Page 43 - Dental Benefit Plan Summary

TEXAS MUTUAL INSURANCE COMPANY DENTAL PPO PLAN

providing incorrect information relating to another person's eligibility or status as a
Dependent.

Note: If UnitedHealthcare and Texas Mutual Insurance Company find that you have
performed an act, practice, or omission that constitutes fraud, or have made an intentional
misrepresentation of material fact Texas Mutual Insurance Company has the right to
demand that you pay back all Benefits Texas Mutual Insurance Company paid to you, or
paid in your name, during the time you were incorrectly covered under the Plan.

Extended Coverage

A 180 day temporary extension of Coverage, only for the services shown below when given
in connection with a Procedure in Progress, will be granted to a Covered Person on the date
the person's Coverage is terminated if termination is not voluntary. Benefits will be extended
until the earlier of: (a.) the end of the 180 day period; or (b.) the date the Covered Person
becomes covered under a succeeding policy or contract providing coverage or services for
similar dental procedures.

Benefits will be Covered for: (a.) a Procedure in Progress or Dental Procedure that was
recommended in writing and began, in connection with a specific dental disease of a
Covered Person while the Plan was in effect, by the attending Dentist; (b.) an appliance, or
modification to an appliance, for which the impression was taken prior to the termination of
Coverage; or (c.) a crown, bridge or gold restoration, for which the tooth was prepared prior
to the termination of Coverage.

Coverage for a Disabled Child

If an unmarried enrolled Dependent child with a mental or physical disability reaches an age
when coverage would otherwise end, the Plan will continue to cover the child, as long as:

■ the child is unable to be self-supporting due to a mental or physical handicap or
disability;

■ the child depends mainly on you for support;

■ you provide to Texas Mutual Insurance Company proof of the child's incapacity and
dependency within 31 days of the date coverage would have otherwise ended because
the child reached a certain age; and
■ you provide proof, upon Texas Mutual Insurance Company's request, that the child
continues to meet these conditions.

The proof might include dental examinations at the Plan's expense. However, you will not
be asked for this information more than once a year. If you do not supply such proof within
31 days, the Plan will no longer pay Benefits for that child.

Coverage will continue, as long as the enrolled Dependent is incapacitated and dependent
upon you, unless coverage is otherwise terminated in accordance with the terms of the Plan.

38 SECTION 8 - WHEN COVERAGE ENDS