FAQ

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How soon can my coverage start?	What is the calendar year maximum?
Who is eligible for coverage?	What is the premium payment?
Who is the Insurance Company?	What is the grace period?
How are benefits covered?	What about premium changes?
What is Dental for One?	Are there any exclusions or limitations?
Who is the Association?	Definitions
What is an Indemnity plan?	General Provisions
What are my payment options?	Who is the Administrator?

How soon can my coverage start?

Coverage starts on the effective date. The effective date issued will begin on the first of the month following Meritain's receipt of the completed Enrollment form and payment of the first month of premium.

Who is eligible for coverage?

This plan is offered to individuals ages 18 and over, their spouses, and their eligible dependents.

Who is the Insurance Company?

Founded in 1911, Pan-American Life Insurance Company has a long and established history of providing its policyholders with trusted financial security.

Pan-American Life’s expertise is based on our deep knowledge and understanding of both the U.S. and Latin American markets in which we do business. As our history evolves and our experience grows stronger, our commitment remains the same: offering our policyholders stability and innovation guided by financial strength.

Pan-American Life serves and protects thousands of customers throughout the Americas. The company is currently licensed in 46 states, the District of Columbia, and Puerto Rico and has affiliates in Colombia, Guatemala and Panama, as well as branch offices in Ecuador, El Salvador and Honduras.

How are benefits covered?

Dental for One pays benefits for each covered person in the following manner:
First, Under 65 you meet the $100 Lifetime Deductible per person. Over age 65, you meet the $100 Annual Deductible per person.
Then Dental for One pays a percentage of covered expenses based on the Reasonable and Customary (R&C) fees for those Covered Expenses under the Indemnity Plan.

Benefits	Basic Plan Indemnity
Benefit Amount	$1,000 Annual Maximum
Preventive Care	100% Co-Insurance - No Waiting Period
Diagnostic Care	80% Co-Insurance - No Waiting Period
Basic Care	80% Co-Insurance - 6 Month Waiting Period
Major Care	50% Co-Insurance - 18 Month Waiting Period

Plans feature $10 office visit copays. Over age 65 feature $25 office visit copays.

Preventive: Cleanings, exams, sealants, fluoride
Diagnostic: Bitewing X-rays, full mouth X-rays
Basic: Fillings, extractions, repairs
Major: Endodontics, Periodontics, Oral Surgery, Crowns, Bridges

What is Dental for One?

Dental for One offers you access to high quality, affordable dental coverage for your entire family. Coverage is provided for preventive, diagnostic, basic and major dental services.

Exclusive Features:

$1,000 maximum per person
No waiting periods on Preventive Care
No age limits
Benefits for preventive, diagnostic, basic, and major services
Accept payment by: MasterCard, Visa, Discover or automatic monthly bank draft

Who is the Association?

Eagle Consumer Association. Through membership in ECA, you will enjoy discounts on a variety of health, travel, consumer, and business-related services.

What is an Indemnity plan?

Indemnity: This plan allows you to see any dentist you wish with no network restrictions. Reimbursement is made on a Usual, Customary and Reasonable basis.

What are my payment options?

You can pay monthly installments by auto bank withdrawal. You can pay annually or semi-annually by auto bank withdrawal or MasterCard, Visa, Discover credit cards.

What is the calendar year maximum?

The maximum amount payable for all Covered Expenses in any calendar year as shown in the Coverage Schedule. The Calendar Year Maximum will apply to each insured person.

What is the premium payment?

DUE DATE AND METHOD OF PAYMENT

Premiums are payable on a monthly basis, unless We agree to some other mode of payment. If We agree to change the method of paying premiums, any pro rata adjusted premium required will be payable.

PAYMENT OF PREMIUMS

Premiums are payable or to Meritain. The first premium for each Insured is due on his/her Insured’s Effective Date. Each monthly payment will pay for the insurance then in force under the Policy for a period of one month.

What is the Grace Period?

GRACE PERIOD

Coverage under the Policy has a 31-day Grace Period. If any premium, except the first, is not paid on or before the date it is due, it may be paid during the following 31 days. The coverage remains in force during this Grace Period. If a premium is not paid by the end of the Grace Period, Your coverage will terminate as of the last date to which premiums have been paid.

Premium Changes

We reserve the right to change premiums, on a class basis, on any premium due date by giving the Insured at least thirty-one (31) days prior written notice.

Are there any exclusions or limitations?

COVERED DENTAL EXPENSES WILL NOT INCLUDE AND NO BENEFITS WILL BE PAYABLE:
1. for charges in excess of those considered Usual, Customary and Reasonable;
2. for overdentures and associated procedures;
3. for replacement of retainers;
4. for athletic mouthguards;
5. for denture duplication;
6. for acid etch;
7. for broken appointments;
8. for prescription or take-home fluoride;
9. for diagnostic photographs;
10. for any treatment which is for cosmetic purposes, or to correct congenital malformations. Facings on crowns or pontics beyond the second bicuspid are considered cosmetic, except for medically necessary care and treatment of cleft lip and palate;
11. to replace any: prosthetic appliance; crown; inlay; or restoration; or fixed bridge that can be repaired or restored to normal function. But if a replacement is required because of an accidental bodily injury sustained while the Insured or Insured Dependent is covered under the Policy, it will be a Covered Expense;
12. for initial placement of any prosthetic appliance or fixed bridge unless such placement is needed because of the extraction of one or more natural teeth while the Insured or Insured Dependent is covered under the Policy. But the extraction of a third molar (wisdom tooth) will not qualify under the above. Any such appliance of fixed bridge must include the replacement of the extracted tooth or teeth;
13. for any procedure begun before the Insured or Insured Dependent was covered under the Policy;
14. for any procedure begun after the Insured's or Insured Dependent’s insurance under the Policy terminates, or for any prosthetic Dental appliance installed or delivered more that 90 days after the Insured's or Insured Dependent’s insurance under the Policy terminates;
15. to replace lost or stolen appliances;
16. for appliances, restorations, or procedures to:

a. alter vertical dimension;
b. restore or maintain occlusion;
c. splint or replace tooth structure lost as a result of abrasion or attrition; or
d. treat disturbances of the temporomandibular joint.

17. for any procedure which is not shown on the Schedule of Benefits;
18. for education or training in, and supplies used for: dietary or nutritional counseling; personal oral hygiene; or Dental plaque control;
19. for the completion of claim forms;
20. for any treatments or supplies for sealants and fluoride application;
21. for subgingival curettage or root planing unless the presence of periodontal disease is confirmed by both x-rays and pocket depth summaries of each tooth involved;
22. because of an injury arising out of, or in the course of, work for wage or profit.
23. to an Insured or Insured Dependent because of a sickness, injury or condition for which he or she is eligible for benefits under any Workers' Compensation act or similar laws;
24. for charges for which the Insured is not liable or which would not have been made had no insurance been in force;
25. for services which are not recommended by a dentist or which are not required for necessary care and treatment;
26. because of war or any act of war, declared or not, or condition contracted or accident occurring while on full-time active duty in the armed forces of any country or combination of countries;
27. for any services related to: equilibration; bite registration; or bite analysis;
28. for crowns for the purpose of periodontal splinting;
29. for charges for: any implants; precision or semi-precision attachments; and any endodontic treatment associated with it; other customized attachments;
30. for any Dental injury or condition that is intentionally self-inflicted;
31. for charges that are applied toward satisfaction of a Deductible, if any;
32. for charges that are generally considered by the dental profession as experimental;
33. for hospital services;
34. for orthodontia.
35. for treatment received outside the United States, its territories, or possessions.

DEFINITIONS

“ADA Code” means the American Dental Association Code assigned to a particular Dental procedure.

“Benefit” means the specific benefit for each particular Dental procedure shown in the Schedule of Benefits.

“Copayment” means the dollar amount that You are required to pay at the time dental services are provided.

“Covered Expense(s)” means an expense for Dental procedures shown in the Schedule of Benefits.

“Deductible” means an amount of Covered Expense incurred by an Insured or Insured Dependent while covered by the Policy which must be paid by an Insured before Our responsibility to pay benefits for any expenses begins. The Deductible amount is shown on the Schedule of Benefits.

“Dentist” means:

A licensed dentist who is acting within the scope of his or her license;
A licensed physician performing Dental services within the scope of his or her license; or
A licensed Dental hygienist acting under the supervision and direction of a dentist.

“Dependent”/“Insured Dependent”
Means any of the following persons, and may vary by state:

The Insured's spouse;
Each unmarried child of the Insured from birth to age 21;
Each unmarried child of the Insured who is a full-time student until age 24 provided such child is attending an accredited college, vocational or high school and enrolled in sufficient courses to maintain full-time status and is dependent on the Insured listed on the face page for their support and maintenance. We may require proof of full-time status.
Each unmarried child of the Insured at least 21 years of age;
who is incapable of self-sustaining employment by reason of mental or physical handicap;
who was so incapacitated and is an Insured Dependent under the Policy on his or her 21st birthday; and
who has been continuously so incapacitated since his or her 21st birthday.

“Geographic Area” means the first three digits of the zip code in which the service, treatment, procedure, drugs or supplies are provided, or a greater area if necessary, to obtain a representative cross-section of charges for a like treatment, service, procedure, device, drug or supply.

“Insured’s Effective Date” means the first day of the month following the Insured’s enrollment and completion of the Waiting Period shown on the Schedule of Benefits, if any.

"Insured", "You", "Your", "Yours" means the individual who has: (a) submitted an application for coverage on himself or herself, his or her Dependents, or both; (b) meets the eligibility and effective date provisions set forth in the Policy; (c) is approved for coverage by Us; and (d) for whom all applicable premiums are paid.

“Policy” means the Group Policy issued to the Policyholder.

“Policyholder” means the entity to which the Policy is issued.

“Policy Year Maximum” means the maximum amount payable by Us for all Covered Expenses in any period of 365 consecutive days. The Policy Year Maximum will apply to each Insured and Insured Dependent.

“Usual, Customary, and Reasonable” means a charge that does not exceed the general level of charges being made by other providers of Dental services in the Geographic Area where the charge is incurred. With respect to Network Dentists, this is the contracted fee schedule amount.

“Vesting Period” is a period of continuous coverage for an Insured under the Policy, starting on the most recent Insured’s Effective Date, during which expenses for certain classes of services are not covered. The lengths of all Vesting Periods, and the classes of service to which they apply, are shown on the Schedule of Benefits.

“Waiting Period” is a period of time that must pass before an Insured or Insured Dependent is eligible to be covered for benefits under the Policy. The lengths of all Waiting Periods and the classes of service to which they apply, are shown on the Schedule of Benefits.

“We”, “Our”, “Us”, “Company” means Pan-American Life Insurance Company.

GENERAL PROVISIONS

COORDINATION OF BENEFITS

If any individual covered under the Policy (referred to as "this Plan") is also covered under one or more other Plans, the benefits payable under this Plan will be coordinated with the benefits payable under all other Plans.

This coordination will apply in determining the benefits payable for any Claim Period if the sum of:

the benefits that would be payable under this Plan in the absence of coordination; and
the benefits that would be payable under all other Plans in the absence of provisions for coordination in those Plans would exceed those Covered Expenses.

Except as provided in the following paragraph, when Coordination of Benefits applies to the benefits payable to an individual for any Claim Period, the benefits that would be payable for Covered Expenses under this Plan in the absence of Coordination of Benefits will be reduced to the extent necessary so that the sum of those reduced benefits and all the benefits payable for those Covered Expenses under all other Plans will not exceed the total of those Covered Expenses. Benefits payable under all other Plans include the benefits that would have been payable had claim been properly made for them.

The rules establishing the order of benefit determination are:

the benefits of a Plan which covers the individual for whom claim is made other than as a Dependent will be determined before the benefits of a Plan which covers that individual as a Dependent.
Except as stated in paragraph 3 below, when this Plan and another Plan cover the same child as a Dependent of different persons, called "parents":
the benefits of the Plan of the parent whose birthday falls earlier in a year are determined before those of the Plan of the parent whose birthday falls later that year; but
if both parents have the same birthday, the benefits of the Plan which covered the parent longer are determined before those of the Plan which covered the other parent for a shorter period of time. However, if the other Plan does not have the rule described in (a) immediately above, but instead uses a different method, and if, as a result, the Plans do not agree on the order of benefits, the rule in the other Plan will determine the order of benefits.

If two or more Plans cover a person as a Dependent child of divorced or separated parents, benefits for the child are determined in this order:

First, the Plan of the parent with custody of the child;
Then, the Plan of the spouse of the parent with custody of the child; and
Finally, the Plan of the parent not having custody of the child. However, if the specific terms of a court decree state that one of the parents is responsible for the health care expenses of the child, and the entity obligated to pay or provide the benefits of that Plan of that parent has actual knowledge of those terms, the benefits of that Plan are determined first. This paragraph does not apply with respect to any Claim Period or Plan year during which any benefits are actually paid or provided before the entity has that actual knowledge.

The benefits of a Plan which covers a person as an employee who is neither laid-off nor retired (or as that employee's Dependent) are determined before those of a Plan which covers that person as a laid-off or retired employee (or as that employee's Dependent). If the other Plan does not have this rule, and if, as a result, the Plans do not agree on the order of benefits, this rule (4) is ignored.

If none of the above rules determines the order of benefits, the benefits of a Plan which has covered the individual for whom claim is made for the longer period of time will be determined before the benefits of a Plan which has covered the individual the shorter period of time.

If We are responsible for secondary coverage for Covered Expenses, We will not deny coverage or payment of the amount We owe as secondary payor solely on the basis of the failure of another group contract, which is responsible for primary coverage, to pay for those Covered Expenses. This will not require Us to pay the obligations of the primary payor.

For the purpose of administering the above provisions of this Plan or any similar provision of other Plans, We may, without consent or notice to any individual, release to or obtain from any other insurance company, organization or individual any information concerning any individual which We consider necessary. Any individual claiming benefits under this Plan will furnish Us with any information necessary.

Whenever payment which should have been made under this Plan in accordance with the above provisions have been made under any other Plans, We will have the right, at Our sole discretion, to pay any organizations making these payments any amount We determine to be due. Amount paid in this matter will be considered to be benefits paid under this Plan and, to the extent of these payments, We will be fully discharged from liability under this Plan.

Whenever payments have been made by Us, for Covered Expenses in a total amount in excess of the maximum amount of payment necessary to satisfy the intent of the above provisions, We will have the right to recover the excess from one or more of the following: (1) other insurance companies; (2) other organizations; (3) individuals to or from whom payments were made.

BENEFITS SUBJECT TO COORDINATION. All benefits provided under the Policy are subject to coordination.

DEFINITIONS. The following definitions apply only to this Coordination of Benefits section.

The term "Plan" means coverage providing hospital, medical or Dental benefits or services by:

group or blanket insurance coverage, except school accident coverage;
group practice or other prepayment coverage on a group basis; or
any coverage under labor-management trusteed Plan, union welfare Plan, employer organization, or employee benefit Plans.

The term "Plan" will be construed separately for a Policy, contract or other arrangement for benefits or services that reserves the right to take the benefits or services of other Plans into consideration in determining it benefits, or separately for that portion which does not reserve the right.

The term "Covered Expense" means any usual, reasonable and customary item of expense all or part of which is covered under one of the Plans.

When a Plan provides benefits in the forms of services rather than cash payments, the reasonable cash value of each service rendered will be considered to be both a Covered Expense and a benefit paid.

The term "Claim Period" means a calendar year or a portion of a calendar year for a claim on an individual covered under this Plan.

POLICY INCONTESTABLE AFTER ONE YEAR

After the Policy has been in force for one year, We do not have the right to contest its various provisions, except for fraud or nonpayment of premium. After coverage for an Insured or Insured Dependent has been in force for one year during the Insured or Insured Dependent's lifetime, We do not have the right to contest the Insured or Insured Dependent's coverage, except for fraud or nonpayment of premium.

NONPARTICIPATION

The Policy will not share in Our surplus earnings.

LEGAL ACTION

No lawsuit may be brought to recover on the Policy until 60 days after written proof of loss has been given to Us. No lawsuit may be brought more than three years (5 years in Kansas; 6 years in South Carolina; or the applicable statute of limitations in Florida) after proof is required to be filed.

ENTIRE CONTRACT

The Policy, application of the Policyholder, the Insured’s enrollment application, and any amendments and endorsements thereto constitute the entire contract. A copy of the application is attached to Your Certificate. All statements made by an Insured will, in the absence of fraud, be deemed representations and not warranties. No such statement will be used in defense of any claim under the Policy, unless it is contained in writing and a copy has been given to the Insured.

MODIFICATION CAN BE MADE ONLY BY AN OFFICIAL

Only Our President, Vice-President, the Secretary or an Assistant Secretary can change or waive any provision of the Policy. Any changes must be made in writing. We will not be bound by any promises or representations made by an agent or anyone other than the above.

CONFORMITY WITH STATE STATUTES

Any provision of the Policy which, on its Effective Date, is in conflict with the statutes of the state in which the Policy was issued is hereby amended to conform to the minimum requirements of such statutes, unless otherwise forbidden by the laws of the state where the Insured lives.

Who is the Administrator?

Meritain, Inc. specializes in providing dental plan services for the group and individual dental market nationwide. Our Focus is dental administrative services for both fully insured and self funded dental plans for groups of 2 or more as well as individuals. Our expertise is in providing customized plans that meet employers needs while exceeding expectations in customer service.
This site provides a brief description of the benefits, exclusions and other provisions of the policy or certificate Form Master Policy DEN-07-P For a complete listing, see the policy or certificate. Benefits may vary in different states. This dental insurance plan may not be available in all states.

One Life Dental

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