Fillable HOSPITAL CONFINEMENT PLAN

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HOSPITAL CONFINEMENT PLAN

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HOSPITAL CONFINEMENT PLAN
INSTRUCTIONS FOR FILING CLAIMS
Please complete the following information related to your Hospital Confinement Plan
(HCP) claim. This information is required in order to process your claim, without delay.
Insured’s Name
Insured’s Date of Birth
Insured’s Social Security Number
Insured’s Employer
Insured’s Mailing Address
Street or P.O. Box
City State Zip Code
Patient’s Name
Patient’s Relation to Insured
Patient’s Date of Birth
Patient’s Social Security Number
Diagnosis (reason for hospital confinement)
Enclose a copy of the hospital bill showing number of days in the hospital.
Mail or Fax the above information to:
Claims Department
USAble Life
P.O. Box 1650
Little Rock, AR 72203
Fax: (501) 235-8416
If you have any questions about how to submit your claim, please call: (800) 370-5856
CL-HCP (9-02) Rev. 4-09
FRAUD NOTICE
For your protection, the laws of some states may require us to furnish you with the following
notice:
Except as otherwise noted below, it is or may be a crime to knowingly provide false, incomplete,
or misleading information to an insurance company for the purpose of defrauding the company
or other person. Penalties may include imprisonment, fines, and denial of insurance benefits in
accordance with applicable state law.
Arizona
Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject
to criminal and civil penalties.
California
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.
Florida
Any person who knowingly and with intent to injure, defraud or deceive any insurance company
files a statement of claim containing any false, incomplete, or misleading information is guilty of
a felony of the third degree.
New Jersey
Any person who knowingly files a statement of claim containing any false or misleading
information is subject to criminal and civil penalties.
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.
Retain for your records.
CL-FRAUD (5-04)
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HOSPITAL CONFINEMENT PLAN

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Completed 28 December 2022

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