This is your Emergency Treatment Dental Policy. Please read it now and then keep it somewhere safe. The Policy and your application should be read together and form the contract of insurance. For any help or assistance please contact Lloyd & Whyte Ltd on 01823 250700. Your policy is arranged by Lloyd & Whyte Ltd and underwritten by PTI Insurance Company Limited.
We have defined below words or phrases used throughout this Policy. To avoid repeating these definitions please note that where these words or phrases appear they have the precise meaning described below unless otherwise stated.
Accident An injury caused by an identifiable direct impact outside of the oral cavity to an Insured Person’s teeth and gums or an internal violent oral impact that happens by chance and which could not have been anticipated (this includes damage to dentures whilst being worn).
Commencement Date The date when cover under this Policy commenced, or the date when the Insured Person joined the Policyholder’s dental plan, whichever is the later.
Cosmetic Treatment Treatment not necessary to maintain oral health and which is solely for the purpose of improving the Insured Person’s appearance.
Cover Cover for Treatment and benefits subject to the terms and conditions of this Policy.
Date of Entry The date when an Insured Person was included under this Policy. Dental Services Services normally undertaken by a dental practice, not otherwise excluded by this Policy. Dentist A fully qualified dental practitioner registered with the General Dental Council or any other person properly qualified and authorised to perform the Dental Services.
Emergency Treatment Dental Services or supplies provided for the immediate relief of severe pain, trauma, swelling or bleeding of an Insured Person by a Dentist out of usual business hours or where the emergency occured away from the Insured Person’s home or registered dental practice.
Insured Person A person who is a registered patient of the Policyholder resident in the United Kingdom and for whom the appropriate premium has been paid and whose name has been forwarded to Lloyd & Whyte Ltd in accordance with the terms of this Policy.
In-Patient An Insured Person who is admitted to hospital and stays for a period of at least 24 hours for the sole purpose of receiving Treatment on the recommendations of a Specialist.
Oral Cancer A malignant (invasive) tumour inside the mouth.
Orthodontics Treatment Treatment undertaken by a Dentist for the prevention and correction of irregularities of the teeth.
Period of Cover The Period of Cover set out following the registration and acceptance of an Insured Person on the Policyholder’s dental plan.
Permanent Facial Permanent facial scarring to part of the neck, face or head
Disfigurement normally exposed to view which has lasted for at least 12 months and is without prospect of recovery.
Policyholder/You/Your The dental practice from whom the premium is received. In the event of a claim it is understood that in certain circumstances settlement will be made to the principal Insured Person on behalf of the Policyholder where appropriate.
Policy This contract being Our contract with the Policyholder providing the Cover as detailed in this booklet. The application forms part of the Policy and must be read together with this document.
Review Date The anniversary of the common renewal date of the Policy, when the Policyholder has the option to renew the Policy.
Specialist A registered medical or dental practitioner who holds or has held a position in the NHS and is registered on the appropriate Specialist list of the General Medical Council or the General Dental Council.
Treatment Dental Services or supplies described in this Policy which are clinically necessary for the restoration of the oral health of an nsured Person provided that such services are:
a) provided by a Dentist;
b) provided in accordance with accepted standards of
c) received by an Insured Person during a Period of Cover
United Kingdom This comprises England, Scotland, Wales, & Northern Ireland, the Channel Islands and the Isle of Man.
We/Our/Us/Insurer PTI Insurance Company Limited.
The purpose of this Policy is to provide an Insured Person with Dental Services as described hereafter during the Period of Cover for Treatment of dental conditions by a Dentist.
We will pay for Emergency Treatment up to the maximum value of £200 per incident, related to Treatment within the United Kingdom or £400 for Treatments received outside of the United Kingdom provided that such Treatment is received by the Insured Person during the Period of Cover. An excess of £15 is applicable to each and every incident.
Treatments will be covered where the Insured Person receives Treatment away from their normal practice or at their normal practice outside of their published opening hours.
All charges for Treatment must be reasonable, fair, clinically necessary and in line with the normal published treatment charges of the treating dental practice.
If an Insured Person requires Treatment following an Accident occurring during the Period of Cover, benefit will be paid for the cost of such Treatment up to the limits specified below, up to a maximum annual aggregate of £12,000.
Treatment must be carried out by the Insured Person’s registered Dentist unless in an emergency.
If Treatment costs are likely to exceed £400 the Insured Person must call Lloyd & Whyte Ltd on 0845 130 1366 to obtain Our prior approval.
Item Treatment Description
a. (i) Porcelain jacket crown (ii) Ceramic bonded crown
b. Metal bonded porcelain crown
c. Bonded metal/porcelain bridge work
d. Full metal crown
Per unit £350
Per unit £475
Per retainer £420
Per pontic £275
Per unit £385
e. All metal bridge work
f. Laboratory constructed adhesive bridge
g. Laboratory constructed adhesive facing or veneer
h. (i) Permanent denture acrylic
(ii) Permanent denture metal
i. Temporary denture following tooth loss where required
(i) Laboratory made temporary bridge following
j. tooth loss (where required)
(ii) Additional units
k. Emergency and other Treatment following dental injury not otherwise specified
(i) Root canal Treatment incisor
l. (ii) Root canal Treatment canine
(iii) Root canal Treatment premolar
(iv) Root canal Treatment molar
Per retainer £325
Per pontic £295
Per retainer £220
Per pontic £215
Per unit £350
Per denture £410
Per incident £180
Up to 3 units £145
Per unit £30
Per incident £420
Per incisor £210
Per canine £210
Per premolar £250
Per molar £365
Per tooth £1,500
Where Treatment involves replacing any crown, bridge facing, veneer or denture, benefit shall be paid according to the cost of a replacement of similar quality within the limits of the Policy.
All charges for Treatment must be reasonable, fair, clinically necessary and in line with the normal published treatment charges of the treatment charges of the treating dental practice.
1. We will not be liable for Treatment directly or indirectly consequent upon:
(i) intra-oral injury caused by foodstuffs in the course of consumption.
(ii) normal wear and tear.
(iii) injury whilst participating in boxing, martial arts, rugby and shinty (other than school rugby/shinty) unless appropriate mouth protection is worn.
(iv) injury caused otherwise than by direct extra-oral impact.
(v) damage which is not apparent within seven days of the date of impact resulting in dental injury.
(vi) damage to dentures occurring other than whilst being worn.
2. We will not pay for any costs incurred by Insured Person more than 18 months after the date of Accident.
3. We shall not be responsible for the first £15 of each and every incident.
If an Insured Person is admitted to hospital as an In-Patient, as a direct result of a dental Accident or for Emergency Treatment, We will pay £85 for each complete 24 hours the Insured Person remains in hospital under the care of a Specialist.
Exclusions to Section 3
1. No payment will be made under this section if a payment is made under section 4 – Oral Cancer.
2. We will not pay for more than 365 days of hospital benefit during any Period of Cover.
If an Insured Person is diagnosed with Oral Cancer We will pay the Insured Person a £3,000 cash benefit. We will only pay this sum for Oral Cancer once the Insured Person has been referred to a Specialist by their general practitioner or Dentist.
1. Benefit under this section will only be paid once per Insured Person and thereafter Cover under the Policy will cease and no refund of premium will be payable by us.
2. Benefit under this section in respect of the Insured Person will only be paid when Oral Cancer is diagnosed by a Specialist in cancer Treatment by the NHS.
This section does not cover:
1. Oral Cancer diagnosed before the Insured Person joined the Emergency Treatment Plan.
2. Cancer or tumours of the throat or any other cancers.
3. Oral Cancer which is related in any way to an HIV infection or AIDS.
4. Oral Cancer resulting from chewing tobacco products (including betel nut juice).
5. Reimbursement for any charges or fees including charges for consultation or tests for invasive/non-invasive tumours.
6. Any cancer resulting from failure to follow medical advice.
If an Insured Person suffers Permanent Facial Disfigurement as a result of an Accident during the Period of Cover We will pay the Insured Person the appropriate benefit according to the severity of the scaring as follows:
(i) Scarring up to 5 cms long in total length – £55
(ii) Scarring more than 5 cms but less than 8 cms in total length – £110
(iii) Scarring 8 cms or more in total length – £550
In respect of all sections, benefits will not be available for:
1. Treatment which a Dentist is unable to provide due to circumstances beyond the control of such Dentist.
2. Services or supplies which are not described in this Policy.
3. Cosmetic Treatment.
4. Services, supplies or drugs which are experimental in nature, or not normally supplied by a dental practice.
5. Dispensing and providing prescription drugs (unless they are antibiotics needed for Emergency Treatment).
7. Any Treatment resulting from self-inflicted injury.
8. Any charges for the completion of the claim form or the submission of a claim.
9. Dental implants.
10. Any costs associated with the administration of general anaesthetics.
11. Charges incurred by the Insured Person resulting from broken appointments.
12. Injuries sustained while engaged in illegal or unlawful activities.
Our liability under this Policy will be conditional upon each Insured Person complying with its terms and conditions and the Policyholder paying or agreeing to pay the premium to Us.
The Policyholder must inform Us, as soon as reasonably possible, of any changes relating to Insured Persons (such as address or other personal details) which affect information given in connection with the application for Cover under this Policy.
a. The Policy shall be for one year and may be continued subject to the terms in force at the time of each Review Date.
b. If the Insured Person obtains Cover after the Commencement/Review Date, the Period of Cover shall be for the period up until the following Review Date and annually renewable thereafter.
c. The premium payable shall be that prevailing generally at the Commencement Date or if later, the appropriate Review Date.
d. The premium payable may be changed by Us from time to time. However, this Policy will not be subject to any alteration in payment rates generally introduced until the next Review Date.
a. Cover will not apply where an Insured Person no longer meets the eligibility criteria of the dental plan.
b. This Policy will be cancelled automatically upon non-payment of the Premium.
c. Whilst We shall not cancel this Policy because of eligible claims made by any Insured Person We may at any time terminate an Insured Person’s Cover or subject his/her Cover to different terms if he/she or the Policyholder has at any time:
(i) misled Us by mis-statement or concealment;
(ii) knowingly claimed benefits for any purpose other than as are provided for under this Policy;
(iii) agreed to any attempt by a third party to obtain unreasonable financial gain to Our detriment;
(iv) otherwise failed to observe the terms and conditions of this Policy or failed to act with utmost good faith.
d. If We cancel the Policy or any Insured Person’s Cover We shall give You 30 days notice sent by first class post to Your last known address. If We do so, You may be entitled to a proportionate refund of premium.
a. The Insured Person should pay for the Treatment provided prior to making a claim.
b. It is a condition of the Policy that all claims are accompanied by a fully completed and signed claim form or a fully itemised printed receipt from the Dentist administering Treatment detailing:
(i) Treatment administered and date of Treatment.
(ii) fully itemised fee breakdown.
(iii) Dentist’s registration details and practice address.
The completed and signed form with all relevant receipts attached, should be returned to Lloyd & Whyte Ltd, Affinity House, Bindon Road, Taunton, Somerset, TA2 6AA.
c. Reimbursement is available only if the Treatment is provided by a Dentist.
d. If any benefit is provided or any payment is made under this Policy as a result of an action by a third party then the Insured Person must:
(i) give Us full details of the potential claim against a third party;
(ii) allow Us to pursue any loss under this Policy at Our expense;
(iii) help Us to take legal action if We ask the Insured Person to.
All claims must be notified (and supporting documentation supplied) within 60 days of the date of completion of a course of Treatment. We will not be liable in respect of any claim notified late unless You provide an explanation for the delay satisfactory to Us.
The Insured Person must obtain at their own expenses from the hospital, their general practitioner, or their Dentist, confirmation of the period of hospitalisation and if requested, any further information to confirm the validity of the claim.
Subject to condition 7 above if an Insured Person requires Emergency Treatment when abroad they should simply obtain the Emergency Treatment needed and ask for the invoice to be written in English and on return to the UK pass it to their registered practice who will then forward it to Lloyd & Whyte Ltd, Affinity House, Bindon Road, Taunton, Somerset, TA2 6AA.
Reimbursement will be in sterling at the equivalent UK benefit scale using the exchange rate in force at the date of the claim settlement.
When there is a dispute over the amount to be paid for a claim under this Policy, the dispute must be referred to an arbitrator to be agreed between You and Us in accordance with the law at the time. When this happens, a decision must be made before You can take any legal action against Us.
We may alter any of the terms of this Policy at any Review Date. Details of the change will be advised to You at such time.
If any claim under this Policy is in any respect fraudulent or unfounded all benefit paid and/or payable in relation to that claim shall be forfeited and (if appropriate) recoverable by Us.
Without prejudice to any other right or remedy We may have against any third party, if there is any other insurance covering any of the same benefits You must disclose or procure that the relevant Insured Person discloses the same to Us. We shall not be liable to pay or contribute more than Our rateable proportion. Any payment or contribution over and above such liability shall be at our absolute discretion and shall be without prejudice to this condition.
Waiver by Us of any term or condition of this Policy will not prevent Us from relying on such term or condition afterwards.
All settlements will be made by cheque made payable to the Insured Person.
We have every reason to believe that You will be totally satisfied with the Policy. However, should You have any concern relating to the Policy or Our service, please write quoting the Policy number together with full details of Your complaint to:
PTI Insurance Company Limited
If You are still not satisfied you can ask the Financial Ombudsman Service (which is entirely in-dependent) at the address below to review Your case without effecting Your right to take legal action;
The Financial Ombudsman Service
Harbour Exchange Square
Tel: 0845 080 1800
Please note that the Financial Ombudsman Service will not consider Your complaint until You have received a final decision from PTI Insurance Company Ltd.
We are covered by the Financial Services Compensation Scheme (FSCS). You may be entitled to compensation from the FSCS if We cannot meet Our obligations. Insurance advising and arranging is covered at 90% of the claim, without any upper limit.
This contract shall be governed by and construed in accordance with English Law unless:
i) You and the Insurer agree otherwise; or
ii) At the date of the contract You are resident of (or, in the case of a business, the registered office or principal place of business is situated in) Scotland or Northern Ireland, in which case (in the absence of agreement to the contrary) the law of that country will apply.
Arranged through Lloyd & Whyte Ltd
Affinity House, Bindon Road, Taunton, Somerset, TA2 6AA
Tel: 01823 250700
Fax: 01823 270357
Lloyd & Whyte Ltd is authorised and regulated by the Financial Conduct Authority. Calls may be recorded for use in quality management, training and customer support.
PTI Insurance Company Limited (PTI) are authorised and regulated in Gibralter by the Financial Services Commission (www.fsc.gi) registration number 33927 and in the United Kingdom by the Financial Conduct Authority (www.fca.gov.uk) registration number 202886. PTI are also members of the Association of British Insurers and subscribe to the Financial Ombudsman Service.