Page 57 - Dental Benefit Plan Summary

TEXAS MUTUAL INSURANCE COMPANY DENTAL PPO PLAN

Your Relationship with Dentists
The relationship between you and any Dentist is that of Dentist and patient. Your Dentist is
solely responsible for the quality of the services provided to you. You:

■ are responsible for choosing your own Dentist;

■ are responsible for paying, directly to your Dentist, any amount identified as a member
responsibility, including Coinsurance, any Annual Deductible and any amount that
exceeds Eligible Expenses;

■ are responsible for paying, directly to your Dentist, the cost of any non-Covered Dental
Service;

■ must decide if any Dentist treating you is right for you (this includes Network Dentists
you choose and Dentists to whom you have been referred); and
■ must decide with your Dentist what care you should receive.

Interpretation of Benefits

Texas Mutual Insurance Company and UnitedHealthcare Dental have the sole and exclusive
discretion to:

■ interpret Benefits under the Plan;
■ interpret the other terms, conditions, limitations and exclusions of the Plan, including
this SPD and any riders and/or Amendments; and

■ make factual determinations related to the Plan and its Benefits.

Texas Mutual Insurance Company and UnitedHealthcare Dental may delegate this
discretionary authority to other persons or entities that provide services in regard to the
administration of the Plan.

In certain circumstances, for purposes of overall cost savings or efficiency, Texas Mutual
Insurance Company may, in its discretion, offer Benefits for services that would otherwise
not be Covered Dental Services. The fact that Texas Mutual Insurance Company does so in
any particular case shall not in any way be deemed to require Texas Mutual Insurance
Company to do so in other similar cases.

Information and Records

Texas Mutual Insurance Company and UnitedHealthcare Dental may use your individually
identifiable health information to administer the Plan and pay claims, to identify procedures,
products, or services that you may find valuable, and as otherwise permitted or required by
law. Texas Mutual Insurance Company and UnitedHealthcare Dental may request additional
information from you to decide your claim for Benefits. Texas Mutual Insurance Company
and UnitedHealthcare Dental will keep this information confidential. Texas Mutual
Insurance Company and UnitedHealthcare Dental may also use your de-identified data for
commercial purposes, including research, as permitted by law.

52 SECTION 10 - OTHER IMPORTANT INFORMATION