Student Insurance Plans

Metlife Exclusions and DIsclaimers

Dental PPO and Vision benefits are underwritten by Metropolitan Life Insurance Company, New York, NY. Dental HMO benefits provided by SafeGuard Health Plans, Inc.,  a MetLife company, Irvine, CA Certain claims and network administration services for vision benefits 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, benefit programs offered by MetLife and its affiliates 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.

Dental PDP Plan Exclusions

  • This plan does not cover the following services, treatments and supplies:
  • Services which are not Dentally Necessary, those which do not meet generally accepted standards of care for treating the particular dental condition, or which we deem experimental in nature;
  • Services for which covered person would not be required to pay in the absence of Dental Insurance;
  • Services or supplies received by a covered person before the Dental Insurance starts for that person;
  • Services which are primarily cosmetic (for Texas residents, see notice page section in Certificate);
  • 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;
  • Services or appliances which restore or alter occlusion or vertical dimension;
  • Restoration of tooth structure damaged by attrition, abrasion or erosion unless caused by a disease;
  • Restorations or appliances used for the purpose of periodontal splinting;
  • Counseling or instruction about oral hygiene, plaque control, nutrition and tobacco;
  • Personal supplies or devices including, but not limited to: waterpicks, toothbrushes, or dental floss;
  • Decoration, personalization or inscription of any tooth, device, appliance, crown or other dental work;
  • Missed appointments;
  • Services:
    • Covered under any workers’ compensation or occupational disease law;
    • Covered under any employer liability law;
    • For which the policyholder of the person receiving such services is required to pay; or
    • Received at a facility maintained by the policyholder, labor union, mutual benefit association, or VA hospital;
  • Services covered under other coverage provided by the policyholder / participating association;
  • Biopsies of hard or soft oral tissue;
  • Temporary or provisional restorations;
  • Temporary or provisional appliances;
  • Prescription drugs;
  • Services for which the submitted documentation indicates a poor prognosis;
  • The following when charged by the Dentist on a separate basis:
    • Claim form completion;
    • Infection control such as gloves, masks, and sterilization of supplies; 
  • Local anesthesia, non-intravenous conscious sedation or analgesia such as nitrous oxide
  • 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;
  • Caries susceptibility tests;
  • Preventive resin restorations;
  • Interim caries arresting medicament application;
  • Modification of removal prosthodontic and other removable prosthetic services;
  • Initial installation of a fixed and permanent Denture to replace one or more natural teeth which were missing before such person was insured for Dental Insurance, except for congenitally missing natural teeth;
  • Other fixed Denture prosthetic services not described elsewhere in the certificate;
  • Precision attachments associated with fixed and removable prostheses, except when the precision attachment is related to implant prosthetics;
  • Addition of teeth to a partial removable Denture to replace one or more natural teeth which were missing before such person was insured for Dental Insurance, except for congenitally missing natural teeth;
  • Adjustment of a Denture made within 6 months after installation by the same Dentist who installed it;
  • Implants including, but not limited to any related surgery, placement, restorations, maintenance, and removal;
  • Repair of implants;
  • Implants supported prosthetics to replace one or more natural teeth which were missing before such person was insured for Dental Insurance, except for congenitally missing natural teeth;
  • Fixed and removable appliances for correction of harmful habits;
  • Appliances or treatment for bruxism (grinding teeth), including but not limited to occlusal guards and night guards;
  • Diagnosis and treatment of temporomandibular joint (TMJ) disorders. This exclusion does not apply to residents of New Mexico
  • Repair or replacement of an orthodontic device;
  • Services, to the extent such services, or benefits for such services, are available under a government plan. This exclusion will apply whether or not the person receiving the services is enrolled for the government plan. We will not exclude payment of benefits for such services if the government plan requires that Dental Insurance under the group policy be paid first.
  • Duplicate prosthetic devices or appliances;
  • Replacement of a lost or stolen appliance, Cast Restoration, or Denture; and
  • Intra and extraoral photographic images.

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