Plan Administrator: USI Affinity Travel Insurance Services | AM Best Rating: A+ "Superior" | Underwriter: Lloyd's of London
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. You shall have 60 days beginning on the last day of the certificate period to submit proof of claim to us.
You must submit a claim for any expenses to be paid by us. This includes treatment or services for which you expect the medical provider is to 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
Proof of Claim
When we receive notice of 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; and
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.
You shall have 60 days beginning on the last day of the certificate period to submit proof of claim to us (unless medical services were rendered after the certificate termination date, in which case you shall 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
If any dispute shall arise as to the amount to be paid under this insurance such dispute shall be referred to arbitration in accordance with procedures of the American Arbitration Association. 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.
Appealing a Claim
In the event we deny all or part of a claim under this insurance, you shall have 90 days from the date the notice of denial was mailed to your last known address to 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.
Within 60 days of our receipt of the appeal, we will review the claim. A written response will be forwarded to you. Within 60 days of receipt of our response to the appeal, you may initiate a second appeal. Within 60 days of 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.