Meridian Clear

Plan Detail

Plan Administrator: Azimuth Risk Solutions | AM Best Rating: A "Excellent" | Underwriter: Lloyd's of London

Claims


CLAIM(S) PROCEDURES:

7.1 PROOF OF CLAIM — When the Scheme Administrator receives notice of a claim for Benefits under this insurance, and it will provide the Participating Member with form(s) (“Claim Form”) for filing a Proof of Claim. The Claim Form is provided with all fulfillment documents issued by the Scheme Administrator. The Claim Form is available at all times via the Scheme Administrator’s website at www.azimuthrisk.com. The following items must be submitted to be considered a complete Proof of Claim eligible for consideration of coverage (“Proof of Claim”):

7.1.1 A duly completed and signed Claim Form; and

7.1.2 Itemized bills from all Physicians, Hospitals and other healthcare or medical service providers involved with respect to the claim(s); and

7.1.3 Receipts for any expenses that have been paid by or on behalf of the Participating Member(s) with respect to the claim(s); and

7.1.4 The Participating Member(s) shall have ninety (90) days from the date a claim is incurred to submit a complete Proof of Claim, and the Scheme Administrator may deny coverage for any Proof of Claim submitted thereafter or for an incomplete Proof of Claims. All claim decisions made by or on behalf of the Scheme Administrator are with the express consent of Underwriters. All Complete Proof of Claim(s) can be submitted as follows:

7.1.4.1 Mail

Azimuth Risk Solutions
PO Box 627
Indianapolis, IN 46206

7.1.4.2 Email: service@azimuthrisk.com

7.1.4.3 Fax – 1 (317) 423-9620/1 (888) 201- 8851 (outside of the US)

7.2CLAIM SETTLEMENT — Eligible and covered claims under this insurance, which have previously been paid by or on behalf of the Participating Member at the time of the Scheme Administrator's adjudication thereof will be reimbursed directly to the Participating Member, by check in USD, at his/her last known place of residence or mail-forwarding address. While the Evidence of Insurance is in effect, the Participating Member shall undertake to promptly notify the Scheme Administrator of any change in such addresses subsequent to the Effective Date of Coverage. Eligible and covered claims that have not yet been paid by or on behalf of the Participating Member at the time of adjudication will be paid by check to the Participating Member at his/her last known place of residence or mail-forwarding address, or at the sole option and discretion of the Scheme Administrator, and as an accommodation to the Participating Member, directly to the provider(s). All claim settlements are subject to the applicable Deductible and Coinsurance, and to the benefit limits and Sub-Limits and all other Terms of this insurance. No provider or other third-party shall have any direct or indirect claim or right of action against the Scheme Administrator under the Master Policy or any Evidence(s) of Insurance issued by the Master Policy, whether by purported assignment of Benefits, subrogation of interests or otherwise, unless first expressly agreed and consented to in writing by the Scheme Administrator, and notwithstanding the Scheme Administrator's exercise or failure to exercise any option or discretion under this section regarding the method of claim payment. No provider or other thirdparty is intended to have or shall have any rights as a third-party Beneficiary under the Master Policy or Evidence of Insurance issued by the Master Policy.

7.3 APPEALING A CLAIM — In the event the Scheme Administrator denies all or part of a claim, the Participating Member shall have ninety (90) days from the date that the Notice of Denial was mailed or mailed to the Participating Member’s last known place of residence or mail-forwarding address to file a written appeal with the Scheme Administrator. Upon receipt of a written appeal, the Scheme Administrator will respond in writing as soon as reasonably practicable and in any event within ninety (90) days from receipt thereof.

7.4 FRAUDULENT CLAIMS — If any claim or request for Benefits under this insurance shall be in any respect fraudulent or deceitful, or if the Participating Member or anyone acting for or on their behalf under this insurance uses any fraudulent or deceitful means or devices, all Benefits and claims under this insurance shall be forfeited and waived, and the Scheme Administrator, Underwriters and/or Master Policyholder shall have no liability for such Benefits or claims.

7.5 ARBITRATION — No claim for Benefits for which liability, eligibility or coverage under this insurance has been denied in whole or in part by the Scheme Administrator, nor any other dispute or controversy arising under or related to this insurance, shall be arbitral or subject to arbitration under any circumstances or for any reason.

PATIENT ADVOCACY— Neither the Underwriters nor the Scheme Administrator shall have any right, obligation or authority of any kind to ultimately select Physicians, hospitals, or other healthcare or health service providers for the Participating Member or to make any medical treatment decisions for or on behalf of the Participating Member, and all such decisions shall be made solely and exclusively by the Participating Member and/or his/her guardians, Family members and treating Physicians and other healthcare providers. Subject to the foregoing, the Scheme Administrator may determine that a particular claim, benefit, treatment, or diagnosis occurring under or relating to this insurance may be placed under the Scheme Administrator's Patient Advocacy program to ensure that Medically Necessary Treatment and supplies are provided in the most cost effective manner. In the event the Scheme Administrator determines that a claim, benefit, treatment, or diagnosis meets the Scheme Administrator's Patient Advocacy program guidelines, the Scheme Administrator will notify the Participating Member as soon as reasonably practicable, and a Patient Advocate will be assigned to the Participating Member. Thereafter, the Patient Advocate may make recommendations of treatment settings and/or procedures and/or supplies that may be more cost-effective for the Scheme Administrator and/or the Participating Member. Such recommendations will be made with input from the Participating Member and/or the Participating Member's guardians, Family members and treating Physicians and other healthcare providers, and will be made only when it can be reasonably demonstrated that the Medically Necessary Treatment and/or supplies can be provided in a more cost-effective manner to the Scheme Administrator and/or the Participating Member. The Scheme Administrator will use its best efforts to evaluate and recommend treatment settings and/or procedures and/or supplies that can reasonably be expected to result in the same or better care of the Participating Member. The Participating Member is under no obligation to accept or follow any of the Scheme Administrator's recommendations. However, if the Participating Member accepts and follows any of the Scheme Administrator's recommendations, the Participating Member agrees to hold the Scheme Administrator harmless from same, and the Scheme Administrator shall not be held liable or otherwise responsible for any treatment or supply provided to the Participating Member except for the payment of claims and Benefits eligible for coverage under the Terms of this insurance. After the Participating Member has been notified that the claim, treatment, benefit or diagnosis meets the Scheme Administrator's Patient Advocacy program guidelines, the Scheme Administrator reserves the right, at its option and in its sole discretion without liability, to:

7.6.1 Make payment for treatment and/or supplies that, although not expressly covered under this insurance, may be beneficial to the Participating Member and cost-effective to the Scheme Administrator; and/or

7.6.2 Deny coverage and/or Benefits for any charges that exceed the amount the Scheme Administrator would have covered had the Participating Member accepted and followed the recommendations of the Patient Advocacy program.

OTHER INSURANCE—The Scheme Administrator shall not be obligated to provide any Benefits or to pay any claim under this insurance if there is any Other Insurance, membership benefit, government program, reimbursement or indemnification coverage, right of contribution, recoupment or recovery, contract, or other third-party obligation or provision of Benefits ("Other Coverage") that would, or that would but for the existence of this insurance, be available or obligated to provide such benefit or to pay such claim, except in respect of any excess beyond the amount payable or provided under such Other Coverage had this insurance not been effected. The Scheme Administrator shall not be obligated to provide any benefit or to pay any claim in respect to treatment or supplies furnished by any program or agency funded by any government.

COOPERATION— The Participating Member and his/her Physicians, Hospitals and other healthcare and medical service providers and suppliers shall undertake to cooperate fully with the Scheme Administrator in reviewing, Investigating, adjudicating and/or administering any claim for Benefits under this insurance, which would include granting full right of access to all relevant or related medical documentation, medical histories, reports, lab or test results, x-rays, and other available evidence relating to or affecting the Investigation, adjudication or administration of the claim. The Scheme Administrator may deny coverage for a claim when there has been a refusal or material failure to cooperate.

APPEAL PROCESS— If the Participating Member disagrees with a Pre-notification decision of the Scheme Administrator, the Participating Member may ask the Scheme Administrator to reconsider the decision and may supply additional documentation to support the appeal. The Scheme Administrator may reconsider its decision based on review of the additional documentation and facts, if any. The Scheme Administrator will advise the Participating Member of its decision.