Below are additional details that is good to know about the Accident Plan…
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Technical Details of the Accident Plan
An ACCIDENT means the unforeseen occurrence of an event that results in an accidental injury to an insured person wholly independent of disease, bodily infirmity, illness, infection or any other physical condition.
An ACCIDENTAL INJURY means a bodily injury to an insured person as the result of an accident, after coverage under this policy takes effect and while this policy is inforce, which results in care within 72 hours (3 days) after the injury is sustained. The following are examples that help describe the difference between an injury and an accidental injury.
How to File an Accident Expense Claim
The claims process begins when you contact the Customer Service Center to request health claim forms. This may be done via their Customer Service phone number (800) 811-2696. You MUST complete the form and submit it, along with any documentation, including Explanation of Benefits (EOB), to the address provided. After receiving all required documentation, they will begin review of the claim. Normal processing time is 10 business days from receipt of all required documents.
Accident & Health Claims – 800-811-2696
ACCIDENT FOLLOW UP CARE BENEFIT: Follow-up treatments are limited to three follow-up treatments. The follow-up treatments must occur within one year of the Accidental Injury or discharge from the hospital, and must be furnished by a Physician in a Physician’s Office or in a Hospital on an outpatient basis. Benefit NOT payable for the same visit that the Physical Therapy Benefit is payable or on the same day for which the Accidental Emergency Care Benefit is payable.
AMBULANCE BENEFIT: Benefit only payable if Accidental Emergency Treatment Benefit is payable
DRUG BENEFIT: Benefits for drugs administered in a Hospital or Urgent Care Center.
FRACTURE BENEFIT: Diagnosis of the Fracture must be within 14 Days of the Accidental Injury.
MAJOR DIAGNOSTIC EXAMINATIONS: Benefit is limited to one Major Diagnostic Exam per Year for each Insured Person. Major Diagnostic Exams are limited to a CT Scan, MRI or EEG (electroencephalogram).
PHYSICAL THERAPY BENEFIT: Physical Therapy must begin within 30 days of the Accidental Injury or discharge from the Hospital and must be completed within six months after the Accidental Injury. Benefit is limited to one Physical Therapy treatment per day, up to a maximum of ten treatments for each Accidental Injury.
PROSTHESIS BENEFIT: Benefit limited to a maximum of one Prosthetic Device received within one year of the Accidental Injury.
X-RAY BENEFIT: The x-ray or set of x-rays must be performed within 14 days of the Accidental Injury.
Insurance Company Legal Mumbo Jumbo
Here is a description from AIG about making sure actual accidents are covered and how they avoid fraudulent claims.
“We reserve the right to request that a Physician of our choice review any Diagnosis in the event of a dispute or disagreement
regarding the appropriateness or correctness of a Diagnosis. We also reserve the right to require that an Insured Person submit to
an examination to confirm a disputed Accidental Injury. We reserve the right to request that an independent and acknowledged
expert in the applicable field of medicine review the evidence used in making any disputed Diagnosis. We will pay for any such
requested examination or review.”
EXCLUSIONS
For any Insured Person:
(a) We will pay NO benefits under the policy if covered services provided are not related to a covered Accident.
(b) We will pay NO benefits for any Accident or any loss caused in whole or in part by, or resulting in whole or in part from the following:
i) the Insured Person’s suicide or attempt at suicide, or intentional self-inflicted injury or sickness, or any attempt at intentional
self-inflicted injury or sickness while sane or insane;
ii) the Insured Person’s alcoholism or drug addiction;
iii) the Insured Person’s commission of or attempt to commit an assault or felony;
iv) the Insured Person engaging in an illegal activity or occupation;
v) the Insured Person’s voluntary participation in any riot or civil insurrection;
vi) declared or undeclared war, or any act of declared or undeclared war; and
vii) any illness, loss, or condition specifically excluded from the definition of any Accident.
Below are our areas of expertise:
- Health Insurance (Every company in Washington State)
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Gary Franke, Tamara Chandler, Justin Cross
Independent Broker
Achieve Alpha Insurance, LLC
12507 Bel-Red Rd, Ste 103
Bellevue, WA 98005
(425) 802-2783
health@achieve-alpha.com
www.achieve-alpha.com