Prudent Buyer Dental Plan
BC Life & Health Insurance Company
 
UCLA MEDICAL CENTER HOUSE STAFF
January 1, 2008

 
 
 
 
 
 
 
 
 
 
 
CERTIFICATE OF INSURANCE
 
BC Life & Health Insurance Company
21555 Oxnard Street
Woodland Hills, California 91367
 
This Certificate of Insurance, including any amendments and endorsements to it, is a summary of the important terms of your dental plan. It replaces any older certificates issued to you for the coverages described in the Summary of Benefits. The Group Policy, of which this certificate is a part, must be consulted to determine the exact terms and conditions of coverage. Your employer will provide you with a copy of the Group Policy upon request.
 
Your dental care coverage is insured by BC Life & Health Insurance Company (BC Life). The following pages describe your health care benefits and includes the limitations and all other policy provisions which apply to you. The insured person is referred to as "you" or "your," and BC Life as "we," "us" or "our." All italicized words have specific policy definitions. These definitions can be found in the definitions section of this certificate.
 
 
 
 
 
 
 
TYPES OF PROVIDERS
PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW FROM WHOM OR WHAT GROUP OF PROVIDERS DENTAL CARE MAY BE OBTAINED.
 
Participating Dentists. BC Life has established a network of various types of "Participating Dentists". These dentists are called "participating" because they have agreed to participate in our preferred dentist organization program (PPO), which we call the Prudent Buyer Plan. They have agreed to provide insured persons with dental care at a negotiated fee. The amount of benefits payable under this plan will be different for non-participating dentists than for participating dentists.
 
We publish a directory of Participating Dentists. You can get a directory from your plan administrator (usually your employer).
 
Non-Participating Dentists. Non-participating dentists are dentists which have not agreed to participate in our Prudent Buyer Plan network. They have not agreed to the dental negotiated rates and other provisions of a Prudent Buyer Plan contract.
 
 
 
 
 
 
 
SUMMARY OF BENEFITS
THE BENEFITS OF THIS CERTIFICATE ARE PROVIDED ONLY FOR THOSE SERVICES THAT WE DETERMINE TO BE "ACCEPTABLE SERVICES". THE FACT THAT YOUR DENTIST PRESCRIBES OR ORDERS A SERVICE DOES NOT, IN ITSELF, MEAN THAT THE SERVICE IS AN ACCEPTABLE SERVICE OR THAT THE SERVICE IS A COVERED DENTAL EXPENSE.
 
This summary provides a brief outline of your benefits. You need to refer to the entire certificate for complete information about the benefits, conditions, limitations and exclusions of your plan.
 
Second Opinions. If you have a question about your dental condition or about a plan of treatment which your dentist has recommended, you may receive a second dental opinion from another dentist. This second opinion visit will be provided according to the benefits, limitations, and exclusions of this plan. If you wish to receive a second dental opinion, remember that greater benefits are provided when you choose a participating dentist. You may also ask your dentist to refer you to a participating dentist to receive a second opinion.
 
All benefits are subject to coordination with benefits under certain other plans.
 
The benefits of this plan may be subject to the REIMBURSEMENT FOR ACTS OF THIRD PARTIES section.
 
DENTAL BENEFITS
 
DENTAL DEDUCTIBLES (per plan year)
· Insured Person Deductible $50
· Family Deductible $150
Exception: The Dental Deductible does not apply to Diagnostic and Preventive Services provided by a participating dentist.
 
 
PAYMENT RATES
 
After the Dental Deductible has been satisfied, we will pay the percentage of covered dental expense shown below, for the type of services received, up to the Dental Benefit Maximum:
 
Participating Dentists
     
  · Diagnostic & Preventive Services 100%
 
  · Restorative Services 80%
 
  · Prosthodontic Services (Fixed & Removable) 50%
 
  · Endodontic Services 80%
 
  · Periodontic Services 80%
 
  · Oral Surgery 80%
 
  · Orthodontic Services 50%
 
Non-Participating Dentists
   
  · Diagnostic & Preventive Services 85%
 
  · Restorative Services 65%
 
  · Prosthodontic Services (Fixed & Removable) 50%
 
  · Endodontic Services 65%
 
  · Periodontic Services 65%
 
  · Oral Surgery 65%
 
  · Orthodontic Services 50%
 
DENTAL BENEFIT MAXIMUMS
· Plan Year Maximum $1,500
· Orthodontic Lifetime Maximum $1,500
     
     
   
YOUR DENTAL BENEFITS
 
We will pay for covered dental expense you incur while covered under this plan, subject to all terms, conditions, limitations and exclusions specified in this certificate.
 
HOW COVERED DENTAL EXPENSE IS DETERMINED
 
Covered dental expense is based on a maximum charge for each covered service or supply which we will accept. It is not necessarily the amount a dentist bills for the service.
 
Covered dental expense will always be the lesser of the billed charge or the amount shown below.
 
Type of Dentist Maximum Covered Dental Expense is..
Participating Dentists the Dental Negotiated Rate
Non-Participating Dentists the Customary and Reasonable Charge
   
Participating dentists have agreed not to charge you more than the dental negotiated rate. When you choose a participating dentist, you will not be responsible for any amount in excess of the dental negotiated rate for the covered services of a participating dentist.
 
You will be responsible for any billed charge which exceeds the customary and reasonable charge for services provided by a non-participating dentist.
 
DENTAL DEDUCTIBLES AND BENEFIT MAXIMUMS
 
After we subtract the Dental Deductible from the total amount of covered dental expense, we will pay benefits at the Payment Rate which applies to such expense, up to the applicable Dental Benefit Maximums. The Deductible amount, Payment Rates, and Dental Benefit Maximums are set forth in the SUMMARY OF BENEFITS.
 
DENTAL DEDUCTIBLES
 
Only charges that are considered covered dental expense will apply toward satisfaction of the Dental Deductible.
 
Insured Person Deductible. Each plan year, you will be responsible for satisfying the Insured Person Deductible before we begin to pay benefits under the plan.
 
Family Deductible. If enrolled members of a family pay Deductible expense during a plan year, equal to the Family Deductible amount shown in the SUMMARY OF BENEFITS, then the Dental Deductible for all insured family members is considered to have been met. No further Dental Deductible is required for the remainder of the plan year.
 
Prior Plan Dental Deductibles. If you were covered for dental benefits under the prior plan any amount paid for dental benefits during the same plan year toward your dental deductible under the prior plan, will be applied toward your Dental Deductible under this plan; provided that, such payments were for charges that would be covered dental expense under this plan.
 
 
DENTAL BENEFIT MAXIMUMS
 
Plan Maximum. Your benefits, excluding orthodontics, are subject to the Plan Year Maximum shown in the SUMMARY OF BENEFITS. We will not pay any benefit in excess of that amount for covered dental expense incurred during a plan year for each insured person. Also, all payments are subject to any waiting periods and limitations specified in this certificate.
Orthodontic Lifetime Maximum. Your orthodontic benefits are subject to the Orthodontic Lifetime Maximum shown in the SUMMARY OF BENEFITS. We will not pay any orthodontic benefits in excess of that amount during an insured person's lifetime.
Prior Plan Maximum Benefits. If this plan replaces a prior plan, the amount of any benefits paid to you under the prior plan will reduce any maximum amounts for which you are eligible under this plan which apply to the same benefit.
 
DENTAL CONDITIONS OF SERVICE
 
The following conditions of service must be met for expense incurred to be considered as covered dental expense.
 
1. You must incur this expense while you are covered for dental benefits under this plan. Expense is incurred on the date you receive the service or supply for which the charge is made
 
2. The service must be provided by a licensed dentist, physician, or dental hygienist and must be for preventive care or for treatment of dental disease, defect or injury.
 
3. The expense must be incurred for a dental service or supply that is included under DENTAL CARE THAT IS COVERED. Additional limits on covered dental expense are included under specific benefits in the SUMMARY OF BENEFITS.
 
4. The expense must not be for a dental service or supply listed under DENTAL CARE THAT IS NOT COVERED. If the service or supply is partially excluded, then only that portion which is not excluded will be considered covered dental expense.
 
5. The expense must not exceed any of the maximum benefits or limitations of this plan.
   
   
PRE-TREATMENT REVIEW
 
If your dentist anticipates the expense for any course of treatment to exceed $300, your dentist should prepare a request for a pre-treatment benefit estimation form, and submit this form to us before any treatment begins. We will review this request and send a copy of our response to you and your dentist.
If the course of treatment is not reviewed before treatment is received, it will be reviewed when the claim is submitted to us for payment and the benefits may be less than you expect.
If you or your dentist disagree with a pre-treatment review decision, you or your dentist may request reconsideration. Any requests for reconsideration (either by telephone or in writing) must be directed to the address and the telephone number included on your written copy of our response.
 
DENTAL CARE THAT IS COVERED
 
Each of the following services or supplies is covered subject to DENTAL CONDITIONS OF SERVICE, provided it meets the requirements explained under HOW COVERED DENTAL EXPENSE IS DETERMINED, and is not for, or in connection with, an exclusion or limitation listed under DENTAL CARE THAT IS NOT COVERED.
 
Diagnostic and Preventive Services
 
· Examinations
· X-rays
   
· Teeth cleaning and fluoride application
   
Restorative Services
 
· Fillings
Prosthodontic Services (Fixed and Removable)
 
· Preparation and installation of bridges
· Crowns attached to a bridge
   
· Crowns not attached to a bridge
   
· Preparation and installation of partial or complete dentures (including repairs)
   
· Cast restorations, porcelain inlays
   
Endodontic Services
 
· Root canal therapy
· Treatment to prevent or correct conditions that affect the tooth pulp, root and related tissue
   
Periodontic Services
 
· Scaling and other procedures to prevent or treat diseases or defects to your gums
Oral Surgery
 
· Extractions of teeth and minor oral surgery. (General anesthesia will be covered with the oral surgery if we determine it to be necessary.)
Orthodontic Services
 
· One case per lifetime
· Consultation
   
· All adjustments
   
· All retainers
   
· Subject to the Orthodontic Lifetime Maximum shown in the SUMMARY OF BENEFITS
   
 
DENTAL CARE THAT IS NOT COVERED
 
No payment will be made under YOUR DENTAL BENEFITSfor expense incurred for, or in connection with, any of the items below. (The titles given to these exclusions and limitations are for ease of reference only; they are not meant to be an integral part of the exclusions and limitations and do not modify their meaning.)
Services Provided Before or After the Term of This Coverage. Services received before your effective date or during an inpatient hospital stay that began before your effective date. Services received after your coverage ends, except as specifically stated under EXTENSION OF BENEFITS.
Experimental or Investigative Procedures. Any procedures which are considered experimental or investigative or which are not widely accepted as proven and effective procedures within the organized dental community.
Acceptable Services. Any service or supply which we determine not to be an acceptable service. (See DEFINITIONS.)
Workers' Compensation. Any work-related conditions if benefits are recovered or can be recovered, either by adjudication, settlement or otherwise under any workers' compensation, employer's liability law or occupational disease law, even if you did not claim those benefits.
Government Programs. Services provided by, or payment made by, any local, state, county or federal government agency including Medicare and any foreign government agency.
No Charge Services. Services received for which no charge is made to you or for which no charge would be made to you in the absence of insurance coverage.
Results Of War. Disease contracted or injuries sustained as a result of war, declared or undeclared or from exposure to nuclear energy, whether or not the result of war.
Provider Related To Insured Person. Professional services received from a person who lives in your home or who is related to you by blood or marriage.
Excess Expense. Any amounts in excess of covered dental expense or the Dental Benefit Maximums.
Professionally Acceptable Treatment. If we determine that more than one treatment plan would be considered an acceptable service for a dental condition, any amount exceeding the cost of the least expensive professionally acceptable treatment plan is not covered.
Transfer Of Care. If you transfer from the care of one dentist to another dentist during the course of treatment, or if more than one dentist renders services for one dental procedure, we shall be liable only for the amount for which we would have been liable if one dentist had rendered the services.
Hospital Charges. Hospital costs and any additional charges by the dentist for hospital treatment.
Services Not Included as a Covered Procedure. Services not included under DENTAL CARE THAT IS COVERED unless they are similar in nature to an included procedure; in such event the benefit payable will be based on the most nearly comparable services included.
Treatment By An Unlicensed Dentist. Charges for treatment by other than a licensed dentist or physician, except charges for dental prophylaxis performed by a licensed dental hygienist under the supervision and direction of a dentist.
Treatment of the Joint of the Jaw. Diagnosis or treatment by any method of any condition related to the jaw joint (temporomandibular joint) or associated musculature, nerves and other tissues.
Vertical Dimension and Attrition. Procedures requiring appliances or restorations (other than those for replacement of structure lost due to dental decay) that are necessary to alter, restore or maintain occlusion. These include but are not limited to:
· Changing the vertical dimension
 
· Replacing or stabilizing tooth structure lost by attrition, abrasion, or erosion
 
· Realignment of teeth
 
· Gnathological recording
 
· Occlusal equilibration
 
· Periodontal splinting
 
Prosthetic Replacements. Replacement of fixed or removable prosthesis for which benefits were paid, if replacement occurs within five years of the original placement, unless the prosthesis is a stayplate used during the healing period for recently extracted anterior teeth.
Crown Replacements. Replacement of crowns and cast restorations including porcelain crowns and inlays for which benefits were paid by BC Life or an affiliated company, if replacement occurs within five years of the original placement.
Denture Repairs, Adjustments or Relines. Repairs, adjustments or relines of full or partial dentures or other prosthesis are not covered for a period of six months from the initial placement if they were paid for under this plan.
Lost or Stolen Dentures or Appliances. Replacement of existing full or partial dentures or prosthetic appliances which have been lost or stolen if replacement occurs within five years of the original placement.
Prosthetics (patients under sixteen years old). Fixed bridges, removable cast partials, cast crowns, with or without veneers, and inlays for patients under sixteen years old.
Implants. Implants (materials implanted into or on bone or soft tissue), or the removal of implants. However, if implants are provided in connection with a covered prosthetic appliance, we will allow the cost of a standard complete or partial denture, or a bridge, toward the cost of the implants and the prosthetic appliances.
Malignancies and Neoplasms. Services for treatment of malignancies and neoplasms.
Cosmetic Dentistry. Any services performed for cosmetic purposes, unless they are for correction of functional disorders or as a result of an accidental injury occurring while you were covered for dental benefits under this plan.
Congenital or Developmental Malformation. Services to correct a congenital or developmental malformation including but not limited to cleft palate, maxillary and mandibular (upper and lower jaw) malformations, enamel hypoplasia (lack of development), fluorosis (discoloration of the teeth), and anodontia (congenitally missing teeth).
X-rays. More than one set of full-mouth X-rays or its equivalent in a three-year period.
Oral Exams. Oral exams are limited to two per plan year.
Prophylaxis or Periodontal Prophylaxis. Prophylaxis or periodontal prophylaxis treatments exceeding two treatments in a plan year. Periodontal prophylaxis must be preceded by active periodontal treatment, such as scaling and root planing or osseous (gum) surgery.
Sealants. Sealants are limited to children under 16 years of age for permanent molars, unrestored. Treatment is limited to once every 36 months per tooth.
Prescription Drugs and Medications. Any prescribed drugs, pre-medication or analgesia.
Oral Hygiene. Oral hygiene instruction.
 
ORTHODONTIC CARE THAT IS NOT COVERED
 
Myofunctional Therapy. Myofunctional therapy and related services. (Myofunctional therapy involves the use of muscle exercises as an adjunct to orthodontic mechanical correction of malocclusion.)
Surgical Procedures Incidental to Orthodontic Treatment. Surgical procedures incidental to orthodontic treatment including, but not limited to, extraction of teeth solely for orthodontic reasons, exposure of impacted teeth, correction of micrognathia or macrognathia, or repair of cleft palate.
Orthodontic Services Provided Before or After the Term of Your Coverage. Orthodontic treatment begun prior to your effective date or after the termination of your coverage. TMJ or Hormonal Imbalance Orthodontic Services. Orthodontic treatment related to temporomandibular joint disturbances (TMJ) and/or hormonal imbalance.
TMJ or Hormonal Imbalance Orthodontic Services. Orthodontic treatment related to temprormandibular joint disturbances (TMJ) and/or hormonal imbalance.
Orthodontic Records. Orthodontic records including, but not limited to, cephalometric tracing, photographs, study models and diagnostic radiographs.
 
 
 
REIMBURSEMENT FOR ACTS OF THIRD PARTIES
 
No payment will be made under this plan for expenses incurred for or in connection with any illness, injury, or condition for which a third party may be liable or legally responsible by reason of negligence, an intentional act or breach of any legal obligation. But we will provide the benefits of this plan subject to the following:
 
1. We will automatically have a lien, to the extent of benefits provided, upon any recovery, whether by settlement, judgment or otherwise, that you receive from the third party, the third party's insurer, or the third party's guarantor. The lien will be in the amount of benefits we paid under this plan for the treatment of the illness, disease, injury or condition for which the third party is liable.
 
2. You must advise us in writing, within 60 days of filing a claim against the third party and take necessary action, furnish such information and assistance, and execute such papers as we may require to facilitate enforcement of our rights. You must not take action which may prejudice our rights or interests under your plan. Failure to give us such notice or to cooperate with us, or actions that prejudice our rights or interests will be a material breach of this plan and will result in your being personally responsible for reimbursing us.
 
3. We will be entitled to collect on our lien even if the amount you or anyone recovered for you (or your estate, parent or legal guardian) from or for the account of such third party as compensation for the injury, illness or condition is less than the actual loss you suffered.
   
   
   
 
COORDINATION OF BENEFITS
 
If you are covered by more than one group dental plan, your benefits under This Plan will be coordinated with the benefits of those Other Plans, as shown below. These coordination provisions apply separately to each insured person, per plan year, and are largely determined by California law.
 
DEFINITIONS
 
The meanings of key terms used in this section are shown below. Whenever any of the key terms shown below appear in these provisions, the first letter of each word will be capitalized. When you see these capitalized words, you should refer to this "Definitions" provision.
 
Allowable Expense is any necessary, reasonable and customary item of expense which is at least partially covered by at least one Other Plan. For the purposes of determining our payment, the total value of Allowable Expense as provided under This Plan and all Other Plans will not exceed the greater of: (1) the amount which we would determine to be eligible expense, if you were covered under This Plan only; or (2) the amount any Other Plan would determine to be eligible expenses in the absence of other coverage.
 
Other Plan is any of the following:
 
1. Group, blanket or franchise insurance coverage;
 
2. Group service plan contract, group practice, group individual practice and other group prepayment coverages;
 
3. Group coverage under labor-management trusteed plans, union benefit organization plans, employer organization plans, employee benefit organization plans or self-insured employee benefit plans.
   
   
The term "Other Plan" refers separately to each agreement, policy, contract, or other arrangement for services and benefits, and only to that portion of such agreement, policy, contract, or arrangement which reserves the right to take the services or benefits of other plans into consideration in determining benefits.
Principal Plan is the plan which will have its benefits determined first.
This Plan is that portion of this plan which provides benefits subject to this provision.
EFFECT ON BENEFITS
 
1. If This Plan is the Principal Plan, then its benefits will be determined first without taking into account the benefits or services of any Other Plan.
 
2. If This Plan is not the Principal Plan, then its benefits may be reduced so that the benefits and services of all the plans do not exceed Allowable Expense.
 
3. The benefits of This Plan will never be greater than the sum of the benefits that would have been paid if you were covered under This Plan only.
   
   
ORDER OF BENEFITS DETERMINATION
 
The following rules determine the order in which benefits are payable:
 
1. A plan which has no Coordination of Benefits provision pays before a plan which has a Coordination of Benefits provision.
 
2. A plan which covers you as an insured employee pays before a plan which covers you as a dependent.
 
3. For a dependent child covered under plans of two parents, the plan of the parent whose birthday falls earlier in the plan year pays before the plan of the parent whose birthday falls later in the plan year. But if one plan does not have a birthday rule provision, the provisions of that plan determine the order of benefits.
   
   
Exception to Rule 3: For a dependent child of parents who are divorced or separated, the following rules will be used in place of Rule 3:
 
a. If the parent with custody of that child for whom a claim has been made has not remarried, then the plan of the parent with custody that covers that child as a dependent pays first.
   
b. If the parent with custody of that child for whom a claim has been made has remarried, then the order in which benefits are paid will be as follows:
   
i. The plan which covers that child as a dependent of the parent with custody.
ii. The plan which covers that child as a dependent of the stepparent (married to the parent with custody).
iii. The plan which covers that child as a dependent of the parent without custody.
iv. The plan which covers that child as a dependent of the stepparent (married to the parent without custody).
       
c. Regardless of a and b above, if there is a court decree which establishes a parent's financial responsibility for that child's health care coverage, a plan which covers that child as a dependent of that parent pays first.
4. The plan covering you as a laid-off or retired employee or as a dependent of a laid-off or retired employee pays after a plan covering you as other than a laid-off or retired employee or the dependent of such a person. But, if either plan does not have a provision regarding laid-off or retired employees, provision 6 applies.
 
5. The plan covering you under a continuation of coverage provision in accordance with state or federal law pays after a plan covering you as an employee, a dependent or otherwise, but not under a continuation of coverage provision in accordance with state or federal law. If the order of benefit determination provisions of the Other Plan do not agree under these circumstances with the order of benefit determination provisions of This Plan, this rule will not apply.
6. When the above rules do not establish the order of payment, the plan on which you have been enrolled the longest pays first unless two of the plans have the same effective date. In this case, Allowable Expense is split equally between the two plans.
OUR RIGHTS UNDER THIS PROVISION
 
Responsibility For Timely Notice. We are not responsible for coordination of benefits unless timely information has been provided by the requesting party regarding the application of this provision
Reasonable Cash Value. If any Other Plan provides benefits in the form of services rather than cash payment, the reasonable cash value of services provided will be considered Allowable Expense. The reasonable cash value of such service will be considered a benefit paid, and our liability reduced accordingly.
Facility of Payment. If payments which should have been made under This Plan have been made under any Other Plan, we have the right to pay that Other Plan any amount we determine to be warranted to satisfy the intent of this provision. Any such amount will be considered a benefit paid under This Plan, and such payment will fully satisfy our liability under this provision.
Right of Recovery. If payments made under This Plan exceed the maximum payment necessary to satisfy the intent of this provision, we have the right to recover that excess amount from any persons or organizations to or for whom those payments were made, or from any insurance company or service plan.
 
 
HOW COVERAGE BEGINS AND ENDS
 
 
HOW COVERAGE BEGINS
 
ELIGIBLE STATUS
 
1. Insured Employees. You are eligible to enroll in this House Staff plan if you are a full-time intern, resident, or fellow with direct patient care responsibilities and if you have been awarded a Doctor of Medicine (or equivalent degree) or Doctor of Dentistry (or equivalent degree). House Staff enrolled in training programs are eligible to enroll in this plan for the duration of the training program, even if performing duties that are not directly related to patient care. Adjunct instructors (junior faculty) who function as House Staff but are paid by both House Staff and faculty funds are also eligible to enroll in this plan.
 
2. Family Members. The following are eligible to enroll as family members: (a) Either the employee's spouse or domestic partner; and (b) An unmarried child.
 
 
Definition of Family Member
 
1. Insured Employees. You are eligible to enroll in this House Staff plan if you are a full-time intern, resident, or fellow with direct patient care responsibilities and if you have been awarded a Doctor of Medicine (or equivalent degree) or Doctor of Dentistry (or equivalent degree). House Staff enrolled in training programs are eligible to enroll in this plan for the duration of the training program, even if performing duties that are not directly related to patient care. Adjunct instructors (junior faculty) who function as House Staff but are paid by both House Staff and faculty funds are also eligible to enroll in this plan.
 
2. Domestic partner is the employee's domestic partner whose domestic partnership is currently registered with a governmental body pursuant to state or local law. Domestic partner does not include any person who is: (a) the opposite sex as the insured employee; (b) covered as an insured employee or spouse; or (c) in active service in the armed forces.
   
  For the purposes of this definition, in lieu being currently registered with a governmental body, the employee and their domestic partner may provide the group with an signed affidavit certifying, under penalty of perjury, that:
   
a. They have an intimate, committed relationship of mutual caring;
 
b. They share the same principal residence(s);
 
c. They agree to be responsible for each other's basic living expenses during their domestic partnership; and also agree that anyone who is owed these expenses can collect from either of them;
 
d. They are both 18 years of age or older;
 
e. Neither of them is legally married;
f. They are not so closely related by blood that legal marriage would otherwise be prohibited;
g. Neither of them has a different domestic partner now; and
 
h. Neither of them has had a different domestic partner in the last six months (this last condition does not apply to a person who had a partner who died).
 
3. Child is the employee's, spouse's or domestic partner's unmarried natural child, stepchild, or legally adopted child, or a child for whom the employee, spouse or domestic partner has been appointed legal guardian by a court of law, subject to the following:
a. The child depends on the employee, spouse or domestic partner for financial support or the employee or spouse is legally required to provide group health coverage for the child pursuant to an administrative or court order. A child is considered financially dependent if he or she qualifies as a dependent for federal income tax purposes
 
b. The unmarried child is under 19 years of age, or if age 19 or over, that child is eligible until his or her 23rd birthday, provided he or she is enrolled as a full-time student (for 12 or more credits) in a properly accredited two year community college, four year college or university, or an accredited post-high school trade or technical school OR continues to depend on the employee, spouse or domestic partner for federal income tax purposes. An overage dependent who enters or returns to an eligible status will become eligible for coverage on the first day of the month following the date an enrollment application is filed on their behalf.
 
  c. A child who is in the process of being adopted is considered a legally adopted child if we receive legal evidence of both: (i) the intent to adopt; and (ii) that the employee, spouse or domestic partner have either: (a) the right to control the health care of the child; or (b) assumed a legal obligation for full or partial financial responsibility for the child in anticipation of the child's adoption. Legal evidence to control the health care of the child means a written document, including, but not limited to, a health facility minor release report, a medical authorization form, or relinquishment form, signed by the child's birth parent, or other appropriate authority, or in the absence of a written document, other evidence of the employee's, spouse's or domestic partner's right to control the health care of the child.
 
  d. A child for whom the employee, spouse or domestic partner is a legal guardian is considered eligible on the date of the court decree (the "eligibility date"). We must receive legal evidence of the decree.
 
  e. The term "child" does not include any person who is: (i) covered as a employee; or (ii) in active service in the armed forces.
 
  f. If both parents are covered as employees, their children may be covered as the family members of either, but not of both.
   
   
ELIGIBILITY DATE
 
1. For Employees: You become eligible for coverage on the first day of the month coinciding with the date you are hired. (This is your "waiting" period.)
2. For Family Members: You become eligible for coverage on the later of: (a) the date the employee becomes eligible for coverage; or (b) the date you meet the family member definition.
Exceptions to the Waiting Period
 
1. If you are hired on June 24th of any year, you are eligible to enroll on the date you are hired.
2. If, after you have completed the waiting period, you cease to be eligible due to termination of employment, and you return to an eligible status within six months after the date your employment terminated, you will become eligible on the first day of the month following the date you return.
3. If you were covered under the prior plan, the time you spent under the prior plan will be used to satisfy, or partially satisfy, your waiting period under this plan.
ENROLLMENT
 
To enroll as an employee, or to enroll family members, the employee must properly file an application. An application is considered properly filed, only if it is personally signed, dated, and given to the group within 31 days from your eligibility date. We must receive this application from the group within 90 days. If any of these steps are not followed, your coverage may be denied.
 
EFFECTIVE DATE
 
Subject to the timely payment of premium on your behalf, your coverage will begin as follows:
 
1. Timely Enrollment. If you enroll for coverage before, on, or within 31 days after your eligibility date, then your coverage will begin as follows: (a) for employees, on your eligibility date; and (b) for family members, on the later of (i) the date the employee's coverage begins, or (ii) the first day of the month after the family member becomes eligible. If you become eligible before the policy takes effect, coverage begins on the effective date of the policy.
 
2. Late Enrollment. If you file an enrollment application or membership change form with the group more than 31 days after your eligibility date, you will be eligible to apply for coverage during the group's next Open Enrollment Period.
 
3. Disenrollment. If you voluntarily choose to disenroll from coverage under this plan, you must wait until the group's next Open Enrollment Period to