Renaissance Max Choice
- Find a provider
- Generous annual maximum of $1,200
- This is a Maximum Allowable Charge (MAC) Plan – Benefit payments are calculated on the Renaissance PPO fees. If the dentist is not a participating PPO dentist, the patient is responsible for the difference between the PPO fee and the providers submitted charge.
- Underwritten by Renaissance Life & Health Insurance Company of America, Indianapolis, IN and in New York by Renaissance Health Insurance Company of New York, Binghamton, NY. Each company has sole financial responsibility for its own products.
- No waiting periods
- Benefits that increase over three years
- Includes coverage for orthodontics (up to age 19)
Benefit Association Disclaimer
One time Non Refundable Processing fee: $35.00
The stated rates above include $1.00 per month for membership in the World Travelers of America, Inc. (WTA), and a $4.00 monthly billing fee. Membership in World Travelers of America, Inc. is required to enroll in this plan. Should you decide to enroll in this dental plan, you will be prompted during the enrollment process to confirm your acceptance of membership in WTA.
|Description||Plan Pays Year 1||Plan Pays Year 2||Plan Pays Year 3|
|Diagnostic and Preventive||Includes exams, cleanings and brush biopsy to detect oral cancer.||100%||100%||100%|
|Basic||Includes topical application of fluoride, radiographs (bitewing x-rays), sealants to prevent decay of permanent molars, emergency palliative treatment to temporarily relieve pain and space maintainers.||40%||60%||80%|
|Major||Includes simple extractions, minor restorative services such as fillings, radiographs/diagnostic imaging/diagnostic casts (x-rays), periodontic services to treat gum disease, after-hours services, endodontic services (root canals), all oral surgery services (extractions and/or dental surgery), periodontal maintenance, major restorative service such as crowns, bridges (including relines/repairs), implants and dentures.||20%||40%||50%|
|Orthodontics||Braces for eligible dependent children to age 19. A separate lifetime maximum of $1,200 per eligible dependent applies to orthodontic benefits.||10%||25%||50%|
- $50 per person per policy year, $150 maximum per family. Applies to all services except in-network diagnostic and preventive services and orthodontics
- Office Co-Pay
Methods of Payment
- American Express
In addition to the exclusions listed in the Benefits Section, RLHICA will not make payment for the following services, items or supplies and all charges for the same will be the responsibility of the Certificate Holder, unless otherwise specified in the Declarations Section:
1. Services for injuries or conditions paid pursuant to Workers’ Compensation or Employer’s Liability laws. Services that are received from any government agency, political subdivision, community agency,
foundation, or similar entity. NOTE: This provision does not apply to any programs provided under Title XIX of the Social Security Act, that is, Medicaid;
2. Services or appliances started prior to the date the person became eligible under this Policy, excluding orthodontic treatment in progress (if a Covered Service);
3. Charges for failure to keep a scheduled visit with the Dentist;
4. Charges for completion of forms or submission of claims;
5. Services, items or supplies for which no valid dental need can be demonstrated, as determined by RLHICA;
6. Services, items or supplies that are specialized techniques, as determined by RLHICA;
7. Services, items or supplies that are investigational in nature, including services, items or supplies required to treat complications from investigational procedures, as determined by RLHICA;
8. Treatment by other than a Dentist, except for services performed by a licensed dental hygienist or other licensed provider under the scope of his or her license as permitted by applicable state law;
9. Services, items or supplies excluded by the policies and procedures of RLHICA;
10. Services, items or supplies which are not rendered in accordance with accepted standards of dental practice, as determined by RLHICA;
11. Services, items or supplies for which no charge is made, for which the patient is not legally obligated to pay or for which no charge would be made in the absence of RLHICA coverage;
12. Services, items or supplies received as a result of dental disease, defect or injury due to an act of war, declared or undeclared;
13. Services, items or supplies that are generally covered under a hospital, surgical/medical or prescription drug program;
14. Services, items or supplies that are not within the categories of Benefits that have been selected by the Policyholder and are not covered in this Policy;
15. Prescription drugs, non-prescription drugs, premedications, localized delivery of chemotherapeutic agents, relative analgesia, non-intravenous conscious sedation, therapeutic drug injections, hospital visits, desensitizing medicaments and techniques, behavior management, athletic mouthguards, house/extended care facility visits, mounted occlusal analysis, complete occlusal adjustments, enamel microabrasions, odontoplasty or bleaching;
16. Correction of congenital or developmental malformations, cosmetic surgery or dentistry for aesthetic reasons as determined by RLHICA;
17. Any appliance, restoration or surgical procedure used to (a) change vertical dimension; (b) restore or maintain occlusion; (c) replace tooth structure lost as a result of abrasion, attrition, abfraction or erosion; or (d) splint or stabilize teeth for periodontal reasons.
In addition to the limitations listed in the Benefits Section, the following limitations apply under this Policy, unless otherwise specified in the Declarations Section:
1. RLHICA’s obligation for payment of Benefits ends on the last day of the month in which coverage is terminated under this Policy;
2. When services in progress are interrupted and completed later by another Dentist, RLHICA will review the claim to determine the amount of payment, if any, to each Dentist;
3. Care terminated due to the death of a Certificate Holder or Eligible Dependent will be paid to the limit of RLHICA’s liability for the services completed or in progress;
4. The Maximum Payment will be limited to the amount specified in the Declarations Section of this Policy;
5. If a Deductible amount is specified in the Declarations Section, RLHICA will not be obligated to pay, in whole or in part, for any services, items or supplies to which the Deductible applies until the Deductible amount is met.
Notice: This website provides a very brief description of some important features of the coverage. It is not the Insurance Group Policy or Certificate. A full explanation of benefits, exclusions and limitations are contained in the Certificate of Insurance under group policy form D-100A-OH V4.