What the Plan covers
What does the Plan cover?
What is the maximum reimbursement?
What is the dental fee guide?
What does the Plan cover if more than one type of treatment exists for a dental condition?
What is a treatment plan?
What does the Plan NOT cover?
How can I verify if an expense is covered or not?

 


What does the Plan cover ?

QPAT's Dental Plan covers the eligible expenses listed below.

Some special notes:

• The expenses must be incurred while the insured person is covered under the Plan.
• The expenses are reimbursed according to the Dental Surgeons Association's dental fee guide for general practitioners in effect two years before the current year.
• If the total cost of a treatment is expected to exceed $600, a treatment plan should be submitted to Industrial Alliance before the treatment begins.
• Whenever laboratory fees are incurred for a major treatment procedure, they will be limited to 60% of the fee established for the procedure.
• Expenses incurred for treatment by a denturist are limited to the normal suggested fee for denturists of the province where treatment is provided.


Eligible
expenses
Type of treatment
 Reimbursement by Plan

Anesthesia
(in relation to surgery)

 Basic 80%
Caries control Basic 80%
Dentures Basic or major 80% or 50%
Endodontics
(such as root canal)		 Basic 80%
Examinations and diagnoses Preventive 80%
Finishing restorations Basic 80%
Interproximal discing of teeth Basic 80%
Oral hygiene instruction (initial instruction only) Preventive 80%
Oral surgery Basic 80%
Periodontics Basic 80%
Pit and fissure sealants Basic 80%
Polishing of coronal portion of teeth (prophylaxis), twice every 12 months Preventive 80%
Prophylactic odontotomy Basic 80%
Restorative care (including crowns) Basic or major 80% or 50%
Space maintainers Preventive 80% or 50%
Tests and laboratory examinations Preventive 80%
Topical application of fluoride Preventive 80%
X-rays Preventive 80%

Covered dental codes

Dentures
 

Eligible
expenses
Type of treatment
 Reimbursement by Plan

Removable dentures

   
• Adjustments
   
• Repairs
   
• Rebasing and
relining
   
• Prophylaxis and
polishing
   
• Complete dentures
   
• Partial dentures
 
   
   
Basic
   
   
Basic
   
   
   
Basic
   
   
   
   
Basic
 
   
Major
   
   
Major
 
   
   
80%
   
   
80%
   
   
   
80%
   
   
   
   
80%
 
   
50%
   
   
50%

Fixed dentures

   
• Crown
   
• Cast post
   
• Pontic
   
• Butterfly bridge
   
• Abutments

Initial fixed or removable dentures are covered in the case of teeth extracted while the person is insured under a similar benefit.

Replacement of fixed or removable dentures is covered if it is necessary for one of the following reasons:

   
• extraction of natural teeth, while the person is insured under a similar benefit;
   
• the dentures are at least 5 years old and can no longer be used;
   
• replacement of temporary dentures fitted less than 12 months before.

However, in no event will the insurance cover lost or stolen dentures.

Major



50%

Covered dental codes for removable dentures
Covered dental codes for fixed dentures

Endodontics

Eligible
expenses
Type of treatment
 Reimbursement by Plan

Pulp capping
Basic
80%
Pulpectomy (excluding final restoration)
Emergency pulpectomy
Endodontic trauma
Root canal therapy
Endodontic surgery
Apexification
Preparation of tooth for treatment
Bleaching (first visit)
Hemisection
Covered dental codes for endodontics


Examinations and diagnoses

Eligible
expenses
Type of treatment
 Reimbursement by Plan

Oral examination, once every 3 years
Preventive
80%
Oral check-up, once every 6 months
Emergency oral examination
Specific oral examination
Covered dental codes for examinations and diagnoses

Oral surgery

Eligible
expenses
Type of treatment
 Reimbursement by Plan

Removal of erupted tooth (uncomplicated)

Basic
80%
Surgical removals (complicated)
Removal of tumours or cysts
Alveoloplasty
Osteoplasty
Tuberoplasty
Removal of hyperplastic tissue
Removal of excess mucosa
Surgical incision and drainage
Simple fracture of the mandibule (reduction)
Simple fracture of maxilla (reduction)
Alveolar fracture
Repair of soft tissue laceration
Repair through and through laceration
Frenectomy
Dislocation of mandibale
Treatment of salivary gland
Antrum lavage
Closure of oro-antral fistula
Hemorrhage control
Post-surgical treatment
Covered dental codes for oral surgery

Periodontics

Eligible
expenses
Type of treatment
 Reimbursement by Plan

Periodontal services, surgical
Basic
80%
Provisional splinting
Periodontal appliance (to control bruxism)
Adjunctive periodontal procedures
Root planing and curettage are covered up to 3 sextants or 2 quadrants or up to 14 teeth per calendar year. These procedures are limited to dentists exclusively and are only covered if testing of periodontal pockets indicates 4 millimeters or more. In all cases, appropriate X-rays and a periodontal chart must be submitted.
Covered dental codes for periodontics


Restorative care

Eligible
expenses
Type of treatment
 Reimbursement by Plan

Amalgam restorations

 Basic 80%
Composite restorations Basic 80%
Retentive pins Basic 80%
Preformed stainless steel crowns Basic 80%
Preformed plastic crowns Basic 80%
Gold foil restorations
(if other substances are inappropriate)		 Major 50%
Metal inlay and onlay restorations Major 50%
Porcelain inlay and onlay restorations
(if other substances are inappropriate)		 Major 50%
Prefabricated post
(pivot)		 Major 50%
Recementing of inlay and onlay or crown Major 50%
Removal of inlay and onlay or crown Major 50%

Space maintainers

Eligible
expenses
Type of treatment
 Reimbursement by Plan

For persons under age 16

 Preventive 80%
Stainless steel crown types (for loss of primary teeth) Major 50%

Tests and laboratory examinations

Eligible
expenses
Type of treatment
 Reimbursement by Plan

Microbiologic culture
Preventive
80%
Biopsy of soft oral tissue
Biopsy of hard oral tissue
Cytologic smear
Pulp vitality tests
Caries susceptibility tests
Unmounted diagnostic cast
Consultation

X-rays

Eligible
expenses
Type of treatment
 Reimbursement by Plan

Intra-oral—periapical: one complete series every 3 years
Preventive
80%
Intra-oral—occlusal
Intra-oral— interproximal
Extra-oral
Sialography
Panoramic: once every 3 years
Radiopaque dyes
Cephalometrics

What is the maximum reimbursement?

Type of expense
Maximum reimbursement
per person per calendar year

Preventive and basic treatments combined
$2,000
Major treatments
$2,000

Note: If you—or one of your dependents—enroll more than 31 days following the eligibility date, reimbursement for dental expenses during the first year of coverage may not exceed $200 per person.

What is the dental fee guide?

The Dental Surgeons Association's dental fee guide is published annually. It describes various treatments and suggests a price for each treatment.

The guide is designed to assist dental practitioners in determining fees that are fair to both the practitioner and the patient. Your dentist may charge any amount he or she wishes, but your reimbursement will be based on the lesser of the amount charged and the suggested fee in the dental fee guide in effect two years before the year in which the expenses are incurred.

If the eligible
expense
is incurred …
The Plan will
reimburse it based
on the fee guide of …

In Canada

 The province where the treatment is given
Outside Canada The insured person's province of residence

Your dentist has a copy of the fee guide if you wish to consult it.

What does the Plan cover if more than one type of treatment exists for a dental condition?

The Plan will reimburse the lesser fee, provided the treatment given is normal and appropriate.

What is a treatment plan?

Description

A written description of:

   
• the proposed treatment required according to your dentist
   
• the cost of this treatment
When it is required Must be submitted to Industrial Alliance before treatment begins if the total cost of the treatment is expected to exceed $600
How to prepare one

Ask your dentist to:

   
• complete a claim form indicating the services that will be performed
   
• provide appropriate
X-rays
   
• specify the probable date and cost of treatment
Who covers the cost, if any, to prepare a treatment plan The insured person
What happens after you submit the treatment plan

Before treatment begins, Industrial Alliance determines how much the Plan will cover.

The insurer may also, if necessary, require laboratory or hospital reports, X-rays, casts, molds, or models used for examination purposes, or any other similar evidence.

What does the Plan NOT cover?

The QPAT Dental Plan does not cover the following expenses:

   
• Care or services necessary due to an attempted suicide or voluntary self-inflicted injury, while sane or insane.
   
• Care or services related to implants.
   
• Care or services rendered free of charge or that would be free of charge were it not for insurance coverage or that are not chargeable to the insured person.
   
• Care or services resulting from civil unrest, insurrection or war, whether war be declared or not, or participation in a riot.
   
• Dental services covered under the health insurance benefit, if such benefit is part of this plan, or under any other group insurance plan.
   
• Expenses that are payable or reimbursable under a worker's compensation act, or would normally have been if a claim had been submitted.
   
• Services and supplies relating to any appliance worn in the practice of a sport.
   
• Services rendered by a dental hygienist and not administered under the supervision of a dentist.
   
• Services that are not medically required, that are given for cosmetic purposes or that exceed ordinary services given in accordance with current therapeutic practice.
   
• Treatment or appliance related directly or indirectly to full mouth reconstruction, to correct vertical dimension or any temporo-mandibular joint (TMJ) dysfunction.

Note: The Dental Plan will reduce all amounts payable by any benefit that:

   
• is payable or reimbursable under a government plan, a group plan, or an individual plan; or
   
• would have been payable had the person submitted a claim.

How can I verify if an expense is covered or not?

Before you incur an expense, verify:

   
• what the Plan covers and to what extent; and
   
• the list of exclusions.

If you are still unsure, call Industrial Alliance to find out if the expense is covered. You can reach a representative at (514) 499-3800 or 1 800 363-3540.

Industrial Alliance, not QPAT, is responsible for applying the terms of the insurance policy.