Table of Benefits – Dental Plan PRSI This Table of Benefits must be read in conjunction with the Rules – Terms and Conditions. Applicable to new registrations or renewals on/or after 1st October, 2009.The Voluntary Health Insurance Board (trading as Vhi Healthcare) is an agent of DeCare Dental. Vhi Healthcare is a Multi-Agency Intermediary regulated by the Financial Regulator.
Benefit Provision
Benefit Limit
Section 1 - Investigative and Preventive Treatment – NO WAITING PERIOD Examinations • One time per 12-month period, in addition to the initial exam covered by PRSI
100%
Radiographs (x-rays): Bitewings coverage: • 1 series per 12 month period for insured persons up to the age of 18 years • 1 series per 24 month period for insured persons over 18 years
100% 100%
Full Mouth (Complete Series) or Panoramic • Covered once per 60-month period
100%
Periapical(s) • 4 single x-rays are covered per 12-month period
100%
Occlusal • 2 series per 24-month period
100%
Scaling and polishing • One time per 12-month period, in addition to the initial cleaning covered by PRSI
100%
Section 2 - Basic treatment – 3 MONTH WAITING PERIOD APPLIES Restorations (fillings) • Once per tooth surface per 24 month period
70%
Pre-fabricated or Stainless Steel Crowns • Once per 60-month period for eligible dependant children up to the age of 19
70%
Sealants • Once per lifetime for permanent first and second molars of eligible dependent children up to the age of 16
70%
Space Maintainers • Once per lifetime on eligible dependent children up to the age of 17 for extracted primary posterior (back) teeth
70%
Periodontal Treatment • Periodontal scaling and root planing - Once per quadrant per 36 month period • Full mouth debridement - Once per tooth per lifetime • Periodontal maintenance - Once per 24 month period
70% 70% 70%
Tooth extractions • Simple tooth extraction - once per tooth per lifetime
70%
Emergency Treatment • Once per 12 month period for the immediate, temporary relief of pain or infection • Emergency treatment is NOT subject to the 3-month wait period
100%
Dental Plan PRSI Section 3 - Major treatment – 12 MONTH WAITING PERIOD APPLIES Policy Excess
€100
Endodontic Therapy on Primary Teeth • Pulpal therapy - once per tooth per lifetime • Theraputic pulpotomy - once per tooth per lifetime
50% 50%
Endodontic Therapy on Permanent Teeth • Root canal therapy - once per tooth per lifetime
50%
Prosthetic Services - Dentures • Reline and rebase - 1 per 24 month period • Repairs, replacement of broken artificial teeth, replacement of broken clasp(s) 1 per 6 month period • Denture adjustments - 2 times per 12 month period • Removable prosthetic services (Dentures) - once per 5 year period Prosthetic Services – Bridge and Implant Supported Crowns • Bridge services •
Implant supported crowns
25% 25% 25% 25% No Cover No Cover
Crowns, Inlays and Onlays • Permanent crowns - once per tooth per 5-year period • Crown repair – once per tooth per 12 month period • Onlays – once per 24 month period • Inlays – once per 24 month period
50% 50% 50% 50%
A separate annual maximum of €500 per period of insurance applies to crowns, inlays and onlays.
€500
Section 4 – Orthodontics Orthodontic treatment
No Cover
Section 5 – Annual Maximum This applies to all sections of your plan (excluding crowns, inlays and onlays which has a separate maximum of €500). Maximum benefits may not be carried over to future years of cover.
This Table of Benefits must be read in conjunction with the Rules – Terms and Conditions. Applicable to new registrations or renewals on/or after 1st October, 2009.The Voluntary Health Insurance Board (trading as Vhi Healthcare) is an agent of DeCare Dental. Vhi Healthcare is a Multi-Agency Intermediary regulated by the Financial Regulator.
€1,000
Dental Plan PRSI
Additional Dental Plan PRSI Information Section A - PRSI Meaning of Words Renewal Date: Will take place annually during the month prior to the policy’s anniversary date. Co-payment: Fixed percentage we pay for covered services received after PRSI has made a benefit determination. Dependant: Policyholder’s spouse who is financially dependent on the policyholder for support and considered eligible for PRSI dental benefits. Children under 25 years of age are also eligible. DSFA: Department of Social and Family Affairs. Policyholder: Individual who has met the contribution requirements as established by DSFA and stated within the Rules Booklet, who subscribes to this policy on behalf of each insured person and pays or undertakes to pay the appropriate premium. PRSI: Pay Related Social Insurance.
Section B - PRSI Benefits We cover the dental procedures outlined in this Table of Benefits subject to the limitations and exclusions listed in the Rules booklet when they are performed by a dentist who has a contract with DSFA and agrees to provide treatment under the dental treatment benefit scheme when necessary and customary as determined by the standards of generally accepted dental practice. We do not determine whether a service submitted for payment under the policy is a dental procedure that is dentally necessary to treat a specific condition or restore dentition for an individual. We evaluate dental procedures submitted to determine if the procedure is a covered benefit already provided by PRSI under your dental policy. Your dental policy includes a preset schedule of dental services that are eligible for benefit by us. Other dental services may be recommended or prescribed by your dentist, which are dentally necessary, offer you an enhanced cosmetic appearance, or are more frequent than covered by us. While these services may be prescribed by your dentist and are dentally necessary for you, they will not be a dental service that is benefited by us or they may be a service where we provide a payment allowance for a service that is considered to be optional treatment. If we give you a payment allowance for optional treatment that is covered, you may apply that payment to the service prescribed by your dentist, which you elected to receive. Services that are not covered by us or exceed the frequency of the policy benefits do not imply that the service is or is not dentally necessary to treat your specific dental condition. You are responsible for dental services that are not covered or benefited by us. Determination of services necessary to meet your individual dental needs is between you and your dentist.
Section C – PRSI Eligibility PRSI Termination of Cover If you are no longer eligible for PRSI please notify us within 30 days. Your cover and that of your eligible dependants will cease on the earliest of the following dates: • You cease to be eligible under PRSI • On the date listed on any cancellation notice confirming your policy is terminated or cancelled. • On the date you fail to pay the required policy payments.
This Table of Benefits must be read in conjunction with the Rules – Terms and Conditions. Applicable to new registrations or renewals on/or after 1st October, 2009.The Voluntary Health Insurance Board (trading as Vhi Healthcare) is an agent of DeCare Dental. Vhi Healthcare is a Multi-Agency Intermediary regulated by the Financial Regulator.
Dental Plan PRSI
Section D- PRSI Payments Dentists Under this policy, you must receive all dental care from a dentist that is enrolled in the PRSI program in Ireland. The relationship between you and the dentist you select to provide your dental services is strictly that of dentist and patient. We cannot and do not make any representations as to the quality of treatment outcomes of individual dentists, nor recommend that a particular dentist be consulted for professional care.
Making a Claim The claim form can be found on the Vhi website, www.vhi.ie, or by phoning Vhi DeCare Dental on CallSave 1850 44 44 44. You will be required to submit a claim form to us after DSFA has made their benefit assessment of the claim. Your claim submission must include a copy of the payment receipt made by DSFA on the services submitted. Please refer to the claim form for specific details. All claims should be submitted within 6 months of the date on which the covered services were provided. A benefit assessment on your claim will be made within 30 working days after receipt of your claim. You will receive written notification of this benefit assessment and any applicable payment. The 30 working day period may be extended to obtain additional information from you. The notice will describe the specific information we need. Without complete information, your claim will not be paid.
Claim Payments Payments are made by us only when the covered dental procedures have been completed, have been previously submitted to DSFA for a benefit determination and you have submitted a properly completed claim form to us. Benefit calculations will assume that DSFA has previously paid for the services submitted. Any benefits payable will be made only after deducting the DSFA payment. We will pay a percentage of the remaining balance due after PRSI has made their benefit assessment. We may require additional information from you or your dentist before a claim can be considered complete and ready for processing. Duplicate claims previously processed will be denied. You must remain eligible for PRSI to be eligible under this policy. Any payments for dental procedures completed during a period of time that you were not eligible for PRSI are subject to recovery. Any benefits payable are not assignable by any insured person or any eligible dependant of any insured person. Claim payments are based on the remaining amount due after determining the amount charged by the PRSI dentist and the amount paid by PRSI. Claim payments are normally sent directly to you. However, we reserve the right to assign benefits to the dentist. The insured person is responsible for all treatment charges made by the dentist.
This Table of Benefits must be read in conjunction with the Rules – Terms and Conditions. Applicable to new registrations or renewals on/or after 1st October, 2009.The Voluntary Health Insurance Board (trading as Vhi Healthcare) is an agent of DeCare Dental. Vhi Healthcare is a Multi-Agency Intermediary regulated by the Financial Regulator.
Dental Plan PRSI
Section E - General Conditions PRSI In respect of Vhi DeCare Dental PRSI plan, the general conditions set out in the terms and conditions booklet apply to the policyholder, as well as the following PRSI general conditions: • •
A policyholder must be eligible to receive dental treatment benefits through PRSI. Eligibility is contingent upon PRSI participation. This policy will become void if you become ineligible for PRSI supplemental dental benefits.
TOBDPRSI V2 Oct09
This Table of Benefits must be read in conjunction with the Rules – Terms and Conditions. Applicable to new registrations or renewals on/or after 1st October, 2009.The Voluntary Health Insurance Board (trading as Vhi Healthcare) is an agent of DeCare Dental. Vhi Healthcare is a Multi-Agency Intermediary regulated by the Financial Regulator.
