Plan Detail

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



The following expenses must always be Pre-certified:
Send completed claim documents to HCC Medical Insurance Services (HCCMIS)
Download Claim Forms Email Fax Mail Claim Enquiry

Claim Form

Non-US Claim Form

Claimant Appeal Request Form

Lost Checked Luggage

Dental Claimants Statement

Accident Questionnaire 1 (317) 262-2140

P.O. Box 2005, Farminton Hills, MI 48333-2005 USA



1 (317) 262-2132

To comply with the Pre-certification requirements, the Member must:

  1. Contact the Plan Administrator at the telephone number contained in the Member’s Certificate as soon as possible before the expense is to be incurred; and
  2. Comply with the instructions of the Plan Administrator and submit any information or documents they require; and
  3. Notify all Physicians, Hospitals and other providers that this insurance contains Pre-certification requirements and ask them to fully cooperate with the Plan Administrator.
If the Member complies with the Pre-certification requirements, and the expenses are Pre-certified, Underwriters will pay Eligible Medical Expenses subject to all terms, conditions, provisions and exclusions herein. If the Member does not comply with the Pre-certification requirements or if the expenses are not Pre-certified:
  1. Eligible Medical Expenses will be reduced by 50%; and
  2. The Deductible will be subtracted from the remaining amount; and
  3. The benefit will be applied.

Emergency Pre-certification: In the event of an Emergency Hospital admission, Pre-certification must be made within 48 hours after the admission, or as soon as is reasonably possible.

Pre-certification Does Not Guarantee Benefits – The fact that expenses are Pre-certified does not guarantee either payment of benefits or the amount of benefits. Eligibility for and payment of benefits are subject to all the terms, conditions, provisions and exclusions herein.

Concurrent Review – For Inpatient stays of any kind, the Plan Administrator will Pre-certify a limited number of days of confinement. Additional days of Inpatient confinement may later be Pre-certified if a Member receives prior approval.

Notice of Claim, Claimant’s Statement and Authorization, and Proof of Claim must be mailed to:
HCC Medical Insurance Services, LLC
P.O. Box 863
Indianapolis, Indiana 46206
Proof of Claim – When Underwriters receive notice of claim, they will provide the Member 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 or on behalf of the Member. The Member shall have 60 days beginning on the Certificate Termination Date to submit Proof of Claim to Underwriters. Subsequent to receipt of Proof of Claim, Underwriters may, at their 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.
Appealing a Claim –
Time Limit – In the event Underwriters deny all or part of a claim under this insurance, the Member shall have 90 days from the date the notice of denial was mailed to the Member’s last known address to file a written appeal with Underwriters. 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.
Appeal Procedure – Within 30 days of Underwriters’ receipt of the appeal, Underwriters’ will review the claim. A written response will be forwarded to the Member. Within 60 days of receipt of Underwriters’ response to the appeal, the Member may initiate a second appeal. Within 30 days of Underwriters’ 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 the Member.