Sep 9, 2013 ... HCC Medical Insurance Services. 251 North Illinois Street, Suite 600 /
Indianapolis, IN 46204. CONFIRMATION OF COVERAGE. To whom it ...
Medical Insurance e Services Group
Prrimary Insure ed: KUMAR SINGH Effective Date: 04/16/2016 ID # VS0123456
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PO OSSESSION OF THE T CARD DOES NOT GUARANTEE E COVERAGE
Filing a C Claim x O Obtain a Claimant’s Statem ment & authorization form by visiting hccmis.com or b by calling 8800-605-2282 or 317-262-2 2132 x C Complete the claim form; a attach original, itemized bills; and forward to H HCC Medical Insurance Se ervices. Be sure to fully complete your Claimant’s S Statement and sign it. x Iff you have already paid ce ertain expenses, attach cop pies of payment receipts. IIn many ccases, payment will be ma de directly to the hospital/p physician that treated you.. Remembber, you are responsible fo r the deductible, coinsuran nce and any ineligible charrges. Pre-Notiffication You are rrequired to notify HCCMIS S of all hospitalizations, surrgeries, emergency evacua ations, emergen cy reunions, trip interruptio ons, repatriation of remains, computerized tomograp phy (CAT aging (MRI). Failure to com mply may result in a deducction of scan) andd magnetic resonance ima benefits. For pre-nnotification or general quesstions regarding eligibility / benefits / claims please ccall 800-605--2282 or 317-262-2132 worldwide toll-free numbe rs online at http://hccmis..com/tollfree *Access w Mail you ur claim form and itemize ed bills including diagnos sis to: Tokio Maarine HCC MIS Group Clai ms Department Box No. 22005 Farmingto ton Hills, MI 48333-2005 United Sttates
Electronic Payer ID: HCCMI
CONFIRMATION OF COVERAGE 04/15/2016
To whom it may concern: We are pleased to confirm short term medical coverage under VisitorSecure™, insured by Syndicate 4141 at Lloyd’s, London and administered by Tokio Marine HCC Medical Insurance Services Group. This coverage is valid in all countries worldwide, including the Destination Country(ies) listed below, except for the member’s Home Country and countries restricted by U.S. economic sanctions and embargo programs.
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Effective Date: 04/16/2016 Home Country: INDIA Destination Country(ies): UNITED STATES
Certificate
KUMAR SINGH
VS0123456
Termination Date
Citizenship INDIA
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Passport
05/01/2016
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VisitorSecure™ Overall Maximum Limit $ 75,000 (€54.255*) Deductible $ 100 (€72*) Medical Expenses (including hospitalization) See Schedule of Benefits Emergency Medical Evacuation** $ 50,000 (€36.170**) Available Only to Members under age 70 Repatriation of Remains $ 7,500 Maximum (€5.426*) Personal Liability $0 Paid in full by Visa This coverage is extendable for up to 364 days. VisitorSecure™ is a scheduled benefit plan. Other limitations and exclusions do apply. Please see policy documents for further details, or feel free to contact us with any questions or concerns. Sincerely,
Mark Carney HCC Medical Insurance Services Plan Administrator for Lloyd’s, Fitzwilliam House, 10 St. Mary Axe, London, England EC3A 8BF * Plan pays in US Dollars only. Amounts in Euros are provided for convenience and are based on conversion rate as of February 5, 2016. ** Except as provided under Acute Onset of Pre-existing Condition
Tokio Marine HCC Medical Insurance Services Group
Lloyd’s, London
Tokio Marine HCC Medical Insurance Services Group (MIS Group) is a service company that is regulated by the State of Indiana in our capacity as Third Party Administrator. Tokio Marine HCC MIS Group has authority to enter into contracts of insurance on behalf of the Lloyd’s underwriting members of Lloyd’s Syndicate 4141, which is managed by HCC Underwriting Agency Ltd.
