D.A. Townley  -  Plan Administrators Iron Workers Union Local 97 International Association of Bridge, Structural, Ornamental and Reinforcing Iron Workers 
 

health
benefits

        
 
 
 
 
 
 
 
 
 
 
 
 
   
        
   
 
 
 
 
   
 
 
 
 
   
 

Dental Claim

Use
Use the Dental Claim form if you've paid your dentist the full cost of the services that are covered under the Plan and you wish to be reimbursed. Many dentists will bill the Plan directly for the portion payable under the Plan using their own Standard Dental Claim Form.


Information Needed to Complete the Form
Your dentist must complete Part 1 of the form. You complete Part 2 and Part 3.

Part 2 is where your Member information is filled in, including your Plan policy number, 70682. This number is pre-printed on the form. (If your dentist uses a Standard Dental Claim Form, the above Plan number must be included).

Part 3 is for patient information whether that is yourself, your spouse, or one of your dependant children. Part 3 also collects information about other Benefit or Insurance Plans that you may be eligible to co-ordinate a claim from.


Notes
The expenses must have been incurred by you or one of the eligible dependents currently on file with the Plan Administrator.

If the cost of the Dental work will exceed $600, you should notify the Plan Administrator in advance of the work to ensure that the Plan will cover the expense. Costs not covered by the Plan must be paid by you.

Completed forms should be forwarded to the Plan Administrator.


Frequently Asked Questions
What expenses can I be reimbursed for?
  • Eligible expenses are listed in the Dental section.
My spouse also has dental coverage through work, how do I coordinate my claim with my spouse's benefits plan?
  • If a Member or any eligible Dependents are entitled to receive similar benefits simultaneously under the Health & Welfare Plan or any other group insurance plan (including Provincial Plans), to prevent over payment, benefits payable under this Plan would be co-ordinated with the other Plan.

    For example: A Member’s wife is covered under her employer’s plan with family coverage. The Member, his spouse and their three children are all covered under both Plans. To determine which plan would be primarily responsible for the dependent children: Between the Member and the spouse, whomever’s birthday falls first in the calendar year, their plan is responsible for the initial reimbursement of benefits for the dependent children, then, any amounts that are not paid by that Plan are submitted to the other parent's plan.

    In the event that the Member’s birthday is in April and the spouse’s birthday is in January. The spouse’s plan would be primarily responsible for the spouse's claims and the claims of the children. Any amounts not paid by the spouse's plan can be submitted to the Member’s Plan for reimbursement. Any amounts for the Member that are not paid by the Member's Plan can be submitted to the spouse's plan for reimbursement.

    Please see the General Information section for a description of "Coordination of Benefits".
Other questions on completing the form should be directed to the Plan Administrator.


 

Form Link
Application for Dental Claim Form
 

Related Links
Dental Benefit Information
 
 
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