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HEART ATTACK / HEART DISEASE / STROKE POLICY 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.
- A uniform itemized hospital bill (form UB-92) must be submitted with the diagnosis of heart attack, heart disease or stroke indicated by ICD code.
- Submit the fully itemized hospital bill that shows the number of days of confinement and itemized charges.
- When your claim is received, it may be necessary that we request the hospital admission and discharge summaries from the hospital where you were confined to verify diagnosis of heart attack, heart disease or stroke.
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