Plan Administrator: Tokio Marine HCC - Medical Insurance Services Group | AM Best Rating: A "Excellent" | Underwriter: Lloyd's
This insurance policy has in it a Claims Procedure which tells you what steps you must take to file a claim, and explains our obligations to you. Beginning on the last day of your certificate period, you shall have 60 days to provide us proof of claim.
APPEALS AND COMPLAINTS
This insurance policy has in it an Appeals and Complaints Procedure which tells you what steps you can take if you wish to make an appeal or complaint.
CLAIM PROCEDURES
Youmust submit a claim for any expenses to be paid by us. This includes treatment or services for which you expect 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
Youshall 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
Youshall 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
Weshall 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.
APPEAL 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 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
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
Weare 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
For both appeals and complaints, you will be contacted within 3 (three) business days 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