A
Abutment
A tooth used to support and anchor a fixed or removable denture prosthesis.
Alternate Treatment
When there are two or more courses of eligible treatment, each of which would produce professionally adequate results for a given condition, Manulife will pay for the least expensive course of treatment, even if a more expensive treament option is chosen by the patient. Manulife determines the adequacy of the various courses of treatment available through a professional dental consultant.
Amalgam Filling
A mixture of mercury, silver, and other materials, used to restore teeth.
Anaesthesia
Drugs used prior to dental treatment to eliminate discomfort. There are two main categories of anaesthesia – Local and General.
- Local anaesthesia – The most common form of anaesthesia, it causes loss of sensation or feeling to a localized or specific area. It is administered by injecting an anesthetic agent near the area in the mouth to be treated.
- General anaesthesia – Causes the patient to become unconscious during the treatment. It is administered either by the inhalation of a gas or by injection into a vein (intravenously).
- Conscious sedation is another type of anaesthesia. This is a management technique that uses inhaled nitrous oxide gas to assist the patient with fear and anxiety so that they can cooperate with the dental treatment. The patient does not lose consciousness during the procedure. Manulife does not pay benefits for conscious sedation.
C
Calendar Year Maximum
A calendar year maximum can apply to certain types of coverage within your plan. It may limit the number of visits to a particular practitioner or the number of times that a specific procedure can receive payment. It may also limit a practitioner or procedure to a specific dollar maximum. The limitations are assessed and accumulate within a calendar year. When the next calendar year begins, the maximums reset to their full value.
Coinsurance
Coinsurance is the percentage of eligible expenses payable by Manulife. For example, if a benefit has a coinsurance of 75%, Manulife pays 75% of eligible costs after any deductible has been satisfied, and the plan member pays the rest.
Composite Filling
A white plastic material used to restore teeth.
Coordination of Benefits
If you have health or dental coverage under another plan, you can get up to 100% of your eligible expenses covered. Industry-wide procedures, determined by Canadian Life and Health Insurance Association (CLHIA) guidelines, establish which plan considers a claim first. Through coordination of benefits, you can submit the unpaid part of a claim to the second plan for payment. For example, if this plan pays 80% of an expense, the other plan may pay the remaining 20%.
Here's how to take advantage of coordination of benefits:
For you
Send your claims to your plan first. Then submit the claim statement -- along with copies of receipts -- for any unpaid portion to your spouse's plan.
For your spouse
Send your spouse's claims to his/her plan first, then submit the claim statement -- along with copies of receipts - for any unpaid portion to this plan.
For your children
- If you are the parent whose birthday (month and day) falls EARLIER in the year, submit your children's claims to your plan first. Then, submit the claim statement for any unpaid portion to the other parent’s plan.
- If you are the parent whose birthday (month and day) is LATER in the year , submit your children's claims to the other parent’s plan first. Then submit the claim statement for any unpaid portion to your plan.
Crowns
Also called a cap, a crown is needed on a tooth when the tooth is weakened by decay, fracture or a very large restoration. A crown is usually made of porcelain and or metal. You will need to submit x-rays with your claim before it can be considered for payment.
D
Deductible
If your plan includes a deductible, it must be paid first before benefits become eligible for payment by Manulife (see also coinsurance).
Dental Coverage Deductible
Your deductible may be shared between several categories of services.
Example:
A plan may have a $25 deductible for Preventative Services, and a $25 deductible for
Basic Restorative Services. This means that satisfying the deductible for Preventative
Services also satisfies the deductible for Basic Restorative Services.
See your benefit booklet for details of your deductibles.
Dental Coverage Maximum
Some dental services may be combined to calculate your coverage maximum.
Example:
A plan may have a $500 maximum for Preventative Services, and a $500 maximum for Basic
Restorative Services. This means that meeting the maximum for Preventative Services also
reaches the maximum for Basic Restorative Services.
See your benefit booklet for details.
Dental Fee Guides
The dental association of each province publishes a dental fee guide. This guide summarizes recommended charges for each dental procedure. Guides are updated annually to account for inflation and other factors.
Plan sponsors can choose which dental fee guide to use to determine the maximum amount
payable for each dental procedure in their plan (e.g. the dental fee guide for the current
year, for a specific year, or for a specific province.)
Denture
A denture is a synthetic replacement for some or all of your teeth in either your upper or your lower jaw.
Dependent Child
A dependent child is a plan member's natural child, adopted child or stepchild (a stepchild must be living with the plan member) who is:
- unmarried;
- not employed on a full-time basis;
- ineligible for insurance as a plan member under this or any other group plan; and
- below the age specified in the dependent definition section of the plan member's plan.
An
over-age dependent child must meet the requirements above and be
a full-time student at an accredited school, college or university;
and/or
- disabled; and
- unable to work full-time.
An over-age child may be eligible for coverage under your plan. Proof of eligibility may be required.
Diagnostic Cast
Also called a study model, a diagnostic cast is a replica of the form of the teeth and tissues made from an impression.
Diagnostic Services
Diagnostic services assist the dentist in evaluating the existing condition of a patient's
mouth. These services are used to determine what dental treatment, if any, is needed. Examples
of diagnostic services include:
- initial
- recall, and
- emergency.
Drugs
Prescription Drug Plan
A Prescription Drug Plan is one including drugs that, by Federal or Provincial
legislation, require a prescription for dispensing and sale, and which have a valid Drug
Identification Number (DIN).
Prescription drugs are only available from a pharmacy when prescribed by a
physician to treat or prevent a medical condition, e.g., insulin.
Prescribed Drug Plan
A Prescribed Drug Plan is one including drugs that, by Federal or Provincial legislation,
require a prescription for dispensing and sale, and which have a valid Drug Identification
Number (DIN). Drugs recommended by a physician (using a written prescription), including
over-the-counter drugs are also covered.
Generic drugs
Generic drugs are a chemically equivalent alternative to brand-name drugs. They contain
the same high quality active ingredients as brand-name drugs. They are federally tested using
the same strict criteria for safety and effectiveness and must meet the same scientific norms
and standards.
Generic drugs' inactive ingredients, such as coatings, may differ (although the fillers
used in drugs come from a limited range of available products) and they may appear different
– in colour or shape – but they work the same. They are less expensive than
brand-name drugs.
Over-the-Counter Drugs
Over-the-counter drugs are drugs that do not require a prescription in order to be purchased.
Drug Formulary
A drug formulary is a defined list of medically effective and cost-effective drugs.
Most commonly used drugs are included in the formularies used by Manulife. Drugs that are
not covered have a suitable alternative within the defined list of drugs and are available
at a lesser cost with similar, equally-effective medical results. Your local pharmacist
can provide you with a current list of eligible drugs or acceptable substitutes.
Dispensing Fee Cap
The plan sponsor can place a fixed dollar limit on dispensing fees (the fee
charged by a pharmacy for filling a prescription).
E
Elastic Stockings
Elastic stockings or support hose are specialized medical compression garments sometimes used to support the legs of a patient with a circulation disorder.
Check your benefit booklet to find out if your plan's coverage includes elastic stockings.
Endodontics
Endodontics is a branch of dentistry that involves treating the inside of a tooth. Many
teeth can be saved by the removing the pulp inside the tooth rather than the whole
tooth itself.
I
Inlays / Onlays and Pins
An inlay or onlay is a gold, porcelain, or composite custom-made filling cemented to the tooth. A pin
helps to stabilize the tooth and support the inlay or onlay in the restoration.
International Travel Assistance (ITA)
International Travel Assistance is provided in partnership with Allianz Global Assistance.
Check your benefit booklet to find out if your plan's coverage
includes International Travel Assistance.
L
Late Applicant or Application
An application is considered late if you:
- Apply for insurance on any person after having been eligible for more than 31 days; or
- Re-apply for insurance for yourself or a dependent whose insurance had earlier been cancelled.
If you apply for benefits that were previously waived because you were covered under
similar benefits with your spouse's plan, your application is considered late if you:
- Apply for insurance more than 31 days after the date benefits terminated under your spouse's plan
Late Filed Limits
Most plans include a deadline for submitting claims. After the deadline has passed, claims will be declined as
late filed.
Example:
Your plan may state that all claims must be submitted within 12 months of the date the expense was incurred.
In this case, if you submit a claim where the date of service was over 12 months ago, the claim will be declined.
M
Maximums
A maximum for a benefit can refer to the
- age limit,
- dollar limit and/or
- time limit
to which you and your covered family members are eligible to receive benefit coverage.
Example of an age maximum: A plan member and the covered family members are
eligible to receive health benefit coverage under the plan until the member reaches 65 years of
age.
Example of a dollar and time maximum: A plan covers a plan member's
prescription drugs up to $10,000 per calendar year.
Medical Services, Supplies and Equipment
The following medical services may be covered:
- private duty nursing,
- diagnostic procedures,
- medically necessary ambulance services,
- dental treatment for accidental injuries to teeth.
The following medical supplies and equipment may be covered:
- medically necessary equipment rentals such as wheelchairs and hospital beds,
- non-dental prostheses, supports and hearing aids,
- ileostomy, colostomy and incontinence supplies,
- medicated dressings, burn garments, oxygen.
See your benefit booklet for more information.
O
Occlusal Equilibriation
Occlusal equilibriation or occlusal adjustment is a procedure that involves reshaping the
occlusal (biting) surfaces of teeth to create even contact between upper and lower teeth.
The procedure is performed quadrant by quadrant (one section of the mouth at a time) and may
require several appointments to fully equalibriate a patient's whole mouth.
Occupational Therapy
Occupational therapy is the therapeutic use of self-care, work, and play activities to increase independent function, enhance development, and prevent disability. This may include adaptation of tasks or environment to achieve maximum independence and to enhance quality of life.
Manulife has basic and major categories of occupational therapy.
Check your benefit booklet to find out if your plan's coverage
includes occupational therapy.
Open Space Limitation
The Open Space limitation may apply to certain dental procedures that use appliances
to replace extracted teeth. When a dentist recommends placing a prosthodontic
appliance – such as a bridge or a denture – as part of the patient's treatment
plan, Manulife needs to know the extraction date for each tooth that the appliance will
be replacing. If your plan includes this limitation, and any of the teeth involved were
extracted before the patient became insured under the plan, Manulife will not pay for the
treatment. Check your benefit booklet to see if your plan
includes the Open Space limitation.
Oral Hygiene Instruction
Oral hygiene instruction provides information about how to brush, floss, and care for teeth.
Oral Surgery
This branch of dentistry deals with the surgical treatment of diseases or defects
of the mouth. Manulife has two categories of oral surgery:
- Basic – Examples of basic services include tooth extractions and removal of cysts or tumors.
- Major – Examples of major services include transplanting erupted teeth and alveoplasty (reshaping and trimming the bone in an area where there are no teeth present).
Check your benefit booklet to find out if your plan's coverage
includes both categories of oral surgery.
Orthodontics
This area of dentistry is concerned with the growth of the jaw, development of the bite, and correction
of dental and facial abnormalities. Orthodontic treatment involves the placement of braces, retainers,
and orthodontic appliances to eliminate dentofacial abnormalities in patients.
Orthotherapy
This system of medical practice is concerned with determining the nature of disorders based on an understanding of the functions of muscles and skeletal systems.
Manulife has basic and major categories of orthotherapy.
Check your benefit booklet to find out if your plan's coverage
includes orthotherapy.
Orthotics
These specialized devices can be inserted into footware to correct misalignments in a patient's gait.
Orthotics must be prescribed by a medical doctor, chiropodist, or podiatrist.
Check your benefit booklet to find out if your plan's coverage
includes orthotics.
Osteopathy
An osteopath treats impaired function within joints and tissue abnormalities.
Manulife has basic and major categories of orthotherapy.
Check your benefit booklet to find out if your plan's coverage
includes osteopathy.
P
Periodontal Disease / Periodontitis
Periodontal disease is an advanced gum disease resulting in the deterioration of the
supporting structures of the teeth.
Periodontal Appliance
Also known as a habit-breaking appliance, a periodontal appliance is designed for a patient
who grinds or clenches his or her teeth. Using a periodontal appliance can relieve jaw pain
and prevent further tooth damage.
Perio-scaling / Periodontal Scaling
Perio-scaling removes deposits of plaque, tartar, and food debris that have accumulated on teeth
or beneath the gum tissue.
Pit and Fissure Sealants
Pit and fissure sealants are plastic coatings applied to grooves of molars to prevent decay.
Podiatrist
A podiatrist specializes in foot care and is licensed to prescribe medicine and perform surgery.
Check your benefit booklet to find out if your plan's coverage
includes treatment by a podiatrist.
Polishing
Polishing a tooth's surface makes it smooth and therefore more difficult for plaque and debris
to accumulate and cause decay or gum disease.
Pre-determination of Benefits
When a proposed course of dental treatment is expected to cost more than $300, a treatment
plan should be filed in advance with Manulife. The dentist outlines the treatment plan, and
Manulife issues an Explanation of Benefits (EOB) to the plan member describing the exact
amount covered by the benefit plan for the treatment.
This provision is a service feature allowing the plan member to make an informed decision
before proceeding with an expensive dental procedure. If a plan member does not have his
or her dentist submit the treatment plan, this will not compromise or invalidate the
eligibility of the claim. However, only eligible expenses will be reimbursed as defined in
the plan.
Preventative Services
Preventative services are dental procedures and actions that keep your teeth healthy and
prevent disease and decay. Regular dental examinations and oral hygine instruction are
examples of preventative services.
Professional Services
The following professional services may be covered depending on your plan:
- chiropractors
- osteopaths
- podiatrists
- massage therapists
- naturopaths
- speech therapists
- physiotherapists
- psychologists.
Professional services can be subject to calendar year maximums for each practitioner, as well as
reasonable and customary dollar maximums per visit.
For a professional services claim to be eligible for coverage, the following requirements
must be met:
- the practitioner must be licensed in his or her field; and
-
in most provinces, the overall maximum benefit (per visit and yearly maximum) under the
provincial plan has been paid.
Note: Referral to a practitioner by a physician may be required. See your benefit booklet
for the complete list of professional services covered under your plan.
Prophylaxis
Prophylaxis is cleaning your teeth.
Prosthetic
A dental prosthetic is an appliance that replaces missing teeth. Manulife has two categories
of prosthetics: Basic and Major.
Prosthodontics
This branch of dentistry is concerned with replacing missing teeth and surrounding
tissue using an artificial appliance, The appliance could either be fixed – like a bridge
– or removable like a denture. Manulife has two categories of prosthodontic services:
- Basic – Relining, Rebasing, or Repairing of a Denture
- Major – Bridgework, Denture (partials and complete)
Check your benefit booklet to find out if your plan's coverage
includes both categories of prosthodontics.
R
Reasonable and Customary (R&C)
A fee is reasonable and customary if its dollar value falls within the usual
range of charges for the same or comparable services (or supplies) made by similar
practitioners in an area.
Example:
The fee a dentist in Ontario charges for a check-up is reasonable and customary if it
is within the range of fees that Manulife deems reasonable, based on information from the
Ontario Dental Association.
Restorative
Restorative services are provided to repair and restore natural teeth to their normal function.
Manulife has two categories of restorative services:
- Basic – An example of a basic restorative service is a filling.
- Major – Examples of major restorative services are inlays, onlays and crowns.
Check your benefit booklet to find out if your plan's coverage
includes both restorative service categories.
Root Canal Treatment
A root canal treatment is a method of saving a tooth by cleaning out a damaged nerve within
a root and filling in the resulting chamber.
