Page 31 - Dental Benefit Plan Summary

TEXAS MUTUAL INSURANCE COMPANY DENTAL PPO PLAN

arising prior to the date individual Coverage under the Plan terminates, except those
conditions Covered under the Extension of Benefits in Section 3.

26. Acupuncture; acupressure and other forms of alternative treatment, whether or not used
as anesthesia.

27. Orthodontic coverage does not include the installation of a space maintainer, any
treatment related to treatment of the temporomandibular joint, any surgical procedure to
correct a malocclusion, replacement of lost or broken retainers and/or habit appliances,
and any fixed or removable interceptive orthodontic appliances previously submitted for
payment under the plan.

28. In the event that a non-Network Dentist routinely waives Coinsurance and/or the
Deductible for a particular Dental Service, the Dental Service for which the Coinsurance
and/or Deductible are waived is reduced by the amount waived by the non-Network
Dentist.

29. Foreign Services are not Covered unless required as an Emergency.

30. Dental Services received as a result of war or any act of war, whether declared or
undeclared or caused during service in the armed forces of any country.

31. Any Dental Services or Procedures not listed in Section 4, Plan Highlights.

26 SECTION 5 - EXCLUSIONS