No benefit is payable for the following dental services and supplies:
- Services or supplies payable or available (regardless of any waiting list) under any government sponsored plan or program unless explicitly listed as covered under the benefit or any portion thereof, that are the legal liability of any other party.
- Any portion of the charge over the usual, customary and reasonable charge of the least expensive alternate service or material consistent with adequate dental services when such alternate service or material is customarily provided.
- Charges for appointments not kept or completion of claim forms.
- Expenses related to services or supplies of the type normally intended for sport or home use, such as but not limited to, mouth guards.
- Charges for dental services due to or resulting from any cause for which indemnity or compensation is provided under any Workers' Compensation Act, Criminal Injuries Compensation Act or similar legislation.
- The portion of the charge which is the legal liability of another party.
- Any services or supply for which there would be no charge in the absence of this coverage.
- For which user fees, co-insurance charges or similar charges are made that are in excess of charges payable by a government dental, hospital or health plan.
- That are not yet approved by the Canadian Dental Association or that, in the opinion of Sun Life, are clearly experimental in nature.
- Services rendered and supplies purchase prior to the date the person became covered under this
- That, in the opinion of Sun Life, are rendered principally for cosmetic purposes including, but not limited to, porcelain or composite facings on crowns or pontics on molar teeth.
- Related to the purchase, repair, modification or replacement of a duplicate prosthodontic appliance, for any reasons.
- For an appliance or a modification of one where an impression is made for such appliance or a modification before the person became covered under the Dental Care Plan.
- For crowns, bridges and gold restorations for which a tooth was prepared before the person became covered under the Dental Care Plan.
- For root canal therapy where the pulp chamber was opened before the person became covered under the Dental Care Plan.
- Rendered as a result of a congenital or developmental malformation that is not a Class I, II or III malocclusion.
- For a periodontal appliance, occlusal equilibration, and other related service as a result of a temporo-mandibular joint dysfunction (TMJ dysfunction) or vertical dimension correction.
- Related to implants, other than the reasonable and customary cost of the least expensive alternate procedure as determined by Sun Life,
- For an orthodontic treatment, in respect of a member or his or her eligible spouse, where the initial appliance was installed before the person became covered for such service under the Dental Care Plan.
Limitations for Prosthodontic Appliances
Charges for a replacement bridge or replacement standard denture, are not considered an eligible expense, unless:
- it is needed as a result of the removal of additional natural teeth after insertion of the existing bridge or standard denture,
- the existing bridge or standard denture is at least 5 years old and cannot be made serviceable,
- the existing bridge or denture was temporarily inserted, provided that the replacement bridge or denture is inserted within 12 months of the temporary bridge or denture and the replacement will thereafter be deemed permanent for the purposes of this provision,
- the replacement bridge or denture is required as the result of the insertion of an initial opposing denture after the date the person becomes covered under this Plan, or
- the replacement bridge or denture is required as the result of accidental dental injury to a natural tooth that occurred after the date the person becomes covered under this Plan.