Professional Dental Care is an Absolute Necessity for Living a Healthy, Happy and Productive Lifestyle

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HIGHLIGHTS OF THE Q-DENT PLAN

  Fully complies with all Louisiana Insurance Laws.

  Louisiana owned, administered and underwritten.

  No waiting periods.

  No annual of lifetime maximums.

  No claim forms.

  No deductible.

  Most pre-existing conditions
are covered.

  Doctor supported.

Membership Summary

Membership Agreement

Subscription Instructions

Participating Dentists

Benefit Schedule

Rate Schedule

The Q-Dent Membership Agreement

When used in this membership agreement, the following words and terms are defined/as follows: Subscriber, means the person who signed the Application. Member, means the subscriber who is named on the ID-Card, including his or her family members who are named on page one of the memberís policy. You and your, also means the member. Family Members, means:(1) The member;(2) The memberís spouse;(3) The Members children until the age of 26 and grand children who are in the legal custody of and residing with the grandparent until the age of 26; (4) the members unmarried children who are dependent on the member for their support due to mental retardation or physical handicap. Policy, means the companyís prepaid dental insurance policy issued to the member in association with membership in the plan. Company, means Guaranty Income Life Insurance Company. We, us, and our, also means the company. Q-Dent, means the trade name used by the company to market and administer the plan. Plan, means the Q-Dent Dental Plan. ID-Card, means the official identification card issued to plan members. Effective Date, means the date printed as such on the ID-Card. Waiting Period, means any number of days between the effective date and the eligibility date. Eligibility Date, means the date printed as such on the ID-Card. Dentist, means any person who is licensed to practice dentistry. Family Dentist, means a dentist whose practice generally includes to a limited degree all phases of dentistry. Participating Dentist, means any family dentist who is willing to contract with us to service your policy. The term Non-participating Dentist, means any dentist who is not willing to contract with us to service your policy for the capitation payments the company pays and the co-payments you must pay. Dental Services, means all dental services that selected dentists are capable of performing for their patients. Dental Specialist, means any dentist who limits his practice to a dental specialty and is recognized as such by the Louisiana State Board of Dentistry. Participating Specialist, means a specialist who is willing to contract with us to provide the benefits included in section 5, of the policy. Specialist Dental Services, means any dental service that your selected dentist determines is beyond the scope of his or her dental practices. Monthly Premium, means the aggregate of charges for membership fees and the policy for one ďbenefit periodĒ as defined by section 2:03 of this agreement.

SECTION 1 - MEMBERSHIP SUMMARY

1:01 MEMBERSHIP SUMMARY: The Q-Dent Dental Plan will contract with all dentists, who are willing to participate, to provide dental services for their patients who are members. The Q-Dent Dental Plan is like an HMO (Health maintenance Organization) who contracts with doctors to provide medical services for their members. A Q-Dent member pays a monthly premium. Each month, Q-Dent pays most of a members premium to a dentist, who was participating before, or who was willing to participate after, being chosen by a Q-Dent member. The Q-Dent payments, all capitation (a uniform per capita payment of a fee per person), are paid monthly to your selected dentist, though a Q-Dent member may not need monthly dental services. When a Q-Dent member needs dental services, Q-dentís capitation payments have prepaid all, or some of the cost, of most dental services a member will generally need.

1:02 NO CHARGE SERVICES: A member does not pay an extra charge to a selected dentist for dental services that are fully prepaid by Q-Dentís monthly capitation payments. The policyís schedule of benefits list NONE on the same line that describes the policyís full prepaid dental services.

1:03 CO-PAYMENT SERVICES: A member pays an extra charge (Co-Payment) to a selected dentist for dental services that were not fully prepaid by Q-Dentsí monthly capitation payments. The policyís schedule of benefits lists that amount of Co-Payment needed to cover the remainder of the cost for dental services, that describes the policyís partially prepaid dental services. Under the terms and provisions of the agreement you must pay all CO-PAYMENTS to your selected dentist.

1:04 USUAL CHARGE SERVICES: Dental services that are not included as a benefit in the planís prepaid dental insurance policy are also available to you at your selected dentistís USUAL CHARGE for such dental services.

1:05 USUAL CHARGE DEFINED: usual charge means the amount usually charged by a dentist for dental services; a dentist determines what is within the scope of his or her dental practice. Usual charge may vary due to the unique and individual nature of treatment and the geographical location of a dentistís dental practice. A dentist establishes his or her own usual charge.

1:06 CHOOSING A DENTIST: You must choose a family dentist who is willing to service your policy. Q-Dent will furnish a directory of the dentists who participate in the plan, and who will accept your policy. All family members must use the same selected dentist. Before you choose a dentist, take time to check your familyís dental care needs. You may want to call the dentist you are considering before making your choice. Q-Dent expects you to stay with the first family dentist you choose for at least one year. You should not hurry this important decision. You may choose and name a dentist on your membership subscription or your may choose a dentist at another time by calling Q-Dent locally at (225)664-1698 or toll free at 1-800-349-3368.

1:07 CHOOSING A NON-PARTICIPATING DENTIST: Under Louisiana law, you have the right to choose the dentist of your choice to furnish dental services offered by this plan, provided the dentist agrees to accept the same payments as a participating dentist, otherwise, you will derive only limited benefits as explained in Section 2:08 of your Policy. This law does not require non-participating dentists to accept you as their patient for delivery of the benefits included in your policy. We are also not required to pay you the difference between the co-payments if the policy and the amounts actually charged by non-participating dentists for similar dental care they perform. We permit all licensed dentists to participate in the plan, therefore, we will not assume liability for any amounts paid by a member to any non-participating dentists.

1:08 SCHEDULING APPOINTMENTS: Participating dentists do not know they were chosen until they receive their first capitation check from Q-Dent. Dentists receive their first capitation check from Q-Dent on the eligibility date shown on the ID-Card. After the eligibility date, selected dentists will schedule appointments based on the availability of their time, taking into consideration the urgency of the membersí dental service needs. Appointments scheduled by a selected dentist on behalf of family members must be honored. Broken appointments without 24 hour notice are subject to charge.

1:09 WE MAY REQUIRE YOU TO CHOOSE ANOTHER DENTIST: Participating dentists maintain control of the dental practice when they participate as dental providers for this plan. Under this provision of the membership agreement, we may require you to choose another dentist for any of the following reasons: (1) W hen a memberís selected dentist cancels his or her partici-pating dentist agreement; (2) When a member chooses a participating dentist who is no longer accepting Q-Dent members; (3) When a memberís selected dentist wants to reduce the number of policies his or her dental practice will service; (4) When a member chooses a dentist who is not willing to participate to contract with us to service a memberís policy for our capitation payments and the policyís co-payments.

1:10 YOU MAY CHOOSE ANOTHER DENTIST: We only approve dental provider changes during the initial membership subscription term under limited circumstances. All requests to choose another dentist are approved at our discretion based on the facts surrounding the request. After completing the initial membership subscription term, following our approval, you may choose another dentist provided all premiums and co-payments are currently paid.

1:11 EMERGENCY DENTAL SERVICE: Emergency dental services may be performed for you by any dentist, provided your selected dentist is not available or the distance to travel to your selected dentist exceeds thirty-five (35) miles. We will reimburse you for the actual charge by any dentist, limited to fifty dollars ($50.00) per emergency and one hundred dollars ($100.00) per year, for any one policy upon receipt of proof acceptable to us that a bona fide emergency existed. Such proof must be furnished to us within thirty (30) days of such emergency treatment.

SECTION 2 - MEMBERSHIP PROVISIONS

2:01 MEMBERSHIP SUBSCRIPTION: The initial membership subscription is for a one year term. The subscriberís signature on the membership subscription constitutes acceptance of the terms and provisions of this Membership Agreement that will accompany your ID-Card. The initial membership subscription term begins on the effective date as shown on your ID-Card.

2:02 PREMIUM PAYMENTS: Several premium payment modes are available to a subscriber for payment of the premium. The premium payment mode selected by a subscriber determines the annual premium for the initial membership subscription term.

2:03 BENEFIT PERIODS: Q-Dent operates exclusively on a monthly basis. Each calendar month constitutes a separate benefit period. Each monthly premium must be paid ten days in advance of each new benefit period to allow Q-Dent to pay the required monthly capitation pay-ment to your selected dentist by the first day of each new benefit period. Membership benefits are suspended for the next new benefit period if the monthly premium is not paid by the member ten days in advance of each new benefit period.

2:04 YOU MAY CANCEL: Following the initial membership subscription term, or during the initial membership subscription term in the event that you move to any location where the plan does not have participating family dentist available to service your policy, you may cancel your membership subscription at any time by giving us thirty (30) days written notice. During the initial membership subscription term, or any time thereafter, you may cancel your membership subscription with or without notice provided we cancel your prepaid dental insurance policy that is associated with membership in the plan.

2:05 WE MAY CANCEL: Following the initial membership subscription term, we may cancel your membership at any time by giving you (60) days written notice. During the initial membership subscription term, or any time thereafter, we may cancel your membership subscription with or without notice provided we cancel your prepaid dental insurance policy.

2:06 AUTOMATIC RENEWAL OF POLICY: Following the initial membership subscription term, your policy will automatically renew for a new membership subscription term of one year. If renewal is not desired you must notify us in writing at least thirty (30) days prior to maturity of initial membership subscription term.

2:07 MEMBERSHIP AGREEMENT SEPARATE FROM POLICY: This membership agreement is a separate agreement from the policy that is between the company and the member. Membership in the plan is required for the subscriber to qualify for the companyís prepaid dental insurance policy.

2:08 TEN DAY RIGHT TO EXAMINE MEMBERSHIP AGREEMENT: Within ten days after this membership agreement is received by the subscriber the membership subscription may be canceled without reason by returning the ID-Card to Q-Dent. Use of the ID-Card during this ten day period constitutes acceptance of the terms and provisions of this membership agreement that will accompany the ID-Card.

SECTION 3 - CHANGE OF STATUS

3:01 DROPPING FAMILY MEMBER COVERAGE: Membership benefits cease for unmarried family members at age 24 in all cases. Membership benefits cease for family members under the age of 24 upon marriage. Membership benefits cease upon final decree of divorce with respect to your spouse. Upon dropping coverage for a family member, the premium will be the appropriate amount for the remaining family members and shall be adjusted on the next monthly premium due date following the month that coverage for a family member was dropped.

3:02 ADDING FAMILY MEMBER COVERAGE: You must give us thirty (30) days written notice to add coverage for additional family members. Upon such notification, when applicable, we will determine the new premium. All benefits are excluded for family members who are not named on page one of the policy.

3:03 CHANGING GROUP MEMBERSHIP STATUS: If membership was obtained by being an employee or an affiliate of a group, you may keep the policy on an individual basis after termination of such employment or affiliation. You may add family members or change the premium payment mode. Forms for any change of status will by supplied by Q-Dent upon request.

SECTION 4 - GENERAL PROVISIONS

4:01 ENTIRE CONTRACT: This membership agreement as delivered to the subscriber constitutes the entire agreement. No changes to this membership agreement are valid until we approve them in writing. No agent has authority to change or waive any terms or provisions of this membership.

4:02 PLACE OF AGREEMENT: This membership agreement shall be interpreted according to Louisiana Law. Any action or claim under this agreement must be brought within the State of Louisiana.

4:03 ASSIGNMENT: Benefits afforded by this membership agreement are non-assignable.

4:04 NOTICES: All notices and requests required by this membership agreement shall be in writing and sent through the U.S. mail by prepaid first class postage. The date of the postmark shall determine the timeliness of such notices and requests. Notices and requests to us shall be given to Q-Dent, Post Office Box 735, Denham Springs, LA 70727-0735. Notices to you shall be mailed to your last known address.


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