This document is a sample only. As the plan administrator, the Company has the obligation to provide participants with the summary plan description and/or plan document. Vitable is not a legal advisor. Vitable recommends that the Company’s counsel reviews and edits this document. Instead of the plan document, you may need an amendment to any existing wrap plan document to include the plan in your consolidated health plan Form 5500.

PLAN DOCUMENT AND

SUMMARY PLAN DESCRIPTION

FOR

Vitable Health Dental Benefit Plan

EFFECTIVE DATE:______________

Type of Plan: The Plan is a self-funded employee benefit plan.

Type of Administration: The administration of the Plan is provided through a Third-Party Claims Administrator. Plan benefits may be self-funded through a benefit fund, or a trust established by the Plan Sponsor and self-funded with contributions from Employees and/or the Plan Sponsor. The Plan is not insured.

Employer

[Employer to provide employer specific information as detailed in the Vitable contract:_______________________]

Claims Administrator

Imagine360 Administrators, LLC

1550 Liberty Ridge Drive, Suite 330

Wayne, PA 19087

(972) 238-7900 or (800) 827-7223

The Plan Administrator has retained the services of the Claims Administrator to administer Claims under the Plan.

The Plan Sponsor [to be provided by employer as detailed in the Vitable contract:______________________] sponsors the Plan for its eligible employees and dependents. The Plan Sponsor has contracted with Imagine360 to provide claims processing and other Plan administration services.

It is important that You review this document carefully as it describes Plan benefits and Your rights and responsibilities under the Plan. Failure to follow the eligibility or enrollment requirements of this Plan may result in delay of coverage or no coverage at all. Reimbursement from the Plan can be reduced or denied because of certain provisions in the Plan, such as coordination of benefits, subrogation, exclusions, utilization review or other cost management requirements, lack of Medical/Dental Necessity, lack of timely filing of claims, or lack of coverage.

The Plan will pay benefits only for the expenses Incurred while this coverage is in force. No benefits are payable for expenses Incurred before coverage began or after coverage terminated. An expense for a service or supply is Incurred on the date the service or supply is furnished.

All benefits described in this Plan Document are subject to the exclusions and limitations described more fully herein including, but not limited to, the Plan Administrator's determination that: care and treatment is Medically/Dentally Necessary; charges are Usual and Reasonable; and services, supplies, and care are not Experimental and/or Investigational. The meanings of these capitalized terms are in the Definitions section of this document.

This document is intended to describe the benefits provided under the Plan but, due to the number and wide variety of different medical/dental procedures and rapid changes in treatment standards, it is impossible to describe all Covered Dental Services and/or exclusions with specificity. Please contact the Claims Administrator regarding questions about specific supplies, treatments, or procedures.

Eligible Classes of Employees.

All Active Employees of the Employer.

Eligibility Requirements for Employee Coverage. A person is eligible for Employee coverage if he or she meets the requirements [to be provided by employer as detailed in the Vitable contract:______________________] .

Eligible Classes of Dependents. A “Dependent” is any one of the following persons:

The term “Spouse” shall mean the person to whom the covered Employee is legally married.

This Plan does not allow coverage for common-law marriage.

The Plan Administrator may require documentation proving a legal marriage.

The term “Spouse” will also include “Domestic Partner” which shall mean a covered Employee’s partner with whom a Domestic Partnership has been established, and any Employer required documentation has been received and accepted by the Employer.

A covered Employee's “Dependent child” includes natural child, Stepchild, adopted child, Domestic Partner’s natural child, a child placed with the covered Employee in anticipation of adoption, or children for whom the Employee or covered Spouse is Legal Guardian. A Dependent child will be eligible until reaching the limiting age of 26.

A “Stepchild” means a child of the Spouse who meets the eligibility requirements of this Plan for whom a covered Employee is the stepparent of the child(ren).

“Legal Guardian” means a person recognized by a court of law as having the duty of taking care of and managing the property and rights of a minor child.

The phrase “child placed with a covered Employee in anticipation of adoption” refers to a child whom the Employee intends to adopt, whether or not the adoption has become final, who has not attained the age of 18 as of the date of such placement for adoption. The term “placed” means the assumption and retention by such Employee of a legal obligation for total or partial support of the child in anticipation of adoption of the child. The child must be available for adoption and the legal process has been initiated.

A child of a covered Employee who is an alternate recipient under a Qualified Medical Child Support Order (QMCSO) shall be considered as having a right to Dependent coverage under this Plan. A Participant of this Plan may obtain, without charge, a copy of the procedures governing QMCSO determinations from the Plan Administrator.

Please be advised, the definition of “Dependent” may not be the same definition as established by the Internal Revenue Code (IRC) for individuals that the covered Employee is permitted to pay qualified medical expenses from a Health Savings Account (HSA), or individuals that can be enrolled as an eligible Dependent for tax-free benefits (i.e., non-IRC Section 152 dependent). There may be tax implications for the Employee if he or she enrolls certain eligible Dependent(s). The Employee should consult his or her tax advisor with any questions on the tax consequences of benefits for his or her eligible Dependent(s).

The Plan Administrator may require documentation proving dependency, including birth certificates or initiation of legal proceedings severing parental rights.

After such two-year period, the Plan Administrator may require subsequent proof not more than once each year. The Plan Administrator reserves the right to have such Dependent examined by a Physician of the Plan Administrator's choice, at the Plan's expense, to determine the existence of such incapacity.

These persons are excluded as Dependents: Other individuals living in the covered Employee’s home, but who are not eligible as defined above; the divorced former Spouse of the Employee, former Domestic Partner of the Employee, grandchild(ren), foster child(ren), or any person who is covered under the Plan as an Employee.

If a Plan Participant covered under this Plan changes status from Employee to Dependent or Dependent to Employee, and the Plan Participant is covered continuously under this Plan before, during and after the change in status, credit will be given for deductibles and all amounts applied to maximums.

If both parents are Employees, their children may be covered as Dependent children of one of the parents, but not of both.

Eligibility Requirements for Dependent Coverage. A family member of an Employee will become eligible for Dependent coverage on the first day that the Employee is eligible for Employee coverage and the family member satisfies the requirements for Dependent coverage.

At any time, the Plan may require proof that a Spouse or a child qualifies or continues to qualify as a Dependent as defined by this Plan.

Please note that the Employee is solely responsible to notify the Plan when their dependent no longer qualifies as an eligible dependent for coverage under the Plan. Failure to timely notify the Plan may result in such Dependent’s coverage being retroactively or prospectively terminated and a loss of Your Dependent’s right to elect COBRA continuation coverage.

ACQUISITIONS

Employees who were enrolled under the health plan of an acquired company or in their eligibility waiting period, if applicable, as of the day before the date of acquisition, will be eligible to enroll themselves and their previously enrolled eligible Dependents for benefits under this Plan as of the date of acquisition, on the date of termination of the acquired company’s benefit plan, or upon satisfaction of the eligibility waiting period, whichever is later. Any deductibles and maximum out-of-pocket amounts previously satisfied under the prior health plan will not be applied toward the coverage under this Plan.

An acquired Employee (and their Dependents) who were not actively enrolled under the health plan offered by the acquired company, will not be eligible to enroll under this Plan until open enrollment or during a Special Enrollment event.

In the event that an acquired company did not have a health plan, all acquired Employees who otherwise meet the eligibility requirements of this Plan (and their eligible Dependents), will be eligible to enroll as of the date of the acquisition, subject to the eligibility waiting period.

Effective Date of Employee Coverage. An Employee will be covered under this Plan [effective date: ] once the Employee satisfies all of the following:

1. The Eligibility Requirement.

2. The Active Employee Requirement.

3. The Enrollment Requirements of the Plan.

Active Employee Requirement. An Employee must be an Active Employee (as defined by this Plan) for this coverage to take effect.

Effective Date of Dependent Coverage. A Dependent's coverage will take effect on the day that the Eligibility Requirements are met; the Employee is covered under the Plan; and all Enrollment Requirements are met.

Enrollment Requirements. An Employee must enroll for coverage by completing an enrollment application along with the appropriate payroll deduction authorization, if applicable. If Dependent coverage is desired, the covered Employee will be required to enroll the Dependent(s).

Enrollment Requirements for Newborn Children.

A newborn child of a covered Employee must be enrolled in the Plan on a timely basis, as defined in the section “Timely Enrollment” following this section, for there to be coverage for the newborn from the date of birth.

TIMELY OR LATE ENROLLMENT AND OPEN ENROLLMENT

If two Employees are covered under the Plan and the Employee who is covering the Dependent children terminates coverage, the Dependent coverage may be continued by the other covered Employee with no waiting period as long as coverage has been continuous.

Unless otherwise required by law, if an individual loses eligibility for coverage as a result of terminating employment, reduction of hours of employment or a general suspension of coverage under the Plan, then upon becoming eligible again due to resumption of employment or due to resumption of Plan coverage, only the most recent period of eligibility will be considered for purposes of determining whether the individual is a Late Enrollee.

The time between the date a Late Enrollee first becomes eligible for enrollment under the Plan and the first day of coverage is not treated as a waiting period. Coverage begins as stated in the Open Enrollment section below.

Plan Participants will receive detailed information regarding open enrollment from their Employer.

SPECIAL ENROLLMENT PERIODS

Federal law provides Special Enrollment provisions under some circumstances. The events described below may create a right to enroll in the Plan under a Special Enrollment Period.

To request Special Enrollment or obtain more detailed information of these portability rules, contact the Plan Administrator.

An Employee or Dependent who is eligible, but not enrolled in this Plan, may enroll if the individual loses eligibility for other coverage and the loss of eligibility for coverage meets all of the following conditions:

a. The Employee or Dependent was covered under a group health plan or had health insurance coverage at the time coverage under this Plan was previously offered to the individual; and

b. If required by the Plan Administrator, the Employee stated in writing at the time that coverage was offered that the other health coverage was the reason for declining enrollment; and

c. Either (i) the other coverage was COBRA coverage and the COBRA coverage was exhausted, or (ii) the other coverage was not COBRA coverage, and the coverage was terminated as the result of loss of eligibility for the coverage or because employer contributions towards the coverage were terminated; and

d. The Employee or Dependent requests enrollment in this Plan after the date of exhaustion of COBRA coverage or the termination of non-COBRA coverage due to loss of eligibility or termination of employer contributions, described above.

For purposes of these rules, a loss of eligibility occurs if one of the following occurs:

i. The Employee or Dependent has a loss of eligibility due to the other plan no longer offering any benefits to a class of similarly situated individuals (for example: part-time employees).

ii. The Employee or Dependent has a loss of eligibility under the other plan as a result of legal separation, divorce, termination of domestic partnership, cessation of dependent status (such as attaining the maximum age to be eligible as a dependent child under the Plan), death, termination of employment, or reduction in the number of hours of employment or contributions towards the coverage were terminated.

iii. The Employee or Dependent has a loss of eligibility when the other coverage is offered through an HMO, or other arrangement, in the individual market that does not provide benefits to individuals who no longer reside, live or work in a service area, (whether or not within the choice of the individual).

iv. The Employee or Dependent has a loss of eligibility when coverage is offered through an HMO, or other arrangement, in the group market that does not provide benefits to individuals who no longer reside, live or work in a service area, (whether or not within the choice of the individual), and no other benefit package is available to the individual.

If the Employee or Dependent lost the other coverage as a result of the individual's failure to pay premiums or required contributions or for cause (such as making a fraudulent claim or an intentional misrepresentation of a material fact in connection with the plan), that individual does not have a Special Enrollment right.

then the Dependent may be enrolled under this Plan. If the Employee is not enrolled at the time of the event, the Employee must enroll under this Special Enrollment Period in order for their eligible Dependents to enroll.

To be eligible for this Special Enrollment, the Dependent and/or Employee must request enrollment during this period.

In the case of birth, adoption, or placement for adoption, marriage and domestic partnerships, the Spouse/Dependents of the covered Employee may also be enrolled as a Dependent of the covered Employee if the Spouse/Dependent is otherwise eligible for coverage.

Employees and their Dependents who are otherwise eligible for coverage under the Plan, but who are not enrolled, can enroll in the Plan provided they request enrollment in writing within 60 days from the date of the following loss of coverage or gain in eligibility if:

If eligible, the Employee and/or Dependent may enroll under this Plan. If the Employee is not enrolled at the time of the event, he or she must enroll under this Special Enrollment Period in order for their eligible Dependent to enroll.

This Special Enrollment Period is a period of 60 days and begins on the date of the loss of coverage under the Medicaid or CHIP plan or on the date of the determination of eligibility for a premium subsidy under Medicaid or CHIP. To be eligible for this Special Enrollment, the Employee must request enrollment in writing during this 60-day period. The effective date of coverage will be the first day of the first month following the date of loss of coverage or gain in eligibility.

If a State in which the Employee lives offers any type of subsidy, this Plan shall also comply with any other State laws as set forth in statutes enacted by State legislature and amended from time to time, to the extent that the State law is applicable to the Plan, the Employer, and its Employees.

For more information regarding special enrollment periods, contact the Plan Administrator.

The Employer or Plan has the right to rescind any coverage of the Employee and/or Dependents for cause, making a fraudulent claim or an intentional material misrepresentation in applying for or obtaining coverage, or obtaining benefits under the Plan. The Employer or Plan may either void coverage for the Employee and/or covered Dependents for the period of time coverage was in effect, may terminate coverage as of a date to be determined at the Plan's discretion, or may immediately terminate coverage. If coverage is to be terminated or voided retroactively for fraud or misrepresentation, the Plan will provide at least 30 days' advance written notice of such action. The Employer will refund all contributions paid for any coverage rescinded; however, claims paid will be offset from this amount. The Employer reserves the right to recoup Plan payments by any method allowed by law.

When Employee Coverage Terminates. Employee coverage will terminate on the earliest of these dates:

1. The date the Plan is terminated or amended such that the covered Employee loses coverage;

2. The date the covered Employee ceases to be in one of the Eligible Classes, or, if applicable, the last day of the stability period for which the covered Employee met the required minimum hours of service established by the Employer. This includes death or termination of active employment of the covered Employee. (See the section entitled COBRA Continuation Coverage.) It also includes an Employee on disability or leave of absence, unless the Plan specifically provides for continuation during these periods;

3. The end of the period for which the required contribution has been paid if the charge for the next period is not paid when due; or

4. As otherwise specified in the Eligibility section.

Note: Except in certain circumstances, a covered Employee may be eligible for COBRA Continuation Coverage. For a complete explanation of when COBRA Continuation Coverage is available, what conditions apply and how to select it, see the section entitled COBRA Continuation Coverage.

Continuation During Family and Medical Leave. When applicable, this Plan shall at all times comply with the Family and Medical Leave Act of 1993 (FMLA) as promulgated in regulations issued by the Department of Labor and amended from time to time, if, in fact, FMLA is applicable to the Employer and all of its Employees and locations. This Plan shall also comply with any other State leave laws as set forth in statutes enacted by State legislature and amended from time to time, to the extent that the State leave law is applicable to the Employer and its Employees covered by this Plan. Leave taken pursuant to any other State leave law shall run concurrently with leave taken under FMLA, to the extent consistent with applicable law.

If applicable, during any leave taken under the FMLA and/or other applicable State leave law, the Employer will maintain coverage under this Plan on the same conditions as coverage would have been provided if the covered Employee had been continuously employed during the entire leave period.

If Plan coverage terminates during the FMLA, coverage will be reinstated for the Employee and their covered Dependents if the Employee returns to work in accordance with the terms of the FMLA and/or other State leave law. Coverage will be reinstated only if the person(s) had coverage under this Plan when the FMLA leave started and will be reinstated to the same extent that it was in force when that coverage terminated.

Outside of FMLA, this Plan does not offer a continuation of coverage policy for an Employee and enrolled Dependents if the Employee’s active, full-time work ceases.

Employees on Military Leave. Employees going into or returning from military service may elect to continue Plan coverage as mandated by the Uniformed Services Employment and Reemployment Rights Act (USERRA) under the following circumstances. These rights apply only to Employees and their Dependents covered under the Plan immediately before leaving for military service.

1. The maximum period of coverage of a person under such an election shall be the lesser of:

a. The 24-month period beginning on the date on which the person's absence begins; or

b. The day after the date on which the person was required to apply for or return to a position of employment and fails to do so.

2. A person who elects to continue group health plan coverage must pay up to 102% of the full contribution under the Plan, except a person on active duty for 30 days or less cannot be required to pay more than the Employee's share, if any, for the coverage.

3. An exclusion or waiting period may not be imposed in connection with the reinstatement of coverage upon reemployment if one would not have been imposed had coverage not been terminated because of service. However, an exclusion or waiting period may be imposed for coverage of any Illness or Injury determined by the Secretary of Veterans Affairs to have been Incurred in, or aggravated during, the performance of uniformed service.

If the Employee wishes to elect this coverage or obtain more detailed information, contact the Plan Administrator. The Employee may also have continuation rights under USERRA. In general, the Employee must meet the same requirements for electing USERRA coverage as are required under COBRA Continuation Coverage requirements. Coverage elected under USERRA runs concurrently with COBRA. The Employee may elect USERRA continuation coverage for the Employee and their Dependents. Only the Employee has election rights. Dependents do not have any independent right to elect USERRA health plan continuation.

The Civilian Reservist Emergency Workforce Act of 2021 (“CREW”) provides eligible Employees, who are called to services by the Federal Emergency Management Agency (FEMA), rights under USERRA.

​When Dependent Coverage Terminates. A Dependent's coverage will terminate on the earliest of these dates:

Note: Except in certain circumstances, a covered Dependent may be eligible for COBRA Continuation Coverage. For a complete explanation of when COBRA Continuation Coverage is available, what conditions apply and how to select it, see the section entitled COBRA Continuation Coverage.

The term Covered Dental Services refers to the items of dental expenses for which dental benefits may be payable.

Covered Dental Expenses are Usual and Reasonable services incurred for the following items of service and supply. A service or supply is considered Usual and Reasonable if it is: 1) appropriate and necessary as provided for the symptoms, diagnosis, or care and treatment of the dental condition or Injury; 2) within standards of good dental practice in the organized dental community; 3) the most appropriate supply or level of service which can be safely provided; and 4) not primarily for the convenience of the Plan Participant, or the Covered Provider.

A “Covered Provider” is an individual who is licensed to practice dentistry in the jurisdiction where such services are provided.

ALTERNATE TREATMENT

Many dental conditions can be treated in more than one way. This Plan has an "alternate treatment" clause which governs the amount of benefits the Plan will pay for treatments covered under the Plan. If a patient chooses a more expensive treatment than is needed to correct a dental problem according to accepted standards of dental practice, the benefit payment will be based on the cost of the treatment which provides professionally satisfactory results at the most cost-effective level. For example, if a regular amalgam filling is sufficient to restore a tooth to health, and the patient and the Dentist decide to use a gold filling, the Plan will base its reimbursement on the Usual and Reasonable Charge for an amalgam filling. The patient will pay the difference in cost.

EXPENSES INCURRED

An expense is Incurred at the time an impression is made for an appliance or change to an appliance. An expense is Incurred at the time the tooth or teeth are prepared for a dental prosthesis or prosthetic crown. For root canal therapy, an expense is Incurred at the time the pulp chamber is opened. All other expenses are Incurred at the time the service is rendered or a supply is furnished.

These charges are subject to the benefit limits, exclusions, and other provisions of this Plan.

Class A Services:
​Preventive and Diagnostic Dental Procedures

Routine Oral Exam (2 per Plan Year)

Fluoride Application (once per Plan Year to age 19)

Emergency Care to relieve pain

Sealants (to age 19)

Bitewing X-rays (2 series per Plan Year)

Full mouth X-rays (once per year)

Panoramic X-rays (2 per Plan Year)

Class B Services:
​Basic Restorative Dental Procedures

Fillings Stainless Steel Crowns (to age 14)

Space Maintainers (to age 12)

Replacement bridges, crowns and inlays

Antibiotic Drugs

Periodontics

Endodontics

Anesthesia

Oral Surgery

Repairs to Dentures/Bridges

Simple Extractions

Occlusal Adjustment

Palliative Emergency Treatment

Class C Services:
​Major Dental Procedures

Crowns

Dentures

Bridges Inlays/Onlays

Extractions

Periodontal Root scaling/planing

The following exclusions and limitations apply to expenses Incurred by all Plan Participants:

A “Claim” means a request for a Plan benefit made by a Claimant (the Plan Participant or an authorized representative) after dental treatment has occurred. When services are received from a health care provider, a Plan Participant should show their Group Health identification card to the provider. Providers may submit Claims on a Plan Participant’s behalf.

If it is necessary for a Plan Participant to submit a Claim, they should request an itemized bill from their health care provider which will include procedure (CPT) and diagnostic (ICD) codes.

The following information must be provided when submitting a Claim for processing:

Claims should be received by the Claims Administrator within 90 days from the date charges for the services were Incurred. Benefits are based on the Plan's provisions in effect at the time the charges were Incurred. Claims received later than that date will be denied.

The Plan Participant must provide sufficient documentation (as determined by the Claims Administrator) to support a Claim for benefits. The Plan reserves the right to have a Plan Participant seek a second medical/dental opinion.

Claims for expenses should be submitted to the applicable address below:

Imagine360 Administrators, LLC

1550 Liberty Ridge Drive, Suite 330

Wayne, PA 19087

(972) 238-7900 or (800) 827-7332

vitablehealthclaims@imagine360.com

A “Claim” means a request for a Plan benefit made by a Claimant (the Plan Participant or an authorized representative) after dental treatment has occurred. A Claim is not a request to determine a Claimant’s eligibility for benefits, nor is it a request for a review prior to receiving dental treatment to determine Dental Necessity.

A Claimant may appoint an authorized representative to act upon his or her behalf with respect to a Claim. Only those individuals who satisfy the Plan’s requirements to be an authorized representative will be considered an authorized representative. A healthcare provider is not an authorized representative simply by virtue of an assignment of benefits. Contact the Claims Administrator for information on the Plan’s procedures for authorized representatives.

A “Post-Service Claim” is a Claim for dental care, treatment, or services that a Claimant has already received.

All questions regarding Claims should be directed to the Claims Administrator. All Claims will be considered for payment according to the Plan’s terms and conditions, limitations and exclusions, and industry standard guidelines in effect at the time charges were Incurred. The Plan may, when appropriate or when required by law, consult with relevant health care professionals and access professional industry resources in making decisions about Claims involving specialized medical/dental knowledge or judgment.

Initial Benefit Determination

A Claim will not be deemed submitted until it is received by the Claims Administrator. The initial benefit determination on a Claim will be made within 30 days of the Claim Administrator’s receipt of the Claim (or 15 days if the Claim is a Concurrent Care Determination). If additional information is necessary to process the Claim, the Claims Administrator will make a written request to the Claimant for the additional information within this initial period. The Claimant must submit the requested information within 45 days of receipt of the request from the Claims Administrator. Failure to submit the requested information within the 45-day period may result in a denial of the Claim or a reduction in benefits.

If additional information is requested, the Plan’s time period for making a determination is suspended until such time as the Claimant provides the information, or the end of the 45-day period, whichever occurs earlier. A benefit determination on the Claim will be made within 15 days of the Plan’s receipt of the additional information.

Notice of Adverse Benefit Determination

If a Claim is denied in whole or in part, the Plan shall provide the Claimant with an Explanation of Benefits (EOB), and/or provide written or electronic notice of the determination to providers, that will include the following:

If applicable:

If the Claimant has questions about the denial, the Claimant may contact the Claims Administrator at the address or telephone number printed on the Explanation of Benefits/Explanation of Payment.

An Adverse Benefit Determination also includes a rescission of coverage when applied as a retroactive cancellation or discontinuance of coverage due to fraud or intentional misrepresentation. A rescission of coverage does not include a cancellation or discontinuance of coverage that takes effect prospectively, nor is it a retroactive cancellation or discontinuance due to the Plan Participant’s failure to pay the required premium in a timely manner.

How to Appeal an Adverse Benefit Determination

A Claimant may appeal an Adverse Benefit Determination. The Plan offers a two-level review procedure to provide the Claimant with a full and fair review of the Adverse Benefit Determination.

The Plan will provide for a review that does not give deference to the previous Adverse Benefit Determination and that is conducted by an individual who is neither the person who made the determination on a prior level of review, nor a subordinate of that person.

In addition, the Plan Administrator may:

First Level Claims Review

The written request for a First Level Claims Review must be submitted within 180 days of the Claimant’s receipt of an Explanation of Benefits/Explanation of Payment that includes the adverse benefit determination.

The Claimant should include the following information in their request for review:

The First Level Claims Review request should be addressed to:

Plan Administrator

c/o Imagine360 Administrators, LLC

1550 Liberty Ridge Drive, Suite 330

Wayne, PA 19087

(972) 238-7900 or (800) 827-7332

An appeal will not be deemed submitted until it is received by the Claims Administrator. The Claimant cannot proceed to the next level of review if the Claimant fails to submit a timely request for a First Level Claims Review.

The First Level Claims Review will be performed by the Claims Administrator on the Plan’s behalf. The Claims Administrator will review the information initially received and any additional information provided by the Claimant and determine if the Initial Benefit Determination was appropriate based upon the terms and conditions of the Plan and other relevant information. The Claims Administrator will send a written or electronic Notice of Determination to the Claimant within 30 days of the receipt of the appeal. The Notice of Determination resulting from a First Level Claims Review shall meet the requirements as stated above.

Second Level Claims Review

If the Claimant does not agree with the determination from the First Level Claims Review, the Claimant may submit a Second Level Claims Review request in writing within 60 days of the Claimant’s receipt of the Notice of Determination from the First Level Claims Review, along with any additional supporting information.

The Second Level Claims Review request should be addressed to:

Plan Administrator

c/o Imagine360 Administrators, LLC

1550 Liberty Ridge Drive, Suite 330

Wayne, PA 19087

(972) 238-7900 or (800) 827-7332

An appeal will not be deemed submitted until it is received by the Plan Administrator or the Claims Administrator on the Plan Administrator’s behalf. The Claimant cannot file suit if the Claimant fails to submit a timely appeal.

The Second Level Claims Review will be completed by the Plan Administrator and/or its designee. The Plan Administrator/designee will review the information initially received and any additional information provided by the Claimant and make a determination on the appeal based upon the terms and conditions of the Plan and other relevant information. The Plan Administrator/designee will send a written or electronic Notice of Determination for the Second Level Claims Review to the Claimant within 30 days of receipt of the appeal (or 15 days for an appeal of a Concurrent Care Claim Determination). The Second Level Claims Review Notice of Determination shall meet the requirements as stated above.

Occasionally, benefits are paid more than once, are paid based upon improper billing or a misstatement in a proof of loss or enrollment information, are not paid according to the Plan’s terms, conditions, limitations, or exclusions, or should otherwise not have been paid by the Plan. As such, this Plan may pay benefits that are later found to be greater than the Usual and Reasonable Charge. In this case, this Plan may recover the amount of the overpayment from the source to which it was paid, primary payers, or from the party on whose behalf the charge(s) were paid. As such, whenever the Plan pays benefits exceeding the amount of benefits payable under the terms of the Plan, the Plan Administrator has the right to recover any such erroneous payment directly from the person or entity who received such payment and/or from other payers and/or the Plan Participant or dependent on whose behalf such payment was made, using any recovery method permitted by law.

A Plan Participant, dependent, provider, another benefit plan, insurer, or any other person or entity who receives a payment exceeding the amount of benefits payable under the terms of the Plan or on whose behalf such payment was made, shall return or refund the amount of such erroneous payment to the Plan within 30 days of discovery or demand. The Plan Administrator shall have no obligation to secure payment for the expense for which the erroneous payment was made or to which it was applied.

The person or entity receiving an erroneous payment may not apply such payment to another expense. The Plan Administrator shall have the sole discretion to choose who will repay the Plan for an erroneous payment and whether such payment shall be reimbursed in a lump sum. When a Plan Participant or other entity does not comply with the provisions of this section, the Plan Administrator shall have the authority, in its sole discretion, to deny payment of any Claims for benefits by the Plan Participant and to deny or reduce future benefits payable (including payment of future benefits for other Injuries or Illnesses) under the Plan by the amount due as reimbursement to the Plan. The Plan Administrator may also, in its sole discretion, deny or reduce future benefits (including future benefits for other Injuries or Illnesses) under any other group benefits plan maintained by the Plan Sponsor, to the extent allowed by law. The reductions will equal the amount of the required reimbursement.

Providers and any other person or entity accepting payment from the Plan or to whom a right to benefits has been assigned, in consideration of services rendered, payments and/or rights, agree to be bound by the terms of this Plan and agree to submit Claims for reimbursement in strict accordance with their State’s health care practice acts, ICD-10 or CPT standards, Medicare guidelines, HCPCS standards, or other standards approved by the Plan Administrator. Any payments made on Claims for reimbursement not in accordance with the above provisions shall be repaid to the Plan within 30 days of discovery or demand or incur prejudgment interest of 1.5% per month. If the Plan must bring an action against a Plan Participant, provider, or other person or entity to enforce the provisions of this section, then that Plan Participant, provider, or other person or entity agrees to pay the Plan’s attorneys’ fees and costs, regardless of the action’s outcome.

Further, Plan Participants and/or their dependents, beneficiaries, estate, heirs, guardian, personal representative, or assignees (Plan Participants) shall assign, or be deemed to have assigned, to the Plan their right to recover said payments made by the Plan, from any other party and/or recovery for which the Plan Participant(s) are entitled, for or in relation to Facility-acquired condition(s), provider error(s), or damages arising from another party’s act or omission for which the Plan has not already been refunded.

The Plan reserves the right to deduct from any benefits properly payable under this Plan the amount of any payment which has been made:

The deduction may be made against any Claim for benefits under this Plan by a Plan Participant or by any of his covered Dependents if such payment is made with respect to the Plan Participant or any person covered or asserting coverage as a Dependent of the Plan Participant.

If the Plan seeks to recoup funds from a provider due to a Claim being made in error, a Claim being fraudulent on the part of the provider, and/or the Claim is the result of the provider’s misstatement, said provider shall, as part of its Assignment of Benefits from the Plan, abstain from billing the Plan Participant for any outstanding amount(s).

Coordination of the benefit plans. The Plan’s Coordination of Benefits provision sets forth rules for the order of payment of Covered Dental Services when two or more plans – including Medicare – are paying. The Plan has adopted the order of benefits as set forth in the National Association of Insurance Commissioners (NAIC) Model COB Regulations, as amended. When a Plan Participant is covered by this Plan and another plan, or the Plan Participant’s Spouse (which is defined to include Domestic Partner, if applicable, in this section) is covered by this Plan and by another plan, or the couple’s covered children are covered under two or more plans the plans will coordinate benefits when a claim is received.

The plan that pays first according to the rules will pay as if there were no other plans involved. The secondary and subsequent plans will pay the balance due up to 100% of the total Allowable Charges.

Benefit plan. This provision will coordinate the medical and prescription drug and dental benefits of a benefit plan. The term benefit plan means this Plan or any one of the following plans:

The term benefit plan does not include hospital indemnity, accident only, specified disease, school accident or non-medical long-term care coverage.

Usual and Reasonable Charge(s). For a charge to be allowable, it must be a usual, customary, and reasonable charge and at least part of it must be covered under this Plan. (See “Usual and Reasonable Charge” in the Definitions section.)

In the case of Health Maintenance Organization (HMO) or other in-network only plans: This Plan will not consider any charges in excess of what an HMO or network provider has agreed to accept as payment in full. Also, when an HMO or network plan is primary and the Plan Participant does not use an HMO or network provider, this Plan will not consider as a Usual and Reasonable Charge any charge that would have been covered by the HMO or network plan had the Plan Participant used the services of an HMO or network provider.

In the case of service type plans where services are provided as benefits, the reasonable cash value of each service will be the Usual and Reasonable Charge.

Benefit plan payment order. When two or more plans provide benefits for the same Allowable Charge, benefit payment will follow these rules:

The first rule that describes which plan is primary is the rule that applies:

Special rule. If: (i) the person covered directly is a Medicare beneficiary, and (ii) Medicare is secondary to Plan B, and (iii) Medicare is primary to Plan A (for example, if the person is Retired), THEN Plan B will pay first.

When a child is covered as a Dependent and the parents are married or living together, these rules will apply:

When a child’s parents are divorced, legally separated or not living together, whether or not they have ever been married, these rules will apply:

If there is no Medical Child Support Order allocating responsibility for the Dependent child’s health care expenses, the order of benefits are as follows:

1st The plan covering the custodial parent,

2nd The plan covering the spouse of the custodial parent,

3rd The plan covering the non-custodial parent, and

4th The plan covering the spouse of the non-custodial parent.

When a child is covered as a Dependent under more than one plan of individuals who are not the parents of the child, the order of benefits shall be determined as if those individuals were parents of the child.

Unless specifically stated otherwise, Medical Child Support Order and custody provisions apply up to age 19 for any Dependent child.

For a Dependent child who has coverage under either or both parents’ plans and also has his or her own coverage as a dependent under a spouse’s plan, Rule (e) applies. If the Dependent child’s coverage under the spouse’s plan began on the same date as the Dependent child’s coverage under either or both parents’ plans, the birthday rule shall apply to the Dependent child’s parents and the Dependent child’s spouse.

COORDINATION WITH AUTOMOBILE INSURANCE COVERAGE

The Plan’s liability for expenses arising out of an automobile Accident is based on the type of automobile insurance law enacted by the Plan Participant’s State. Nationally, there are three types of State automobile insurance laws:

Coordination With Automobile No-fault Coverage. Except as required by law, the Plan is secondary to any No-Fault Automobile coverage. It is not intended to reduce the level of coverage that would otherwise be available through a No-Fault Automobile Insurance policy nor does it intend to be primary in order to reduce the premiums or cost of No-Fault Automobile coverage.

If the Plan Participant or his/her covered Dependent incur Covered Dental Services as a result of an automobile Accident (either as driver, passenger, or pedestrian), the amount of Covered Dental Services that the Plan will pay is limited to:

An individual is considered to be covered under an automobile insurance policy if he/she is either:

Coordination With Financial Responsibility Law. The Plan is secondary to automobile coverage or to any other party who may be liable for the Plan Participant’s medical expenses resulting from the automobile Accident. If the Plan Participant’s State has a “financial responsibility” law which does not allow the Plan to pay benefits as secondary or which does not allow the Plan to advance payments with the intent of subrogating or recovering the payment, the Plan will not pay any benefits related to an automobile Accident for the Plan Participant or their Dependents.

Coordination With Other Automobile Liability Insurance. If the Plan Participant’s State does not have a No-Fault Automobile Insurance law or a “financial responsibility” law, this Plan is secondary to their automobile insurance coverage or to any other party who may be liable for the Plan Participant’s medical expenses resulting from the automobile Accident.

Coordination With Underinsured/Uninsured Motorist Coverage. If the Plan Participant is involved in an automobile Accident and, as a result of the Accident, the Plan pays benefits, and if the Plan Participant receives a settlement from their underinsured or uninsured motorist policy, the Plan is entitled to receive from the proceeds of the settlement with the underinsured or uninsured motorist coverage, the expenses of the Plan. The Plan is not entitled to receive any recovery that is in excess of its expenses. The Plan agrees to payment of benefits prior to the receipt by the Plan Participant of any recovery from their underinsured or uninsured motorist policy. The Plan Participant agrees to notify the Plan of the existence of a recovery from an underinsured or uninsured motorist policy and further agrees to remit to the Plan the proceeds of any recovery received from an underinsured or uninsured motorist policy up to the expenditures made by the Plan. Any expenses by the Plan which are in excess of the proceeds received by the underinsured/ uninsured motorist policy will be the responsibility of the Plan pursuant to the terms and conditions of the Plan.

Claims determination period. Benefits will be coordinated on a Calendar Year or Plan Year basis, as shown in the Schedule of Benefits section. This is called the claims determination period.

Right to receive or release necessary information. To make this provision work, this Plan may give or obtain needed information from another insurer or any other organization or person. This information may be given or obtained without the consent of or notice to any other person. A Plan Participant will give this Plan the information it asks for about other plans and their payment of Usual and Reasonable Charges.

Facility of payment. This Plan may repay other plans for benefits paid that the Claims Administrator determines the Plan should have paid. That repayment will count as a valid payment under this Plan.

Right of recovery. This Plan may pay benefits that should be paid by another benefit plan. In this case this Plan may recover the amount paid from the other benefit plan or the Plan Participant. That repayment will count as a valid payment under the other benefit plan.

Further, this Plan may pay benefits that are later found to be greater than the Usual and Reasonable Charge. In this case, this Plan may recover the amount of the overpayment from the source to which it was paid.

Exception to Medicaid. In accordance with ERISA (if applicable), the Plan shall not take into consideration the fact that an individual is eligible for or is provided medical assistance through Medicaid when enrolling an individual in the Plan or making a determination about the payments for benefits received by a Plan Participant under the Plan.

then the Plan Participant(s) authorizes the Plan to pursue, sue, compromise and/or settle any such Claims in the Plan Participant(s) and/or the Plan’s name and agrees to fully cooperate with the Plan in the prosecution of any such Claims. The Plan Participant(s) assigns all rights to the Plan or its assignee to pursue a Claim and the recovery of all expenses from any and all sources listed above.

The Plan’s right to reimbursement extends to any incident related care that is received by the Plan Participant(s) (“Incurred”) prior to the liable party being released from liability. The Plan Participant’s/Plan Participants’ obligation to reimburse the Plan is therefore tethered to the date upon which the Claims were Incurred, not the date upon which the payment is made by the Plan. In the case of a settlement, the Plan Participant has an obligation to review the “lien” provided by the Plan and reflecting Claims paid by the Plan for which it seeks reimbursement, prior to settlement and/or executing a release of any liable or potentially liable third party, and is also obligated to advise the Plan of any incident related care Incurred prior to the proposed date of settlement and/or release, which is not listed but has been or will be Incurred, and for which the Plan will be asked to pay.

If at the time of Injury, Illness, or disability there is available, or potentially available, any Coverage (including but not limited to Coverage resulting from a judgment at law or settlements), the benefits under this Plan shall apply only as an excess over such other sources of Coverage, except as otherwise provided for under the Plan’s Coordination of Benefits section. The Plan’s benefits shall be excess to:

Benefits paid by the Plan, funds recovered by the Plan Participant(s), and funds held in trust over which the Plan has an equitable lien exist separately from the property and estate of the Plan Participant(s), such that the death of the Plan Participant(s), or filing of bankruptcy by the Plan Participant(s), will not affect the Plan’s equitable lien, the funds over which the Plan has a lien, or the Plan’s right to subrogation and reimbursement.

In the event that the Plan Participant(s) dies as a result of his/her injuries and a wrongful death or survivor Claim is asserted against a third party or any Coverage, the Plan’s subrogation and reimbursement rights shall still apply.

1. It is the Plan Participant(s) obligation at all times, both prior to and after payment of benefits by the Plan to:

If timely repayment is not made, or the Plan Participant(s) and/or his or her attorney fails to comply with any of the requirements of the Plan, the Plan has the right, in addition to any other lawful means of recovery, to deduct the value of the Plan Participant’s amount owed to the Plan. To do this, the Plan may refuse payment of any future benefits and any funds or payments due under this Plan on behalf of the Plan Participant(s) in an amount equivalent to any outstanding amounts owed by the Plan Participant to the Plan. This provision applies even if the Plan Participant has disbursed settlement funds.

2. If the minor’s parents or court-appointed guardian fail to take such action, the Plan shall have no obligation to advance payment of benefits on behalf of the minor. Any court costs or legal fees associated with obtaining such approval shall be paid by the minor’s parents or court-appointed guardian.

The Plan Administrator retains sole, full, and final discretionary authority to construe and interpret the language of this provision, to determine all questions of fact and law arising under this provision, and to administer the Plan’s subrogation and reimbursement rights. The Plan Sponsor may amend the Plan at any time without notice.

In the event that any section of this provision is considered invalid or illegal for any reason, said invalidity or illegality shall not affect the remaining sections of this provision and Plan. The section shall be fully severable. The Plan shall be construed and enforced as if such invalid or illegal sections had never been inserted in the Plan.

The Plan has the right to recover any benefits the Plan paid in error to the Plan Participant or on behalf of a Plan Participant to which the Plan Participant is not entitled, for services which were not covered under the Plan, or for benefits paid in excess of the Plan’s Usual and Reasonable Charges. The Plan may recover benefits paid in error from the Plan Participant, the provider who received a payment from the Plan on the Plan Participant’s behalf, or from any person who may have benefited. The Plan may also offset any future benefits otherwise payable to or on the Plan Participant’s behalf, or from any other Plan Participant enrolled through the same covered Employee (or retiree, if applicable).

The Plan will not use or disclose Protected Health Information (“PHI”) except as permitted by this section or as otherwise permitted or required by law, including but not limited to the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 (the “HIPAA Privacy Rule”), as may be amended from time to time. Nothing in this section shall be construed to prohibit the Plan Sponsor’s receipt of “summary health information,” as described in the HIPAA Privacy Rule, for certain Plan Sponsor-related purposes, including obtaining premium bids for health insurance, making Plan design and funding decisions, and modifying, amending, or terminating the Plan.

The Plan will disclose PHI to the Plan Sponsor only upon receipt of a certification by the Plan Sponsor to the Plan that the Plan has been amended to provide for the Plan Sponsor’s receipt of PHI and that the Plan Sponsor agrees to comply with the following provisions:

The Plan will not use or disclose ePHI except as permitted by this section or as otherwise permitted or required by law, including but not limited to the requirements of 45 C.F.R. Sections 164.314(b)(1) and (2) and its implementing regulations, 45 C.F.R. parts 160, 162, and 164 of the Security Standards of the Health Insurance Portability and Accountability Act of 1996 (the “HIPAA Security Standards”), as they may be amended from time to time. Nothing in this section shall be construed to prohibit the Plan Sponsor’s receipt of “summary health information,” as described in the HIPAA Security Standards, for certain Plan Sponsor-related purposes, including obtaining premium bids for health insurance, making Plan design and funding decisions, and modifying, amending, or terminating the Plan.

The Plan will disclose ePHI to the Plan Sponsor only upon receipt of a certification by the Plan Sponsor that the Plan has been amended to provide for the Plan Sponsor’s receipt of ePHI and that the Plan Sponsor agrees to comply with the following provisions:

The Health Information Technology for Economic and Clinical Health Act (HITECH) of the American Recovery and Reinvestment Act of 2009 (ARRA) imposes notification in the event of a Breach of unsecured PHI.

The Plan Sponsor will report to the Privacy Official of the Plan any use or disclosure of PHI not permitted by HIPAA, along with any Breach of unsecured PHI. The Plan Sponsor will treat the Breach as being discovered in accordance with HIPAA’s requirements. The Plan Sponsor will make the report to the Privacy Official not more than 30 calendar days after the Plan Sponsor learns of such non-permitted use or disclosure. If a delay is requested by a law enforcement official in accordance with 45 C.F.R. § 164.412, the Plan Sponsor may delay notifying the Privacy Official for the time period specified by such regulation. The Plan Sponsor’s report will at least:

The Plan Sponsor will report to the Privacy Official within 30 calendar days any attempted or successful: a) unauthorized access, use, disclosure, modification, or destruction of ePHI; and b) interference with the Plan Sponsor’s system operations in the Plan Sponsor’s information systems, of which the Plan Sponsor becomes aware. The Plan Sponsor will make this report upon the Privacy Official’s request, except if any such Security Incident resulted in a disclosure or Breach of PHI or ePHI not permitted by the HITECH Act, the Plan Sponsor will make the report in accordance with the above.

PLAN ADMINISTRATOR. Vitable Health Dental Benefit Plan is the benefit plan of Vitable Health, the Plan Administrator, also called the Plan Sponsor. It is to be administered by the Plan Administrator in accordance with the provisions of ERISA, if applicable. An individual or committee may be appointed by Vitable Health to be Plan Administrator and serve at the convenience of the Employer. If the Plan Administrator or a committee member resigns, dies or is otherwise removed from the position, Vitable Health shall appoint a new Plan Administrator as soon as reasonably possible.

The Plan Administrator shall administer this Plan in accordance with its terms and establish its policies, interpretations, practices, and procedures. It is the express intent of this Plan that the Plan Administrator shall have maximum legal discretionary authority to construe and interpret the terms and provisions of the Plan, to make determinations regarding issues which relate to eligibility for benefits, to decide disputes which may arise relative to a Plan Participant's rights, and to decide questions of Plan interpretation and those of fact relating to the Plan. The decisions of the Plan Administrator will be final and binding on all interested parties.

Service of legal process may be made upon the Plan Administrator.

DUTIES OF THE PLAN ADMINISTRATOR

The duties of the Plan Administrator include the following:

PLAN ADMINISTRATOR COMPENSATION. The Plan Administrator serves without compensation; however, all expenses for plan administration, including compensation for hired services, will be paid by the Plan.

If age is a factor in determining eligibility or amount of coverage and there has been a misstatement of age, the coverages or amounts of benefits, or both, for which the person is covered shall be adjusted in accordance with the Plan Participant's true age. Any such misstatement of age shall neither continue coverage otherwise validly terminated, nor terminate coverage otherwise validly in force. Benefits will be adjusted following the date of the discovery of such misstatement.

No term, condition, or provision of the Plan shall be waived, and there shall be no estoppel against the enforcement of any provision of the Plan, except by written direction of the Plan Administrator. No such waiver shall be deemed a continuing waiver unless specifically stated. Each waiver shall operate only as to the specific term or condition waived and shall not constitute a waiver of such term or condition for the future or as to any act other than that specifically waived.

This Plan is not in lieu of and does not affect any requirement for coverage by Workers' Compensation Insurance or, where permitted and applicable, any other alternative form of Workers’ Compensation benefits.

A benefit payment made via check must be cashed or deposited within one year after the date the check was issued or it will be treated as a forfeiture and may be used by used the plan administrator to pay plan benefits or offset plan administrative expenses.

This Plan shall be deemed to automatically be amended to conform as required by any applicable law, regulation, or the order or judgment of a court of competent jurisdiction governing provisions of this Plan, including, but not limited to, stated maximums, exclusions, or limitations. In the event that any law, regulation, or the order or judgment of a court of competent jurisdiction causes the Plan Administrator to pay Claims which are otherwise limited or excluded under this Plan, such payments will be considered as being in accordance with the terms of this Plan Document.

The following actions by a Plan Participant or a Plan Participant’s knowledge of such actions being taken by another, constitute fraud and will result in termination of all coverage under this Plan for the entire family unit of which the Plan Participant is a member:

In addition to being considered fraud on the Plan and an intentional misrepresentation, enrolling ineligible dependents, or maintaining coverage for a person who no longer satisfies the dependent eligibility rules violates company policy. If the company determines that an ineligible dependent has been enrolled, coverage may be canceled retroactively. The company reserves the right to recover any and all benefit payments made for services received by ineligible dependents and to terminate a Plan Participant’s employment, if applicable.

A Plan Participant may not assign or transfer any benefits or rights that arise under the Plan or applicable law to any other person, including a healthcare provider, and any purported assignment or transfer is void. This includes (but is not limited to) an attempted assignment or transfer of claims for payment of benefits, breach of fiduciary duty, penalties or any other claim or remedy. For convenience, the Plan may pay any undisputed benefit directly to the healthcare provider, but this is not a waiver of this anti-assignment provision and does not make the healthcare provider an assignee or confer any other rights on the provider. Similarly, the Plan recognizes an authorized representative for purposes of the Plan’s claims and appeal procedures, but the authorized representative is not an assignee and has no derivative rights with respect to the claim. However, this anti-assignment provision will not apply (1) to an assignment of a Plan Participant’s rights to the Plan or the Plan Administrator, or (2) to the extent required under Medicaid laws.

The Plan reserves the right to allocate the deductible amount to any Covered Dental Services and to apportion the benefits to the Plan Participant and any assignees. Such allocation and apportionment shall be conclusive and shall be binding upon the Plan Participant and all assignees.

If a Claimant is a minor or is physically or mentally incapable of giving a valid release for payment, the Claims Administrator, at its option, may make payment to a party who has assumed responsibility for the care of such person. Such payments will be made until Claim is made by a guardian. If a Claimant dies while benefits remain unpaid, benefits will be paid at the Claim Administrator’s option to:

Such payment will release the Plan Administrator and Claims Administrator of all further liability to the extent of payment.

A Claims Administrator is not a fiduciary under the Plan by virtue of paying claims in accordance with the Plan's rules as established by the Plan Administrator.

The Plan is not to be construed as a contract for or of employment.

Any clerical error by the Plan Administrator or an agent of the Plan Administrator in keeping pertinent records or a delay in making any changes will not invalidate coverage otherwise validly in force or continue coverage validly terminated. An equitable adjustment of contributions will be made when the error or delay is discovered.

If an overpayment occurs in a Plan reimbursement amount, the Plan retains a contractual right to the overpayment. The person or institution receiving the overpayment will be required to return the incorrect amount of money. In the case of a Plan Participant, the amount of overpayment may be deducted from future benefits payable.

The Plan Sponsor reserves the right, at any time, to amend, suspend or terminate the Plan in whole or in part at any time and for any reason. This includes amending the benefits under the Plan or the Trust agreement (if any). Subject to the requirements of ERISA §402 (if applicable), in the event of a termination or partial termination of the Plan or Trust (if applicable), the rights of the Plan Participants are limited to expenses Incurred before termination and the Plan Sponsor shall direct the disposition of Plan assets, including assets held in a Trust, if any, which may include transfer of such assets to another employee benefit plan or trust maintained by the Plan Sponsor.

The following terms have special meanings and when used in this Plan will be capitalized.

Accident means a sudden and unforeseen event, or a deliberate act resulting in unforeseen consequences.

Active Employee is an Employee who is on the regular payroll of the Employer and who has begun to perform the duties of his or her job with the Employer.

Calendar Year means January 1st through December 31st of the same year.

COBRA means the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended.

Congenital Anomaly means a physical, metabolic or anatomic deviation from the normal pattern of development that is apparent at birth or detected during the first year of life.

Cosmetic Dentistry means dentally unnecessary procedures.

Covered Dental Service(s) means those Dentally Necessary services or supplies that are covered under this Plan.

Dentist is a person who is properly trained and licensed to practice dentistry and who is practicing within the scope of such license.

Employee means a person who is classified by his Employer as an Active, common law Employee.

Employer is [to be provided by employer as detailed in the Vitable contract:______________________]

Experimental and/or Investigational means services, supplies, care, and treatment which does not constitute accepted medical practice properly within the range of appropriate medical practice under the standards of the case and by the standards of a reasonably substantial, qualified, responsible, relevant segment of the medical community or government oversight agencies at the time services were rendered.

The Plan Administrator must make an independent evaluation of the Experimental/non-experimental standings of specific technologies. The Plan Administrator shall be guided by a reasonable interpretation of Plan provisions. The decisions shall be made in good faith and rendered following a detailed factual background investigation of the claim and the proposed treatment. The decision of the Plan Administrator will be final and binding on the Plan. The Plan Administrator will be guided by the following principles:

Reliable Evidence shall mean only published reports and articles in the authoritative medical and scientific literature; the written protocol or protocols used by the treating Facility or the protocol(s) of another Facility studying substantially the same drug, service, medical treatment or procedure; or the written informed consent used by the treating Facility or by another Facility studying substantially the same drug, device, medical treatment, or procedure.

Drugs are considered Experimental if they are not commercially available for purchase and/or they are not approved by the Food and Drug Administration for general use.

Family Unit is the covered Employee and the family members who are covered as Dependents under the Plan.

Fiduciary is the entity that exercises discretionary authority or control over management of the Plan or the disposition of its assets, renders investment advice to the Plan or has discretionary authority or responsibility in the administration of the Plan.

Incurred means the date the service is rendered or the supply is obtained. With respect to a course of treatment or procedure which includes several steps or phases of treatment, expenses are Incurred for the various steps or phases as the services related to each step are rendered and not when services relating to the initial step or phase are rendered.

Injury means an accidental physical Injury to the body caused by unexpected external means.

Lifetime is a word that appears in this Plan in reference to benefit maximums and limitations. Lifetime is understood to mean while covered under this Plan. Under no circumstances does Lifetime mean during the Lifetime of the Plan Participant.

Medical Child Support Order means any judgment, decree or order (including approval of a domestic relations settlement agreement) issued by a court of competent jurisdiction that:

Medical Emergency means a medical condition manifesting itself by acute symptoms of sufficient severity including severe pain such that a prudent layperson with average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in (1) serious jeopardy to the health of an individual (or, in the case of a pregnant woman, the health of the woman or her unborn child), (2) serious impairment to body functions, or (3) serious dysfunction of any body organ or part. A Medical Emergency includes such conditions as heart attacks, cardiovascular accidents, poisonings, loss of consciousness or respiration, convulsions or other such acute medical conditions.

Medically or Dentally Necessary (Medical or Dental Necessity) means care and treatment is recommended or approved by a Physician or Dentist; is consistent with the patient's condition or accepted standards of good medical/dental practice; is medically/dentally proven to be an effective treatment of the condition; is not performed mainly for the convenience of the patient or provider of medical/dental services; and is the most appropriate level of services which can be safely provided to the patient.

All of these criteria must be met; merely because a Physician/Dentist recommends or approves certain care does not mean that it is Medically/Dentally Necessary. The Plan Administrator has the discretionary authority to decide whether care or treatment is Medically/Dentally Necessary.

Medicare is the Health Insurance for the Aged and Disabled program under Title XVIII of the Social Security Act, as amended.

No-Fault Auto Insurance is the basic reparations provision of a law providing for payments without determining fault in connection with automobile accidents.

Physician means a Doctor of Dental Surgery (D.D.S.), Doctor of Dental Medicine (D.M.D.), and any other practitioner of the healing arts who is licensed and regulated by a state or federal agency and is acting within the scope of his or her license.

Plan means Vitable Health Dental Benefit Plan, which is a benefits plan for certain Employees of the Employer [to be provided by employer as detailed in the Vitable contract:______________________] and as described in this document.

Plan Amendment means a formal document that changes the provisions of the Plan Document, duly signed by the authorized person or persons as designated by the Plan Sponsor.

Plan Participant is any Employee or Dependent who is covered under this Plan.

Plan Year is the 12-month period beginning on the effective date [to be provided by employer as detailed in the Vitable contract:______________________] through the following consecutive 12 months.

Usual and Reasonable Charge is a charge which is not higher than the usual charge made by the provider of the care or supply and does not exceed the general level of charges made by most providers of like service in the same geographic area. This charge means an amount equivalent to the 90th percentile of a commercially available database or such other database methodologies as may be available and adopted by the Plan. If there are no charges submitted for a given procedure, the Plan will determine a Usual and Reasonable Charge based upon charges made for similar services. Determination of the Usual and Reasonable Charge will consider the nature and severity of the condition being treated. It will also consider medical complications or unusual circumstances that require more time, skill, or experience.

In circumstances where a network arrangement or other discounting or negotiated arrangement exists, the Usual and Reasonable Charge means the contracted amount established by the network arrangement, or other discounting or negotiated arrangement with a provider. The Plan Administrator has the discretionary authority to decide whether a charge is Usual and Reasonable.

You / Your means the Employee and, when applicable, covered Dependents.