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| INDIVIDUAL BENEFIT CONTRACT ("CONTRACT") |
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This Contract is a nonparticipating Policy providing Dental Coverage for individual Enrollees and their dependents, if any.
Renewable at the Option of the Insurer:The Contract Term is one year. Coverage will renew automatically at the end of each Contract Term as long as the annual premium is paid before the end of the 30 day grace period. However, Delta reserves the option to cancel coverage under certain limited circumstances. Premium rates are subject to change at the end of each annual Contract Term. Refer to Renewable at Option of Insurer, Cancellation and Termination of Benefits and Grace Period.
Dependent children are eligible up to the age of 19, or if they are full-time students, up to age 23. Refer to Who is Eligible for Coverage for additional information.
Notice of Insured's Right to Examine Policy for Ten Days
Pennsylvania insurance law requires that you have an opportunity to request a full refund of the Premium and the one-time enrollment fee within ten days from the date you receive this copy of the Contract. The Contract may be returned to Delta at either of the addresses printed below. If you request this refund, no coverage will have been, or will be, provided. You will be responsible for any services obtained.
Provided by:
Delta Dental of Pennsylvania
One Delta Drive
Mechanicsburg, PA 17055
(800) 932-0783
Administered by:
Delta Dental Insurance Company
dba Delta Dental ("Delta Dental")
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12898 Towne Center Drive
Cerritos, CA 90703
800-422-4234
Dental Benefits will be provided as described in this Contract subject to all of the terms and conditions of the Contract.
This document is an Individual Benefit Contract ("Contract") for your DeltaCare USA Individual/Family Dental Program ("Program") provided by:
Delta Dental of Pennsylvania
One Delta Drive
Mechanicsburg, PA 17055
(800) 932-0783
This Contract discloses the terms and conditions of the Program available in Pennsylvania. Please read the entire document completely and carefully. You have a right to review this Contract prior to enrollment
This Program provides Benefits through contracting Dentists. Please read the following information so that you will know how to obtain dental services. Additional information about your Benefits is available by calling the Customer Service department at (800) 422-4234, 8 a.m. – 9 p.m., Eastern Time, Monday through Friday.
In the absence of fraud, all statements made by any Applicant or Applicants or the policyholder or by an insured person shall be deemed representations and not warranties. No statement made for the purpose of effecting insurance shall avoid such insurance or reduce Benefits, unless contained in a written instrument signed by the Applicant and a copy has been furnished to the Applicant. |
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