Metlife Exclusions and DIsclaimers

Like most group benefit programs, benefit programs offered by MetLife and its affiliates contain certain exclusions, exceptions, reductions, limitations, waiting periods and terms for keeping them in force. Please contact MetLife or your plan administrator for costs and complete details. Dental insurance and Vision insurance are underwritten by Metropolitan Life Insurance Company, New York, NY. Certain claims and network administration services for vision benefits are provided through Superior Vision Services, Inc. (“Superior Vision”), a Delaware corporation. Superior Vision is part of the MetLife family of companies.

Group dental insurance policies featuring the Preferred Dentist Program are underwritten by Metropolitan Life Insurance Company, New York, NY 10166.

Dental PDP Plan Exclusions

  • Services which are not dentally necessary, those which do not meet generally accepted standards of care for treating the particular dental condition, or which we deem experimental in nature
  • Services for which a covered person would not be required to pay in the absence of dental insurance
  • Services or supplies received by a covered person before the insurance starts for that person.
  • Services which are neither performed nor prescribed by a dentist except for those services of a licensed dental hygienist which are supervised and billed by a dentist and which are for scaling or polishing of teeth or fluoride treatment
  • Services which are primarily cosmetic. (For residents of Texas: Services which are primarily cosmetic unless required for the treatment or correction of a congenital defect of a newborn child).
  • Services or appliances which restore or alter occlusion or vertical dimension.
  • Restoration of tooth structure damaged by attrition, abrasion or erosion unless caused by disease.
  • Restorations or appliances used for the purpose of periodontal splinting.
  • Counseling or instruction about oral hygiene, plaque control, nutrition and tobacco;
  • Personal supplies or devices including, but not limited to: water piks, toothbrushes, or dental floss
  • Initial installation of a Denture to replace one or more teeth which were missing before such person was insured for Dental Insurance, except for congenitally missing natural teeth.
  • Decoration or inscription of any tooth, device, appliance, crown or other dental work.
  • Missed appointments
  • Services covered under any workers’ compensation or occupational disease
  • For residents of North Carolina for the treatment of an Occupational Injury or Sickness which are paid under the North Carolina Workers’ Compensation Act only to the extent such services are the liability of the Member, employer or workers’ compensation insurance carrier according to a final adjudication under the North Carolina Workers’ Compensation Act or an order of the North Carolina Industrial Commission approving a settlement agreement under the North Carolina Workers’ compensation Act.
  • Services paid or payable under any employer liability law.
  • Services for which the employer of the person receiving such services is not required to pay.
  • Services received at a facility maintained by the Policyholder, labor union, mutual benefit association, or VA hospital.
  • Services covered under other coverage provided by the Policyholder.
  • Temporary or provisional restorations.
  • Temporary or provisional appliances.
  • Prescription drugs
  • Services for which the submitted documentation indicates a poor prognosis.
  • Services, to the extent such services, or benefits for such services, are available under a government plan. This exclusion will apply whether or not the person receiving the services is enrolled for the government plan. We will not exclude payment of benefits for such services if the government plan requires that Dental Insurance under the group policy be paid first.
  • The following when charged by the dentist on a separate basis – Claim form completion; infection control such as gloves, masks, and sterilization of supplies; or local anesthesia, non-intravenous conscious sedation or analgesia such as nitrous oxide.
  • Dental services arising out of accidental injury to the teeth and supporting structures, except for injuries to the teeth due to chewing and biting of food.
  • Caries susceptibility tests.
  • Precision attachments associated with fixed and removable prostheses.
  • Adjustment of a denture made within 6 months after installation by the same dentist who installed it.
  • Duplicate prosthetic devices or appliances.
  • Replacement of a lost or stolen appliance, cast restoration or denture.
  • Intra and extraoral photographic images.
  • Fixed and removable appliances for correction of harmful habits.
  • Appliances or treatment for bruxism (grinding teeth), including but not limited to occlusal guards and night guards.