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Guardian Dental Select Gold

Coverage Summary
(see your policy for further details)
Choose any Dentist
In-Network Dentist

Guardian’s negotiated rates save you up to 35% at In-Network Dentists

Out-of-Network Dentist

Charges for services provided by participating dentists are based on negotiated, discounted fee schedules, and are reimbursed directly from Guardian. If you choose to see a dentist outside of the Network, you'll be reimbursed based on Usual and Customary (UCR) charges. You would be responsible for the deductible and any amounts over the UCR as well as any co-insurance

Your Plan Benefits
Guardian Pays
Waiting period is the time period following the coverage start date during which no benefits are paid
Preventive Services

Most routine dental services, including oral exams, cleanings, x-rays

100%
No waiting period
Basic Services

Moderately complex dental services, including fillings and simple extractions

70%
No waiting period
Major Services

More complex dental services including crowns, complex extractions, oral surgery, periodontal, and endodontic services

50%
No waiting period
Implants
50%
No waiting period
Orthodontia
 
Not covered
Deductibles
What you pay out-of-pocket before your plan pays benefits
You Pay
Preventive Services
$0 In-Network
$50 Out-of-Network
All Other Dental Services
$50
Maximum Payouts
The maximum amount Guardian will reimburse you for dental services received
Maximum Guardian Pays
Total Benefit Maximum

Maximum payout each benefit year

Benefit Year Max $1,750
Implant Maximum

See limitations & exclusions below

Lifetime Max $1,250
Orthodontia Maximum
Not covered
Limitations and Exclusions
(see your policy for further details)

We will not pay for:

 

  • Treatment for which no charge is made. This usually means treatment furnished by: (1) the covered person’s employer, labor union or similar group, in its dental or medical department or clinic; (2) a facility owned or run by any governmental body; and (3) any public program, except Medicaid, paid for or sponsored by any governmental body.
  • Treatment needed due to: (1) an on-the-job or job-related injury; or (2) a condition for which benefits are payable by Worker’s Compensation or similar laws, only to the extent such benefits are the liability of the employee, 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.
  • Any service or treatment method which does not meet professionally recognized standards of dental practice or which is considered to be experimental in nature.
  • Educational services, including, but not limited to: (1) oral hygiene instruction; (2) tobacco counseling; or (3) nutritional counseling.
  • Duplication of radiograph images, the completion of claim forms, OSHA or other infection control charges.
  • Any service performed in conjunction with, as part of, or related to a service which is not covered by this Policy.
  • Any service furnished solely for cosmetic reasons. This includes, but is not limited to: (1) characterization and personalization of a Dental Prosthesis; (2) bleaching of discolored teeth; and (3) odontoplasty. But, We will cover cosmetic services needed to treat medically diagnosed congenital defects and birth abnormalities for a dependent child.
  • The replacement of extracted or missing third molars (wisdom teeth).
  • Detailed and extensive oral evaluations.
  • Cephalometric radiographic images.
  • Oral /facial photographic images.
  • Pulp vitality tests or caries susceptibility tests.
  • The localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue.
  • Maxillofacial prosthetics that repair or replace facial and skeletal anomalies, maxillofacial surgery, orthognathic surgery or any oral surgery requiring the setting of a fracture or dislocation that is incidental to or results from a medical condition.
  • Overdentures and related services including root canal therapy on teeth supporting an overdenture.
  • Precision attachments.
  • Temporary or provisional Dental Prosthesis or Appliances except interim partial dentures (stayplates) to replace Anterior Teeth extracted while covered under this Policy.
  • A fixed bridge replacing the extracted portion of a hemisected tooth or the placement of more than one unit of a crown and/or bridge, per tooth.
  • Any service performed on a tooth or teeth with a guarded, questionable or poor prognosis.
  • Any restoration, service, Appliance or Dental Prosthesis used solely to: (1) alter vertical dimension; (2) restore or maintain occlusion; (3) treat a condition necessitated by attrition or abrasion; or (4) splint or stabilize teeth for periodontal reasons.
  • Replacement of a lost, missing or stolen Appliance or Dental Prosthesis or the fabrication of a spare Appliance or Dental Prosthesis.
  • Tooth re-implantation or tooth transplantation.
  • Any service, Appliance, Dental Prosthesis, modality or surgical service intended to treat or diagnose disturbances of the temporomandibular joint (TMJ) that are incidental to, or result from, a medical condition unless required due to state law.
  • Orthodontic treatment, unless the Policy provides specific benefits for orthodontic treatment.
  • Separate charges for local anesthetic.
  • Application of desensitizing medicaments and desensitizing resins for cervical and/or root surface.
  • Bite registration, bite analysis or occlusion analysis – mounted case.
  • Prescription medication.

Renewability

This Policy is issued for a term of one year from the Policy Effective Date. All Policy years and Policy months will be calculated from the Policy Effective Date. All periods of insurance will begin and end at 12:01 AM Standard Time at Your place of residence, subject to the Grace in Payment of Premiums.

You may renew this Policy for a further term by timely payment of renewal, unless We send You sufficient notice in writing to Your last known address shown on record of Our intention not to renew.kn Sufficient notice shall be, during the first year of any Policy, or during the first year following any lapse and reinstatement, a period of 30 days before the premium due date. After one continuous year of coverage and acceptance of premium for any portion of the second or subsequent year sufficient notice shall be a number of full months most nearly equivalent to one fourth the number of months of continuous coverage from the inception date of the Policy, to the date of mailing of the notice. However, no period of required notice shall exceed two years. If We do refuse, We must do so for a reason other than the deterioration of Your health on all Policies of this form issued under the same class in Your state. Non-renewal will not affect any otherwise valid claim that starts while this Policy is in force.

We reserve the right to change rates on this Policy issued to persons of the same class in Your state following the initial twelve month period. If We do raise Your premium due to a change in rates, then at least 60 days prior to Your renewal date, We will send written notice to You at Your last known address shown on record.

 

For North Carolina residence, any reference on this site to "child" includes "foster child." 

 

THIS POLICY IS NOT A MEDICARE SUPPLEMENT POLICY. If You are eligible for Medicare, review the Guide to Health Insurance for People with Medicare, which is available from the Company.

 

Dental Insurance is underwritten by The Guardian Life Insurance Company of America, New York, NY. Products are not available in all states. Policy limitations and exclusions apply. Those shown above are illustrative only. The actual limitations and exclusions that apply to your Dental Plan are governed by the policy forms approved for use in your state. Please refer to your plan documents for a complete list of limitations and exclusions. Plan documents are the final arbiter of coverage. This policy provides DENTAL insurance only.

IP-DEN-16-NC