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HOSPITAL INDEMNITY – ACCIDENTAL DEATH AND DISMEMBERMENT RIDER CLAIMS
- Use claim form C101.
- Complete the section entitled "Claimant's Statement". Please be sure to date and sign the blanks provided at the bottom of the form.
- Submit a certified copy of the death certificate if the claim is for accidental death.
- If the claim is for dismemberment, the physician must complete PART B "Attending Physician's Statement" on the reverse side of claim form C101.
- A copy of the police accident report is required for all accidents investigated by any law enforcement agency.
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HOSPITAL INDEMNITY – EMERGENCY ACCIDENT RIDER CLAIMS
- Use claim form C101.
- Complete the section entitled "Claimant's Statement". Please be sure to date and sign in the blanks provided at the bottom of the form.
- Submit the statement from the physician or emergency room that shows the date of service, the diagnosis (ICD-9 codes), the procedures performed (CPT codes) and the itemized charges. The statement should show the name, address and tax identification number of the physician.
- A copy of the police accident report is required for all accidents investigated by any law enforcement agency.
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HOSPITAL INDEMNITY – HOSPITAL CONFINEMENT AND ANNUAL FIRST OCCURRENCE BENEFIT CLAIMS
- Use claim form C101.
- Complete the section entitled "Claimant's Statement". Please be sure to date and sign in the blanks provided at the bottom of the form.
- The claim form should be submitted with a copy of your itemized hospital bill that shows the number of days you were confined to the hospital, the amount charged and the diagnosis.
- A copy of the police accident report is required for all accidents investigated by any law enforcement agency.
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HOSPITAL INDEMNITY – OUTPATIENT SICKNESS RIDER CLAIMS
- Use claim form C101.
- Complete the section entitled "Claimant's Statement". Please be sure to date and sign in the blanks provided at the bottom of the form.
- Submit the statement from the physician or emergency room that shows the date of service, the diagnosis (ICD-9 codes), the procedures performed (CPT codes) and the itemized charges. The statement should show the name, address and tax identification number of the physician.
- A copy of the police accident report is required for all accidents investigated by any law enforcement agency.
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HOSPITAL INDEMNITY – SURGICAL AND ANESTHESIA BENEFIT CLAIMS
- Use claim form C101.
- Complete the section entitled "Claimant's Statement". Please be sure to date and sign in the blanks provided at the bottom of the form.
- Submit the bill from the surgeon that shows the diagnosis (ICD-9 code), the procedure code (CPT) for the surgery performed and the charge.
- Submit bill from the anesthesiologist that shows the procedure code (CPT) and the charge.
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HOSPITAL INDEMNITY – WELLNESS BENEFIT / DIAGNOSTIC TESTING CLAIMS
- Use claim form C101.
- Complete the section entitled "Claimant's Statement". Be sure to date and sign in the blanks provided at the bottom of the form.
- The physician's itemized statement of services rendered must accompany the claim form. This is the walkout statement you receive from the doctor's office at the end of your appointment.
- For diagnostic testing performed in an imaging center, please submit the bill from the imaging center.
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