Fillable Critical Illness Claim

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Critical Illness Claim

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Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand. | page 1 | ColonialLife.com | 7-19 | 65017-17
Colonial Life & Accident Insurance Company, Columbia, SC | CRITICAL ILLNESS | Fax: 1-800-880-9325 | Telephone: 1-800-325-4368
Critical Illness Claim
FAX this direction
FAX this form: 1-800-880-9325
Or mail: P.O. Box 100195, Columbia SC 29202
From:
Number of pages:
Section 1 – Claimant statement
(completed by policy owner)
Claimant name:
£ Male £ Female
DOB: ____ /____ /______
SSN:
Relationship to policy owner:
£ Self £ Spouse £ Domestic partner £ Dependent
Policy owner information
(if other than claimant)
Name:
DOB: ____ /____ /______
SSN:
Address: City: State: ZIP:
Email: Contact number:
Type of illness are you claiming:
Date you were first treated for the illness: ______ /______ /_________
Do you have a disability policy with us? £ Yes £ No
Employer name:
Employer telephone: Employer fax:
n If your name has changed, attach a copy of legal
documentation of the change.
n Dates should be written in month/day/year format
(i.e. 12/14/1980).
n Social Security number is indicated by SSN.
Incomplete claim form submission may result in a delay in the processing of your claim.
Complete each section before submitting your claim.
n Benefits are payable to you unless we receive written authorization to pay them
elsewhere. This is called an assignment.
n If this claim is for an individual covered by Medicaid, most non-disability benefits are
automatically assigned according to state regulations. This means we must pay the
benefits to Medicaid or to the medical provider to reduce the charges billed to Medicaid.
Optional Service Release Agreement
Please indicate below for optional services you desire. Any marks used (check mark, X, initials, etc.) will be considered as
your authorization and will be processed as if they were selected.
I authorize Colonial Life to facilitate processing this claim by releasing its details to the following individual inquiring on my behalf.
Note: Leave blank if you do not want anyone accessing your claim information.
______ Sales representative ______ Employer ______ Spouse, family member or significant other Name: _________________________
______ I want Colonial Life to update me on the status of my claim through prerecorded messages at my contact number indicated on this
form. I understand that messages will be left with anyone who answers the phone or on my answering machine. Note: To avoid blocked
calls, you should program the number 1-800-325-4368 into your phone.
______ Yes, I want ALL payment(s) for this claim sent by overnight delivery. I understand payment(s) under $100.00 cannot be sent overnight.
I also understand that if I wish my claim to be sent by overnight delivery, a $22.00 fee will be deducted from my claim payment.
This fee is subject to rate increases by carrier and does not include weekend delivery. I understand that Colonial Life is unable to
send overnight mail to a P.O. Box. I also understand that I must notify Colonial Life to discontinue this service.
File Your Claim Online
u
Simply log into your account at Coloniallife.com and click on “File an Online Claim”.
u
As an added convenience, you may also select Direct Deposit when filing online.
u
Not a member? Log onto Coloniallife.com and click on “Register” then “Join the Policyholder Website” to set up your account.
Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand. | page 2 | ColonialLife.com | 7-19 | 65017-17
Colonial Life & Accident Insurance Company, Columbia, SC | CRITICAL ILLNESS | Fax: 1-800-880-9325 | Telephone: 1-800-325-4368
Claim Fraud Statements
For your protection, the laws of several states, including Alaska, Arkansas, Delaware, Idaho, Indiana, Louisiana, Minnesota,
New Hampshire, Ohio, Oklahoma, and others, require the following statement to appear on this claim form. Fraud Warning: Any
person who knowingly, and with intent to injure, defraud, or deceive an insurance company, files a statement of claim containing
any false, incomplete, or misleading information is guilty of insurance fraud, which is a felony.
Alabama: Any person who knowingly presents a false or fraudulent claim
for payment of a loss or benefit or who knowingly present false information
in an application for insurance is guilty of a crime and may be subject to
restitution fines or confinement in prison, or any combination thereof.
Arizona: For your protection Arizona law requires the following
statement to appear on this form: Any person who knowingly
presents a false or fraudulent claim for payment of a loss is
subject to criminal and civil penalties.
California, Rhode Island, Texas and West Virginia: For your protection,
California, Rhode Island, Texas and West Virginia law requires the following
to appear on this form: Any person who knowingly presents false or
fraudulent claim for the payment of a loss is guilty of a crime and may
be subject to fines and confinement in state prison.
Colorado: It is unlawful to knowingly provide false, incomplete, or misleading
facts or information to an insurance company for the purpose of defrauding
or attempting to defraud the company. Penalties may include imprisonment,
fines, denial of insurance and civil damages. Any insurance company or
agent of an insurance company who knowingly provides false, incomplete,
or misleading facts or information to a policyholder or claimant for the
purpose of defrauding or attempting to defraud the policyholder or claimant
with regard to a settlement or award payable from insurance proceeds shall
be reported to the Colorado Division of Insurance within the Department of
Regulatory Agencies.
District of Columbia: It is a crime to provide false or misleading information
to an insurer for the purpose of defrauding the insurer or any other person.
Penalties include imprisonment and/or fines. In addition, an insurer may
deny insurance benefits if false information materially related to a claim
was provided by the applicant.
Florida: Any person who knowingly and with intent to injure, defraud, or
deceive any insurer files a statement of claim or an application containing
any false, incomplete, or misleading information is guilty of a felony of the
third degree.
Kentucky: For your protection, Kentucky law requires the following to
appear on this form: Any person who knowingly and with intent to defraud
any insurance company or other person files a statement of claim
containing any materially false information or conceals, for the purpose
of misleading, information concerning any fact material thereto commits
a fraudulent insurance act, which is a crime.
Maine, Tennessee, Virginia and Washington: It is a crime to knowingly
provide false, incomplete or misleading information to an insurance
company for the purpose of defrauding the company. Penalties may
include imprisonment, fines or a denial of insurance benefits.
Maryland: Any person who knowingly or willfully presents
a false or fraudulent claim for payment of a loss or benefit
or who knowingly or willfully presents false information in
an application for insurance is guilty of a crime and may be
subject to fines and confinement in prison.
New Jersey and New Mexico: Any person who knowingly
files a statement of claim containing any false or misleading
information is subject to criminal and civil penalties.
New York: Any person who knowingly and with intent to
defraud any insurance company or other person files an
application for insurance or statement of claim containing
any materially false information, or conceals for the purpose
of misleading, information concerning any fact material
thereto, commits a fraudulent insurance act, which is a crime,
and shall also be subject to a civil penalty not to exceed five
thousand dollars and the stated value of the claim for each
such violation.
Pennsylvania: Any person who knowingly and with intent
to defraud any insurance company or other person files an
application for insurance or statement of claim containing
any materially false information or conceals for the purpose
of misleading, information concerning any fact material
thereto commits a fraudulent insurance act, which is a crime
and subjects such person to criminal and civil penalties
Puerto Rico: Any person who knowingly and with the
intention of defrauding presents false information in an
insurance application, or presents, helps, or causes the
presentation of a fraudulent claim for the payment of a loss
or any other benefit, or presents more than one claim for
the same damage or loss, shall incur a felony and, upon
conviction, shall be sanctioned for each violation with the
penalty of a fine of not less than five thousand (5,000)
dollars and not more than ten thousand (10,000) dollars,
or a fixed term of imprisonment for three (3) years, or both
penalties. If aggravating circumstances are present, the
penalty thus established may be increased to a maximum
of five (5) years; if extenuating circumstances are present;
it may be reduced to a minimum of two (2) years.
Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand. | page 3 | ColonialLife.com | 7-19 | 65017-17
Colonial Life & Accident Insurance Company, Columbia, SC | CRITICAL ILLNESS | Fax: 1-800-880-9325 | Telephone: 1-800-325-4368
Hospital admission: £ Yes £ No
Treating hospital: Telephone:
Address: City: State: ZIP:
Admission date: _______ / _______ / __________ Time:________
£ AM £ PM Date released: _______ / _______ / __________ Time:________ £ AM £ PM
Treating hospital: Telephone:
Address: City: State: ZIP:
Admission date: _______ / _______ / __________ Time:________
£ AM £ PM Date released: _______ / _______ / __________ Time:________ £ AM £ PM
Section 1 – Claimant statement ~ continued
(completed by policy owner)
Treating physician
Name:
Address: City: State: ZIP:
Email: Telephone: Fax:
Primary physician
Name:
Address: City: State: ZIP:
Email: Telephone: Fax:
Referring physician/hospital
Name:
Address: City: State: ZIP:
Email: Telephone: Fax:
Policy owner name: Policy owner SSN:
If other than policy owner
Claimant name: Claimant SSN:
Select the condition
for this claim
Please note that coverage for the conditions listed below depends on your specific policy. Some policies may provide a benefit for a
dependent child diagnosed with Cerebral Palsy, Cleft Lip or Palate, Cystic Fibrosis, Down Syndrome or Spina Bifida. If filing for a
dependent with one of these conditions, the claimant name in all sections of this form should be the dependent's name. Please include
a completed Physician's Statement (Section 2 in this form) or other information that confirms the diagnosis. Review your policy for
specific conditions and documentation required.
CONDITION EXAMPLES OF MEDICAL DOCUMENTATION THAT MAY BE REQUIRED
£ Blindness
(if applicable to your policy)
Medical documentation of clinically proven irreversible reduction of sight in both eyes that has persisted for a period of at least 180
consecutive days. Sight must be reduced to a corrected visual acuity of less than 6/60 (Metric Acuity) or 20/200 (Snellen or E-Chart Acuity);
or visual field restriction to 20 degrees or less in both eyes.
£ Bypass surgery as a result of
coronary artery disease
Surgical report that documents procedure to bypass a narrowing or blockage of one or more coronary arteries utilizing venous or arterial grafts.
£ Cancer and/or carcinoma in situ
A pathology report confirming the pathological diagnosis of cancer or carcinoma in situ by a certified pathologist. If a pathological diagnosis cannot be
made provide medical evidence to support a clinical diagnosis of cancer or carcinoma in situ based on the study of symptoms.
£ Coma
Medical records substantiating the coma resulting from a covered accident or a covered sickness has lasted 7 or more consecutive days. In some
policies intubation for respiratory assistance may also be required.
£ Coronary artery disease
Medical documentation indicating a narrowing or blockage of one or more coronary artieries for which a cardiologist recommends that coronary artery
bypass graft surgery occur within 60 days following the date of the recommendation.
£ End stage renal failure
Medical documentation that documents the date regular hemodialysis or peritoneal dialysis began.
£ Heart attack (myocardial infarction)
Diagnosis supported by three or more of the following indicators: medical records documenting typical chest pain suggestive of heart attack; new
EKG report showing changes indicative of myocardial infarction; medical reports documenting increase of specific cardiac markers typical for heart
attack, or medical reports of confirmatory imaging studies. (In the event of death, an autopsy confirmation identifying heart attack as the cause of
death will be accepted.)
£ Major organ failure/Major Organ
Transplant
Medical documentation that the Insured has been placed on the United Network for Organ Sharing list. Some policies may require a copy of the
transplant surgical report.
£ Occupational Infections
(HIV or Hepatitis B, C or D)
Provide the following: copy of report that was reported and recorded within five days of the covered accident by the appropriate person according
to legislation, regulations, standards or guidelines that apply to the covered person’s occupation or profession; copy of investigated covered accident
report filed with your employer that confirms events surrounding work-related injury; confirmatory antibody HIV or Hepatitis B, C or D test taken
with five days of the Covered Accident and HIV or Hepatitis B, C or D is not present; all HIV or Hepatitis B, C or D tests are performed by a state
certified and licensed laboratory; and follow-up confirmatory antibody HIV or Hepatitis B, C or D test is taken between 90 days and 180 days after
the Covered Accident, and the result is positive.
£ Permanent paralysis (due to covered
accident) if applicable to your policy
Medical documentation of complete and permanent loss of the use of two or more limbs for a continuous period of 180 days.
£ Stroke
Evidence of persistent neurological deficits confirmed by a neurologist at least 30 days after the event and confirmatory neuroimaging studies
consistent with the diagnosis of a new stroke.
Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand. | page 4 | ColonialLife.com | 7-19 | 65017-17
Colonial Life & Accident Insurance Company, Columbia, SC | CRITICAL ILLNESS | Fax: 1-800-880-9325 | Telephone: 1-800-325-4368
Policy owner name: Policy owner SSN:
If other than policy owner
Claimant name: Claimant SSN:
____________________________________________________
Print claimant’s name
____________________________________________________
Claimant’s signature
______________________________
Date (MM/DD/YYYY)
____________________________________________________
Print policy owner’s name
____________________________________________________
Policy owner’s signature
______________________________
Date (MM/DD/YYYY)
Certification
Policy owner’s name: _________________________________________________________________________ SSN: _________________________
I have checked the answers on this claim form, and they are correct. I certify under penalty of perjury that my correct Social Security number is shown
on this form. I acknowledge that I received the Claim Fraud Statements on page two of this form and that I read the statement required by the State
Department of Insurance for my state, if my state was listed on the form.
Fraud Warning: Any person who knowingly and with intent to
defraud any insurance company or other person files a statement of claim containing any materially false information or conceals, for the
purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.
Beneficiary’s SSN:
Beneficiary’s DOB: ______ / ______ / ________
Relationship to deceased:
Beneficiary’s address:
City: State: ZIP: Telephone:
Witness’ name: Witness’ signature:
Witness’ address: City: State: ZIP:
_______________________________________________ ______________________________________________ ________________________
Beneficiary’s name Beneficiary’s signature Date (MM/DD/YYYY)
If deceased, attach a death certificate and complete below.
Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand. | page 5 | ColonialLife.com | 7-19 | 65017-17
Colonial Life & Accident Insurance Company, Columbia, SC | CRITICAL ILLNESS | Fax: 1-800-880-9325 | Telephone: 1-800-325-4368
Fraud warning: Any person who knowingly files a statement of claim containing false or misleading information is subject to
criminal and civil penalties. This includes attending physician portions of the claim form.
_________________________________________________________________________________________
Physician signature
___________________________________
Date (MM/DD/YYYY)
Physician/group name: Tax ID or SSN:
Physician’s specialty: Telephone: Fax:
Address: City: State: ZIP:
Section 2 – Physician statement
(completed by physician)
Patient name: SSN:
DOB: ______ / ______ / _________
Select the condition
for this claim
Please check the condition that applies to this patient and provide the test results, operative reports, pathology reports, and/or your
detailed medical statement as required for the condition indicated below (check all that apply). If confirming a diagnosis of Cerebral
Palsy, Cleft Lip or Palate, Cystic Fibrosis, Down Syndrome or Spina Bifida on a dependent, include medical documentation that confirms
the diagnosis.
CONDITION MEDICAL DOCUMENTATION THAT MAY BE REQUIRED
£ Blindness
(if applicable to the policy)
Documentation of clinically proven irreversible reduction of sight in both eyes that has persisted for a period of at least 180
consecutive days.
£ Bypass surgery as a result of
coronary artery disease
Date CABG performed: _____________________
£ Cancer and/or carcinoma in situ
Send pathology report. Date of first diagnosis of cancer _____________________
£ Coma
Medical records substantiating the coma resulting from an accident or a sickness lasting 7 or more consecutive days.
£ Coronary artery disease
Date CABG recommended: _____________________ Date CABG performed: _____________________
£ End stage renal failure
Medical documentation that documents the date regular hemodialysis or peritoneal dialysis began. Date dialysis began _________________
£ Heart attack (myocardial infarction)
Medical records documenting typical chest pain suggestive of heart attack; new EKG report showing changes indicative of myocardial infarction;
medical reports documenting increase of specific cardiac markers typical for heart attack, or medical reports of confirmatory imaging studies.
£ Major organ failure/Major Organ
Transplant
Date placed on United Network for Organ Sharing list. (UNOS) for transplant _____________________
If applicable: Date of transplant _____________________ Type of transplant _________________________________________
£ Occupational Infections
(HIV or Hepatitis B, C or D)
Provide a copy of the report that confirms the HIV antibody or positive Hepatitis B,C, or D test taken between 90 days and 180 days after the
covered accident. Tests must be performed by a state certified and licensed laboratory.
£ Permanent paralysis (due to covered
accident) if applicable to the policy
Medical documentation of complete and permanent loss of the use of two or more limbs for a continuous period of 180 days.
£ Stroke
Any continued deficits past 30 days: £ Yes £ No If yes, list deficits _______________________________________________________
Date of confirmatory neuroimaging studies _____________________
Has patient been treated for same or similar condition prior to this occurrence? £ Yes £ No
Diagnosis First date of treatment Referring physician Telephone
Diagnosis(es) Date of diagnosis (MM/DD/YYYY) ICD-9 code(s)
Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand. | page 6 | ColonialLife.com | 7-19 | 65017-17
Colonial Life & Accident Insurance Company, P.O. Box 100195, Columbia, SC 29202 | CRITICAL ILLNESS | Fax: 1-800-880-9325 | Telephone: 1-800-325-4368
Authorization for Colonial Life & Accident Insurance Company
Sign and return this authorization to Claims Department at the address listed above. This authorization is designed to comply with the
Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule.
I hereby authorize the disclosure of the following information about me and, if applicable, my dependents, from the sources listed below
to Colonial Life & Accident Insurance Company and its duly authorized representatives (Colonial Life).
Health information may be disclosed by any medical or medically related provider or institution, rehabilitation professionals, vocational
evaluators, health plan or health care clearinghouse that has any records or knowledge about me, including prescription drug database
or pharmacy benefit manager, ambulance or other medical transport service, any insurance company, Medicare or Medicaid agencies
or the Medical Information Bureau (MIB). Non-health information may be disclosed by any entity, person or organization that has any
records about me, including but not limited to my employer, employer representative and compensation sources, insurance company,
financial institution, consumer reporting agencies including credit bureaus, professional licensing bodies, attorneys or governmental
entities.
Health information includes my entire medical record, prescription drug history and insurance claim history, including HIV, AIDS or other
disorders of the immune system, use of drugs or alcohol, mental or physical history, condition, advice or treatment, but does not include
psychotherapy notes. Non-health information, includes earnings, financial or credit history, professional licenses, employment history
or any other facts deemed necessary by Colonial Life to evaluate my application or claim forms.
Any information Colonial Life obtains pursuant to this authorization will be used for the purpose of evaluating and administering my
claim for benefits or for evaluating my eligibility for insurance, including checking for and resolving any issues that may arise regarding
incomplete or incorrect information on my application or claim forms. Some information, once obtained, may not be protected by
certain federal regulations governing the privacy of health information, but the information is protected by state privacy laws and other
applicable laws. Colonial Life will not re-disclose the information unless permitted or required by those laws or as authorized by me.
I also authorize Colonial Life to disclose my information to the following persons (for the purpose of reporting claim status, or experience,
or so that the recipient may carry out health care operations, claims payment, administrative or audit functions related to any benefit,
plan or claim): any employee benefit plan sponsored by my employer; any person providing services or insurance benefits to (or on
behalf of) my employer, any such plan or claim, or any benefit offered by Colonial Life; or, the Social Security Administration. Colonial
Life will not condition the payment of insurance benefits on whether I authorize Colonial Life to re-disclose my information. For the
purposes of these disclosures by Colonial Life, this authorization is valid for one year or for the length of time otherwise permitted by law.
This authorization is valid for two (2) years from its execution or the duration of my claim (to include any subsequent financial
management and/or benefit recovery review), whichever is earlier, and a copy is as valid as the original. I know that I, or my authorized
representative, may request a copy of this authorization. This authorization may be revoked by me or my authorized representative at any
time except to the extent Colonial Life has relied on the authorization prior to notice of revocation or has a legal right to contest coverage
under the contract or the contract itself. If I do not sign this authorization or if I alter or revoke it, except as specified above, Colonial Life
may not be able to evaluate my claim or eligibility for insurance. I may revoke this authorization by sending written notice to the Claims
Department at the address listed above.
_____________________________________________________________________ ______________________________________________
Signature Date signed (MM/DD/YYYY)
_____________________________________________________________________ XXX-XX-_______________ ____________________
Printed name of individual subject to this disclosure Last four digits of SSN Date of birth (MM/DD/YYYY)
If applicable, I signed on behalf of the insured as ___________________________________ (indicate relationship). If legal guardian,
power of attorney designee, conservator, beneficiary or personal representative, please attach a copy of the document granting authority.
_______________________________________________ __________________________________________ ______________________
Printed name of legal representative Signature of legal representative Date signed (MM/DD/YYYY)
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Critical Illness Claim

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Completed 15 June 2021

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