Dental and Vision Insurance

Metlife Exclusions and DIsclaimers

Dental Disclaimers:

Like most group benefit programs, benefit programs offered by MetLife and its affiliates contain certain exclusions, exceptions, reductions, limitations, waiting periods and terms for keeping them in force. You may be financially responsible for copayments, deductibles, or any other amounts in excess of those MetLife is required to pay for covered services as described in your dental certificate and/or policy. Please contact HUB Benefits at 1-877-247-8817 for costs and complete details.

Vision Disclaimer:

Important: If you or your family members are covered by more than one health care plan, you may not be able to collect benefits from both plans. Each plan may require you to follow its rules or use specific doctors and hospitals, and it may be impossible to comply with both plans at the same time. Before you enroll in this plan, read all of the rules very carefully and compare them with the rules of any other plan that covers you or your family.

Your actual savings from enrolling in a vision plan will depend on various factors, including the plan chosen, plan premiums, number of visits to an eye care professional by your family per year, and the cost of services and materials received. Be sure to review the Schedule of Benefits for your plan’s specific benefits and other important details.

MetLife Vision benefits are underwritten by Metropolitan Life Insurance Company, New York, NY. Certain claims and network administration services are provided through Superior Vision, Inc. (“Superior Vision”), a New York corporation. Superior Vision is part of the MetLife family of companies.

Like most group benefit programs, Superior Vison by MetLife plans contain certain exclusions, exceptions, reductions, limitations, waiting periods and terms for keeping them in force. Please contact MetLife or your plan administrator for costs and complete details.

All product and company names are trademarks or registered trademarks of their respective holders. Use of them does not imply any affiliation with or endorsement by them.

University of Miami Dental PDP Plan Exclusions

We will not pay Dental Insurance benefits for charges incurred for:

  1. services which are not Dentally Necessary, or those which do not meet generally accepted standards of care for treating the particular dental condition;
  2. services for which You would not be required to pay in the absence of Dental Insurance;
  3. services or supplies received by You or Your Dependent before the Dental Insurance starts for that person;
  4. services which are neither performed nor prescribed by a Dentist, except for those services of a licensed Dental Hygienist which are supervised and billed by a Dentist, and which are for:
  • scaling and polishing of teeth; or
  • fluoride treatments;
  1. services which are primarily cosmetic unless such service is:
  • required for reconstructive surgery which is incidental to or follows surgery which results from trauma, an infection or other disease of the involved part; or
  • required for reconstructive surgery because of a congenital disease or anomaly of a Child which has resulted in a functional defect;
  1. services or appliances which restore or alter occlusion or vertical dimension;
  2. restoration of tooth structure damaged by attrition, abrasion or erosion, unless caused by disease;
  3. restorations or appliances used for the purpose of periodontal splinting;
  4. counseling or instruction about oral hygiene, plaque control, nutrition and tobacco;
  5. personal supplies or devices including, but not limited to: water piks, toothbrushes, or dental floss;
  6. decoration or inscription of any tooth, device, appliance, crown or other dental work;
  7. missed appointments;
  8. services:
  • paid under any workers’ compensation or occupational disease law;
  • paid under any employer liability law;
  • for which You are not required to pay; or
  • received at a facility maintained by the Policyholder, labor union, mutual benefit association, or VA hospital;
  1. services covered under other coverage provided by the Policyholder;
  2. biopsies of hard or soft oral tissue;
  3. temporary or provisional restorations;
  4. temporary or provisional appliances;
  5. prescription drugs;
  6. services for which the submitted documentation indicates a poor prognosis;
  7. the following, when charged by the Dentist on a separate basis:
  • claim form completion;
  • infection control, such as gloves, masks, and sterilization of supplies; or
  • local anesthesia, non-intravenous conscious sedation or analgesia, such as nitrous oxide;
  1. dental services arising out of accidental injury to the teeth and supporting structures, except for injuries to the teeth due to chewing or biting of food;
  2. caries susceptibility tests;
  3. implant supported Cast Restorations;
  4. modification of removable prosthodontic and other removable prosthetic services;
  5. implants including, but not limited to any related surgery, placement, maintenance, and removal;
  1. implant supported Dentures;
  2. repair of implants;
  3. fixed and removable appliances for correction of harmful habits;
  4. appliances or treatment for bruxism (grinding teeth);
  5. initial installation of a Denture to replace one or more teeth which were missing before such person was insured for Dental Insurance, except for congenitally missing teeth;
  6. precision attachments associated with fixed and removable prostheses;
  7. adjustment of a Denture made within 6 months after installation by the same Dentist who installed it;
  8. duplicate prosthetic devices or appliances;
  9. replacement of a lost or stolen appliance, Cast Restoration or Denture;
  10. orthodontic services or appliances;
  11. repair or replacement of an orthodontic device;
  12. diagnosis and treatment of temporomandibular joint disorders and cone beam imaging associated with the treatment of temporomandibular joint disorders;
  13. intra and extraoral photographic images.

University of Miami Dental HMO Plan Exclusions

  1. Any procedures not specifically listed as a Covered Service in this SCHEDULE OF BENEFITS or dental procedures or services performed solely for Cosmetic purposes (unless specifically listed as a Covered Service in this SCHEDULE OF BENEFITS), are not covered.
  2. Covered Services must be performed by Your Selected General Dental Office or a SafeGuard Specialty Care Dentist to whom You are referred in accordance with the terms of Your evidence of coverage and SCHEDULE OF BENEFITS. Services performed by any Dentist not contracted with SafeGuard are not Covered Services, without prior approval by SafeGuard or Your Selected General Dentist, in accordance with the terms of Your evidence of coverage and SCHEDULE OF BENEFITS (except for out-of-area emergency services).
  3. Dental procedures started prior to Your or Your Dependent’s eligibility under this SCHEDULE OF BENEFITS or started after Your or Your Dependent’s benefits have For example, teeth prepared for Crowns, root canals in progress (the tooth has been opened into the pulp (nerve chamber)), or full or partial Dentures for which an impression has been taken.
  4. Any dental services, or appliances, which are determined to be not reasonable and/or necessary for maintaining or improving You or Your Dependent’s dental health, as determined by the Selected General Dentist, and Us based on generally accepted dental standards of care.
  5. Orthognathic
  6. Inpatient/outpatient hospital charges of any kind, including prescriptions or General anesthesia or IV sedation is not covered for any reason if rendered in an out patient facility or hospital. Dental charges will be covered, if the procedure performed is covered by the Plan.
  7. Replacement of Dentures, Crowns, appliances or Bridgework that have been lost, stolen or
  8. Treatment of malignancies, cysts, or neoplasms, unless specifically listed as a Covered Service in the SCHEDULE OF BENEFITS. Any services related to pathology laboratory fees.
  9. Procedures, appliances, or restorations whose primary purpose is to change the vertical dimension of occlusion, correct congenital malformation, developmental, or medically induced dental disorders including, but not limited to, treatment of myofunctional, myoskeletal, or temporomandibular joint disorders unless otherwise specifically listed as a Covered Service in this SCHEDULE OF BENEFITS.
  10. Dental services provided for or paid by a federal or state government agency or authority, political subdivision, or other public program other than Medicaid or Medicare.
  11. Dental services required while serving in the armed forces of any country or international
  12. Dental services considered Experimental in
  13. Treatment required due to an accident from an external force, unless otherwise listed as Covered Service in this SCHEDULE OF BENEFITS.
  14. The following are not included as Orthodontic benefits:
    • Repair or replacement of lost or broken appliances;
    • Retreatment of Orthodontic cases;
    • Treatment involving:
      • Maxillo-facial surgery, myofunctional therapy, cleft palate, micrognathia, macroglossia;
      • Hormonal imbalances or other factors affecting growth or developmental abnormalities;
      • Treatment related to temporomandibular joint disorders;
    • Composite or ceramic brackets, lingual adaptation of Orthodontic bands and other specialized or Cosmetic alternatives to standard fixed and removable Orthodontic appliances.
    • Invisalign services are excluded

University of Miami Vision Exclusions

We will not pay Vision Insurance benefits for charges incurred for:

  1. Services and/or materials not specifically included in the SCHEDULE OF BENEFITS as covered Plan
  2. Any portion of a charge in excess of the Maximum Benefit Allowance or reimbursement indicated in the SCHEDULE OF BENEFITS.
  3. Plano lenses (lenses with refractive correction of less than ± .50 diopter).
  4. Two pairs of glasses instead of
  5. Replacement of lenses, frames and/or contact lenses furnished under this Plan which are lost, stolen or damaged, except at the normal intervals when Plan Benefits are otherwise available.
  6. Orthoptics or vision training and any associated supplemental
  7. Medical or surgical treatment of the
  8. Prescription or non-prescription
  9. Contact lens insurance policies and service
  10. Refitting of contact lenses after the initial (90-day) fitting
  11. Contact lens modification, polishing and
  12. Any eye examination or any corrective eyewear required as a condition of
  13. Services or supplies received by You or Your Dependent before the Vision Insurance starts for that
  14. Missed
  15. Services or materials resulting from or in the course of a Covered Person’s regular occupation for pay or profit for which the Covered Person is entitled to benefits under any Workers’ Compensation Law, Employer’s Liability Law or similar law. You must promptly claim and notify the Company of all such
  16. Local, state and/or federal taxes, except where MetLife is required by law to
  17. Services:
    • for which the employer of the person receiving such services is required to pay by law; or
    • received at a facility maintained by the employer, labor union, mutual benefit association, or VA
  18. Services or materials received as a result of disease, defect, or injury due to war or an act of war (declared or undeclared), taking part in a riot or insurrection, or committing or attempting to commit a
  19. Services and materials obtained while outside the United States, except for emergency vision
  20. Services, procedures, or materials for which a charge would not have been made in the absence of