent due to the acts of the Eligible Person, it may recover that payment from the Eligible Person. The Eligible Person authorizes Delta Dental to recover any payxnent deternuned to be based on false, fraudulent, misleading, or misrepresented information by deducting that amount from any payments properly due to the Eligible Person. Delta Dental will provide an explanation of the payment being recovered at the time the deduction is made. Leaallv Mandated Benefits If any applicable law requires broader coverage or more favorable treatment for the Subscriber or an Eligible Dependent than is provided by this Certificate, that law shall control over the language of this Certificate. Any person who, with intent fo defraud or knowing that he or she is facilitating a fraud against an insurer, submits an application or files a claim confaining a fa/se or deceptive statement is guilty of insurance fraud. lnsurance fraud signi~cantly increases the cosf of healfh care. If you are aware of any false informafion submitted to Delta Dental, please call our toll-free hotline. Only anti-fraud ca/!s can be accepted on this line. ANTI-FRAUD TOLL-FREE HOTLINE: (800) 524-0147 Form No. 1752-NC 17 NCPPOpIus-A Ot/2012