Atlas International

Plan Detail

Plan Administrator: Tokio Marine HCC - Medical Insurance Services Group | AM Best Rating: A "Excellent" | Underwriter: Lloyd's

Claims


Article 9 - Claim Procedures

You must submit a claim for any expenses to be paid by us. This includes treatment or services for which the medical provider will bill us directly. No payments will be made by us without you first submitting a claim.

Notice of claim, Claimant’s Statement and Authorization, and proof of claim must be mailed to:

Tokio Marine HCC - MIS Group
P.O. Box 2005
Farmington Hills, MI 48333-2005
USA

Proof of Claim

When we receive notice of a claim, we will provide you with forms for filing proof of claim. The following is considered to be proof of claim:

1. A completed and signed Claimant’s Statement and Authorization form, together with any/all required attachments;
2. Original itemized bills from physicians, hospitals and other medical providers; and
3. Original receipts for any expenses which have already been paid by you or on your behalf.

Beginning on the last day of your certificate period, you shall have 60 days to provide us proof of claim (unless medical services were rendered after the certificate termination date, in which case you shall have 60 days from the date the claim is incurred). Subsequent to receipt of proof of claim, we may, at our sole discretion, request and require additional information, including but not limited to medical records, necessary to confirm the validity of any claim prior to payment thereof.

Claims Cooperation

You shall provide assistance and co-operate with us or our representatives in obtaining any other records we or they feel necessary to evaluate the incident or claim. Following notification of a claim, you shall provide, when asked, all authorizations necessary to obtain your medical records. If you do not co-operate with us and/or our investigation of the claim, we shall not be liable to pay any claim.

Access to Additional Materials

You shall provide us, or our designated representatives, all information, documentation, medical information that we or they may reasonably require during the term of this policy, or until all claims have been resolved, whichever is later.

Other Insurance

We shall not pay any claim if there is other insurance which would, or would but for the existence of this insurance, pay such claim. This insurance will apply with respect to expenses in excess of the amount paid or payable under such other insurance. We shall not pay any claim in respect to care, treatment, services or supplies furnished by any program or agency funded by any government

Arbitration

Any controversy or claim arising out of or relating to this contract, or the breach thereof, shall be settled by arbitration by the American Arbitration Association in accordance with its Consumer Arbitration Rules, and judgment on the award rendered by the arbitrator(s) may be entered in any court having jurisdiction thereof. Where any dispute is by this provision referred to arbitration, the making of an award shall be a condition precedent to any right of action against us.

Subrogation

You undertake to cooperate with us in the prosecution of any and all valid claims you may have against third parties arising out of any occurrence which results or may result in a loss payment by us and to account for any amounts recovered on the basis that we are entitled to recover first in full any sums paid by them before you share in any amount so recovered. Should you fail to prosecute any valid claims against third parties and we thereupon become liable to make payment under this insurance, then we shall be subrogated to all your rights. Any amount recovered us shall be used to pay the expenses of collection and reimburse us for any amount that we may have paid or become liable to pay under this insurance. Any remaining amounts shall be paid to you.

Right of Recovery

In the event of overpayment of any claim hereunder because:

1. all or some of the expenses were not paid for by you or on your behalf or were subsequently recovered by you or on your behalf; or
2. any relative of you or any person in your family, whether or not that person is or was a member, is repaid for all or some of those expenses by a source other than us; or
3. all or some of the expenses were not Eligible Expenses; or
4. all or some of the expenses were paid or reimbursed based on incorrect benefit application.

We have the right to recover the amount of overpayment from you and/or the hospital, physician or other provider of services or supplies. The amount of the recovery is the difference between:

1. the amount of expenses actually paid by us; and
2. the amount of expenses which should have been paid by us.

If you or the hospital, physician or other provider of services or supplies does not promptly make any such refund to us, we may, in addition to any other remedies available, either:

1. reduce the amount of any future claim that is otherwise eligible for payment hereunder, to the full extent of the refund due to us; or
2. cancel this certificate issued to you by giving 30 days advance written notice by mail to your last known address.

Claims Assistance

Every attempt will be made to help you understand the benefits provided by this insurance, however, any statement made by our employee will be deemed a representation and not a warranty. Actual benefit payment can only be determined at the time a claim is submitted and all facts are presented in writing. If a definite answer to a specific question is required, you can submit a written request, including all pertinent information and a statement from the attending physician (if applicable), and a written reply will be sent to you and kept on file.

Patient Advocacy

We may determine that a particular claim or diagnosis occurring under this insurance may be placed under the Patient Advocacy program to ensure that medically necessary services and supplies are provided in the most cost-effective manner. In the event we determine that a claim or diagnosis meets the Patient Advocacy program requirements, we will notify you, and a Patient Advocate will be assigned. Thereafter, the Patient Advocate may make recommendations of alternative treatment settings and/or procedures and/or supplies, which may be more cost effective for us and/or you. Such recommendations will be made with input from you and your physician(s) and will be made only when it can be reasonably demonstrated that the medically necessary services and supplies can be provided in a more cost-effective manner to us and/or you. We will use best efforts to evaluate and recommend alternative treatment settings and/or procedures and/or supplies, which can reasonably be expected to result in the same or better care for you. You, in accepting the recommendations, agree to hold us harmless and we shall not be held liable or otherwise responsible for any treatment, service, supply, procedure or care provided to you except for the payment of benefits under this insurance. After you have been notified that the claim or diagnosis meets the Patient Advocacy program requirements, we reserve the rights to:

1. Make payment for treatments, services and/or supplies which are not covered under this insurance which would be beneficial to you and cost effective to us; and
2. Deny payment for expenses which would otherwise be covered under this insurance which are over the amount we would have paid had you followed the recommendations of the Patient Advocacy program.

Article 10 – Appeals and Complaints Procedure

APPEALING A CLAIM: In the event we deny all or part of a claim under this insurance, you may file a written appeal with us. The written appeal must include sufficient information to identify the claim under appeal and must specify the reason(s) for the appeal with supporting documentation, if applicable.

Please provide your written appeal online, by email, or by postal mail at the following:

Online: http://service.hccmis.com/
Email: mis-appeals@tmhcc.com
Postal Mail: Tokio Marine HCC
Appeals P.O. Box 2058 Farmington Hills, MI 48333 USA

When we receive the appeal, we will review the claim and a written response will be sent to you. After you receive our response to the appeal, you may initiate a second appeal. With our receipt of the second appeal, medical and/or claims personnel who were not involved in the original claim determination or the initial appeal will review the claim. A final determination will be made and a letter will be sent to you.

Please note that appealing a claim is not a requirement to following the complaints procedure detailed below.

Complaints Procedure

We are dedicated to providing a high-quality service and want to ensure that it is maintained at all times. If you feel that we or another party connected with this policy have not offered a first-class service please contact us and we will do our best to resolve the problem.

Please provide your written complaint online or by postal mail at the following:
http://service.hccmis.com/ or Tokio Marine HCC - MIS Group
P.O. Box 2005
Farmington Hills, MI 48333-2005
USA

You will be contacted within 3 (three) business days of receiving your complaint to inform you of what action is being taken. We will try to resolve the problem and give you an answer within four weeks. If it will take longer than four weeks we will tell you when you can expect an answer. If you have not been given an answer within 8 (eight) weeks we will tell you how you can take your complaint to the Financial Ombudsman Service for review. This complaints procedure does not affect any legal right you have to take action. Once you have received your final response from us, and if you are still not satisfied you can contact the Financial Ombudsman Service:

Financial Ombudsman Service
Exchange Tower, Harbour Exchange Square, London, E14 9SR
Phone: +44 (0) 20 7964 0500
Email: complaint.info@financial-ombudsman.org.uk

If you have purchased your policy online or by other electronic means within the European Union (EU) you may also make your complaint via the EU’s online dispute resolution (ODR) platform. The website for the ODR platform is: http://ec.europa.eu/odr

ARBITRATION AND CLASS ACTION WAIVER

Excluding claims for injunctive or other equitable relief, any dispute or controversy between a Member and any of the MIS Group, Underwriters or their affiliates arising out of or relating to this Master Policy, including without limitation, any and all disputes, claims (whether in tort, contract, statutory or otherwise) or disagreements concerning the existence, breach, interpretation, application or termination of this Master Policy, shall be resolved by final and binding arbitration pursuant to the Federal Arbitration Act and in accordance with the JAMS Inc. Comprehensive Arbitration Rules & Procedures then in effect. Such claims shall be arbitrated on an individual basis only and the parties waive any right or authority for any claims to be resolved in a class, consolidated, representative, collective or private attorney general action or arbitration. Instructions regarding how to commence an arbitration are available on the JAMS website, located at https://www.jamsadr.com. The arbitration shall take place in Houston, Texas or at the option of the party seeking relief, by telephone, online, or via written submissions alone, and be administered by JAMS. The arbitral tribunal (“Tribunal”) shall be composed of one arbitrator, who shall be independent and impartial. If the parties fail to agree on the arbitrator within twenty (20) calendar days after the initiation of an arbitration hereunder, JAMS shall appoint the arbitrator. The arbitration shall be conducted in the English language. The decision of the arbitrator will be final and binding on the parties. Judgment on any award(s) rendered by the arbitrator may be entered in any court having jurisdiction thereof. The arbitrator shall have the authority to determine arbitrability of any disputes arising out of or relating to this Master Policy. Nothing in this Section shall prevent either party from seeking immediate injunctive relief from any court of competent jurisdiction, and any such request shall not be deemed incompatible with the agreement to arbitrate or a waiver of the right to arbitrate. The parties undertake to keep confidential all awards in their arbitration, together with all confidential information, all materials in the proceedings created for the purpose of the arbitration and all other documents produced by the other party in the proceedings and not otherwise in the public domain, save and to the extent that disclosure may be required of a party by legal duty, to protect or pursue a legal right or to enforce or challenge an award in legal proceedings before a court or other judicial authority. The arbitrator shall award all fees and expenses, including reasonable attorney’s fees, to the prevailing party. This agreement to arbitrate does not apply to claims Members may have for medical malpractice against their medical providers.

Members may choose to opt out of the agreement to arbitrate by mailing a written opt-out notice (“Notice”) to Tokio Marine HCC – MIS Group. The Notice must be postmarked no later than sixty (60) days after the last day of your certificate period. The Notice must be mailed to: HCC Insurance Holdings, 13403 NW Freeway, Houston, Texas 77040, to the attention of General Counsel. This procedure is the only mechanism by which you can opt out of the agreement to arbitrate. Opting out of the agreement to arbitrate has no effect on any other parts of this Master Policy, or any previous or future arbitration agreements that you have entered into with Tokio Marine HCC-MIS Group.