Page 50 - Dental Benefit Plan Summary

TEXAS MUTUAL INSURANCE COMPANY DENTAL PPO PLAN

SECTION 9 - COORDINATION OF BENEFITS

What this section includes:
■ How your Benefits under this Plan coordinate with other plans;

■ How coverage is affected if you become eligible for Medicare; and

■ Procedures in the event the Plan overpays Benefits.

Coordination of Benefits Applicability
This coordination of benefits (COB) provision applies when a person has dental coverage
under more than one Coverage Plan. "Coverage Plan" is defined below.

The order of benefit determination rules below determine which Coverage Plan will pay as
the primary Coverage Plan. The primary Coverage Plan that pays first pays without regard to
the possibility that another Coverage Plan may cover some expenses. A secondary Coverage
Plan pays after the primary Coverage Plan and may reduce the benefits it pays so that
payments from all group Coverage Plans do not exceed 100% of the total allowable expense.

Definitions

For purposes of this Section, Coordination of Benefits, terms are defined as follows:

■ A "Coverage Plan" is any of the following that provides benefits or services for dental
care or treatment. However, if separate contracts are used to provide coordinated
coverage for members of a group, the separate contracts are considered parts of the
same Coverage Plan, and there is no COB among those separate contracts.

- "Plan" includes: group insurance, closed panel or other forms of group or group-
type coverage (whether insured or uninsured); dental benefits under group or
individual automobile contracts; and Medicare or other governmental benefits, as
permitted by law.
- "Plan" does not include: individual or family insurance; closed panel or other
individual coverage (except for group-type coverage); school accident type coverage;
benefits for non-dental components of group long-term care policies; Medicare
supplement policies, Medicaid policies and coverage under other governmental
plans, unless permitted by law.

Each contract for coverage under either definition of "Plan" is a separate Coverage Plan.
If a Coverage Plan has two parts and COB rules apply only to one of the two, each of
the parts is treated as a separate Coverage Plan.
■ The order of benefit determination rules determine whether this Coverage Plan is a
"primary Coverage Plan" or "secondary Coverage Plan" when compared to another
Coverage Plan covering the person.
When this Coverage Plan is primary, its benefits are determined before those of any
other Coverage Plan and without considering any other Coverage Plan's benefits. When

45 SECTION 9 - COORDINATION OF BENEFITS