Page 63 - Dental Benefit Plan Summary

TEXAS MUTUAL INSURANCE COMPANY DENTAL PPO PLAN

The fact that a Dentist has performed or prescribed a procedure or treatment or the fact that
it may be the only treatment for a particular dental disease does not mean that it is a
Necessary Covered Dental Service as defined in this SPD. The definition of Necessary used
in this SPD relates only to Coverage and differs from the way in which a Dentist engaged in
the practice of dentistry may define necessary.

Network – a group of Dentists who are subject to a participation agreement to provide
Dental Services to Covered Persons. The participation status of Dentists will change from
time to time.

Network Benefits – benefits available for Covered Dental Services when provided by a
Dentist who is a Network Dentist.

Non-Network Benefits – coverage available for Dental Services obtained from Non-
Network Dentists.

Open Enrollment – the period of time, determined by Texas Mutual Insurance Company,
during which eligible Participants may enroll themselves and their Dependents under the
Plan. Texas Mutual Insurance Company determines the period of time that is the Open
Enrollment period.

Participant – an eligible person who is properly enrolled for Coverage under the Plan, as
described under Eligibility in Section 2, Introduction. The Participant is the person (who is not
a Dependent) on whose behalf coverage under the Plan is provided.

Plan – Texas Mutual Insurance Company Employee Benefit Plan.

Plan Administrator – Texas Mutual Insurance Company or its designee.

Plan Sponsor – Texas Mutual Insurance Company.

Procedure in Progress – all treatment for Covered Services that results from a
recommendation and an exam by a Dentist. A treatment procedure will be considered to
start on the date it is initiated and will end when the treatment is completed.

Retired Employee – an Employee who retires while covered under the Plan.

Spouse – as interpreted by the Internal Revenue Service, an individual to whom you are
legally married.

Usual and Customary – Usual and Customary fees are calculated based on available data
resources of competitive fees in that geographic area.

Usual and Customary fees 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 Usual and
Customary.

58 SECTION 11 - GLOSSARY