Accident Injury Benefit

An accident injury is damage to the hard and soft tissue of the mouth caused directly and independently of all other causes by external forces.  Damage to the hard and soft tissue of the mouth from normal chewing function is covered under Schedule A, Description of Benefits and Co-payments.

PMI will pay up to 100% of the Contract Dentist's "filed fees", for expenses an Enrollee incurs for an accident injury, less any applicable Co-payment(s), up to a Maximum of $1,600.00 in any 12 month period.

Accident injury benefits include the following procedure in addition to those listed in Schedule A, Description of Benefits and Co-payments.

CODE  D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth and/or alveolus - includes splinting and/or stabilization.

Payment of accident injury benefits is subject to Schedule B, Limitations and Exclusions of Benefits, in addition to the following provisions:

Maximum
Accident injury benefits will be provided for each Enrollee up to a maximum of $1,600.00 in any 12-month period.

Limitation
Accident injury benefits are limited to services provided as a result of an accident, which occurred (a) while the Enrollee was covered under the DeltaCare program, or (b) while the Enrollee was covered under another DeltaCare program, and if the benefits for the expenses incurred would have been paid if the Enrollee had remained covered under that program.

Exclusions
B, limitations #13, #15, #20, #21 and #24 and exclusions #1-9, #11-15 and #18-20, the following exclusions apply:

1. Prophylaxis;
2. Extra-oral grafts (grafting of tissues from outside the mouth to oral tissue);
3. Replacement of existing restorations due to decay;
4. Orthodontic services (treatment of malalignment of teeth and/or jaws);
5. Replacement of existing restorations, crowns, bridges, dentures and other dental or orthodontic appliances damaged by accident injury.