Page 61 - Dental Benefit Plan Summary

TEXAS MUTUAL INSURANCE COMPANY DENTAL PPO PLAN

Dental Service or Dental Procedures – dental care or treatment provided by a Dentist to a
Covered Person while the Plan is in effect, provided such care or treatment is recognized by
the Plan Administrator as a generally accepted form of care or treatment according to
prevailing standards of dental practice.

Dentist – any dental practitioner who is duly licensed and qualified under the law of
jurisdiction in which treatment is received to render dental services, perform dental surgery
or administer anesthetics for dental surgery.

Dependent – an individual who meets the eligibility requirements specified in the Plan, as
described under Eligibility in Section 2, Introduction. A Dependent does not include anyone
who is also enrolled as a Participant. No one can be a Dependent of more than one
Participant.

Eligible Expenses – Eligible Expenses for Covered Dental Services, incurred while the
Plan is in effect, are determined as stated below:

■ For Network Benefits, when Covered Dental Services are received from Network
Dentists, Eligible Expenses are UnitedHealthcare Dental's contracted fee(s) for the
Dental Service with that Dentist.

■ For Non-Network Benefits, when Covered Dental Services are received from Non-
Network Dentists, Eligible Expenses are the Usual and Customary fees as defined
below.

Eligible Expenses must not exceed the fees that the Dentist would charge any similarly
situated payor for the same services. In the event that a Dentist routinely waives
Coinsurance and/or the Annual Deductible for Benefits, Dental Services for which the
Coinsurance and/or the Annual Deductible are waived are not considered to be Eligible
Expenses.

Emergency – a dental condition or symptom resulting from dental disease which arises
suddenly and, in the judgment of a reasonable person, requires immediate care and
treatment, and such treatment is sought or received within 24 hours of onset.

Enrolled Dependent – a Dependent who is properly enrolled for Coverage under the Plan.

Experimental, Investigational or Unproven Services – medical, dental, surgical,
diagnostic, or other health care services, technologies, supplies, treatments, procedures, drug
therapies or devices that, at the time UnitedHealthcare Dental makes a determination
regarding coverage in a particular case, are determined to be:

■ not approved by the U.S. Food and Drug Administration ("FDA") to be lawfully
marketed for the proposed use and not identified in the American Hospital Formulary
Service or United States Pharmacopoeia Dispensing Information as appropriate for the
proposed use; or

■ subject to review and approval by any institutional review board for the proposed use; or

56 SECTION 11 - GLOSSARY