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SPECIMENCoinsurance means your payment of eligible expenses as specified in the Schedule of Benefits and
Limits.
Deductible means the dollar amount of eligible expenses, specified in the Schedule of Benefits and
Limits that you must pay per certificate period before eligible expenses are paid.
Usual, Reasonable and Customary means the lesser of the following:
1. One and a half times (150%) of the charges payable under the United States Medicare program,
for claims incurred outside the PPO network within the U.S., or
2. Most common charge for similar services, medicines or supplies within the area in which the
charge is incurred, so long as those charges are reasonable. What is defined as usual,
reasonable and customary charges will be determined by us. In determining whether a charge
is usual, reasonable and customary, we may consider one or more of the following factors: the
level of skill, extent of training, and experience required to perform the procedure or service; the
length of time required to perform the procedure or services as compared to the length of time
required to perform other similar services; the severity or nature of the illness or injury being
treated; the amount charged for the same or comparable services, medicines or supplies in the
locality; the amount charged for the same or comparable services, medicines or supplies in other
parts of the country; the cost to the provider of providing the service, medicine or supply; such
other factors we, in the reasonable exercise of discretion, determine are appropriate.
U.S. PREFERRED PROVIDER ORGANIZATION (PPO)
REQUIREMENTS
Nothing contained in this insurance restricts or interferes with your right to select the hospital,
physician or other medical service provider of your choice. Nothing contained in this insurance
restricts or interferes with the relationship between you and the hospital, physician or other
providers with respect to treatment or care of any condition, nor your right to receive, at your own
expense, services and/or supplies that are not covered under this insurance.
To comply with the United States Preferred Provider Organization (PPO) requirements, you must
receive medical treatment from PPO providers while in the United States. If you choose to seek
treatment from a PPO provider, we will remit payment for eligible expenses directly to the provider.
You may review a listing of hospitals, physicians and other medical service providers included in
the PPO Network for the area where you will be receiving treatment by accessing the Internet website
for Tokio Marine HCC - MIS Group at: www.hccmis.com. For assistance locating a provider, contact
us at 1-800-605-2282.
CLAIM PROCEDURES
You must submit a claim for any expenses to be paid by us. This includes treatment or services for
which the medical provider will 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
USA
PROOF OF CLAIM
When we receive notice of a 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;
2. Original itemized bills from physicians, hospitals and other medical providers; and
9 Atlas Travel Description of Coverage | Tokio Marine HCC - MIS Group
Limits.
Deductible means the dollar amount of eligible expenses, specified in the Schedule of Benefits and
Limits that you must pay per certificate period before eligible expenses are paid.
Usual, Reasonable and Customary means the lesser of the following:
1. One and a half times (150%) of the charges payable under the United States Medicare program,
for claims incurred outside the PPO network within the U.S., or
2. Most common charge for similar services, medicines or supplies within the area in which the
charge is incurred, so long as those charges are reasonable. What is defined as usual,
reasonable and customary charges will be determined by us. In determining whether a charge
is usual, reasonable and customary, we may consider one or more of the following factors: the
level of skill, extent of training, and experience required to perform the procedure or service; the
length of time required to perform the procedure or services as compared to the length of time
required to perform other similar services; the severity or nature of the illness or injury being
treated; the amount charged for the same or comparable services, medicines or supplies in the
locality; the amount charged for the same or comparable services, medicines or supplies in other
parts of the country; the cost to the provider of providing the service, medicine or supply; such
other factors we, in the reasonable exercise of discretion, determine are appropriate.
U.S. PREFERRED PROVIDER ORGANIZATION (PPO)
REQUIREMENTS
Nothing contained in this insurance restricts or interferes with your right to select the hospital,
physician or other medical service provider of your choice. Nothing contained in this insurance
restricts or interferes with the relationship between you and the hospital, physician or other
providers with respect to treatment or care of any condition, nor your right to receive, at your own
expense, services and/or supplies that are not covered under this insurance.
To comply with the United States Preferred Provider Organization (PPO) requirements, you must
receive medical treatment from PPO providers while in the United States. If you choose to seek
treatment from a PPO provider, we will remit payment for eligible expenses directly to the provider.
You may review a listing of hospitals, physicians and other medical service providers included in
the PPO Network for the area where you will be receiving treatment by accessing the Internet website
for Tokio Marine HCC - MIS Group at: www.hccmis.com. For assistance locating a provider, contact
us at 1-800-605-2282.
CLAIM PROCEDURES
You must submit a claim for any expenses to be paid by us. This includes treatment or services for
which the medical provider will 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
USA
PROOF OF CLAIM
When we receive notice of a 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;
2. Original itemized bills from physicians, hospitals and other medical providers; and
9 Atlas Travel Description of Coverage | Tokio Marine HCC - MIS Group
