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SPECIMEN3. 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
You shall provide assistance and cooperate 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 cooperate 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
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.
10 Atlas Travel Description of Coverage | Tokio Marine HCC - MIS Group
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
You shall provide assistance and cooperate 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 cooperate 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
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.
10 Atlas Travel Description of Coverage | Tokio Marine HCC - MIS Group
