Notice of Claim
When should I notify the Company of a claim?
You, or the person who has the right to claim benefits, must give Us, written notice of a claim within 30 days after the date of death. If notice cannot be given within that time, it must be given as soon as reasonably possible after that. Such notice must include the claimant,s name, address and the Policy Number.
Are special forms required to file a claim?
We will send forms to the claimant to provide Proof of Loss, within 15 days of receiving a Notice of Claim. If We do not send the forms within 15 days, the claimant may submit any other written proof which fully describes the nature and extent of the claim.
Proof of Loss
What is Proof of Loss?
Proof of Loss may include, but is not limited to, the following:
- a completed claim form;
- a certified copy of the death certificate (if applicable);
- Your Beneficiary Designation (if applicable);
- documentation of:
- the date Your Disability began;
- the cause of Your Disability; and
- the prognosis of Your Disability;
- any and all medical information, including x-ray films and photocopies of medical records, including histories, physical, mental or diagnostic examinations and treatment notes;
- the names and addresses of all:
- Physicians or other qualified medical professionals You have consulted;
- hospitals or other medical facilities in which You have been treated; and
- pharmacies which have filled Your prescriptions within the past three years;
- Your signed authorization for Us to obtain and release medical, employment and financial information (if applicable); or
- Any additional information required by Us to adjudicate the claim.
All proof submitted must be satisfactory to Us.
Sending Proof of Loss
When must Proof of Loss be given?
Written Proof of Loss should be sent within 90 day(s) after the loss. All Proof of Loss should be sent to Us. However, all claims should be submitted to Us within 90 day(s) of the date coverage ends.
If proof is not given by the time it is due, it will not affect the claim if:
- it was not possible to give proof within the required time; and
- proof is given as soon as possible; but
- not later than 1 year after it is due unless You, or the person who has the right to claim benefits, are not legally competent.
Physical Examination and Autopsy
Can We have a claimant examined or request an autopsy?
While a claim is pending We have the right at Our expense:
- to have the person who has a loss examined by a Physician when and as often as We reasonably require; and
- to have an autopsy performed in case of death where it is not forbidden by law.
When are benefit payments issued?
When We determine that benefits are payable, We will pay the benefits in accordance with the Claims to be Paid provision.
Claims to be Paid
To whom will benefits for my claim be paid?
Life Insurance Benefits will be paid in accordance with the life insurance Beneficiary Designation.
If no beneficiary is named, or if no named beneficiary survives You, We may, at Our option, pay:
- the executors or administrators of Your estate; or
- all to Your surviving Spouse; or
- if Your Spouse does not survive You, in equal shares to Your surviving Children; or
- if no child survives You, in equal shares to Your surviving parents.
In addition, We may, at Our option, pay a portion of Your Life Insurance Benefit up to $500 to any person equitably entitled to payment because of expenses from Your burial. Payment to any person, as shown above, will release Us from liability for the amount paid.
If any beneficiary is a minor, We may pay his or her share, until a legal guardian of the minor,s estate is appointed, to a person who at Our option and in Our opinion is providing financial support and maintenance for the minor. We will pay:
- $200 at Your death; and
- monthly installments of not more than $200.
Payment to any person as shown above will release Us from all further liability for the amount paid.
If benefits are payable and meet Our guidelines, then We may pay benefits into a draft book account (checking account) which will be owned by:
- You, if living; or
- Your beneficiary, in the event of Your death.
The account owner may elect a lump sum payment by writing a check for the full amount in the account. However, an account will not be established for a benefit payable to Your estate.
We will make any payments, other than for loss of life, to You. We may make any such payments owed at Your death to Your estate. If any payment is owed to:
- Your estate;
- a person who is a minor; or
- a person who is not legally competent,
then We may pay up to $1,000 to a person who is related to You and who, at Our sole discretion, is entitled to it. Any such payment shall fulfill Our responsibility for the amount paid.
How do I designate or change my beneficiary?
You may designate or change a beneficiary by doing so in writing on a form satisfactory to Us and filing the form with the Employer. Only satisfactory forms sent to the Employer prior to Your death will be accepted.
Beneficiary designations will become effective as of the date You signed and dated the form, even if You have since died. We will not be liable for any amounts paid before receiving notice of a beneficiary change from the Employer.
In no event may a beneficiary be changed by a Power of Attorney.
What notification will my Beneficiary or I receive if a claim is denied?
If a claim for benefits is wholly or partly denied, You or Your Beneficiary will be furnished with written notification of the decision. This written notification will:
- give the specific reason(s) for the denial;
- make specific reference to the provisions on which the denial is based;
- provide a description of any additional information necessary to perfect a claim and an explanation of why it is necessary; and
- provide an explanation of the review procedure.
What recourse do my Beneficiary or I have if a claim is denied?
On any claim, the claimant or his or her representative may appeal to Us for a full and fair review. To do so, he or she:
- must request a review upon written application within:
- 180 days of receipt of claim denial if the claim requires Us to make a determination of disability; or
- 60 days of receipt of claim denial if the claim does not require Us to make a determination of disability; and
We will respond in writing with Our final decision on the claim.
Who interprets the terms and conditions of The Policy?
We have full discretion and authority to determine eligibility for benefits and to construe and interpret all terms and provisions of The Policy. This provision applies where the interpretation of The Policy is governed by the Employee Retirement Income Security Act of 1974, as amended (ERISA).
When can The Policy be contested?
Except for non-payment of premiums, the Life Insurance Benefit of The Policy cannot be contested after two years from the Policy Effective Date.
In the absence of Fraud, no statement made by You relating to Your insurability will be used to contest the insurance for which the statement was made after the insurance has been in force for two years during Your lifetime. In order to be used, the statement must be in writing and signed by You.
Are there any rights of assignment?
You have the right to absolutely assign Your rights and interest under The Policy including, but not limited to the following:
- the right to make any contributions required to keep the insurance in force;
- the right to convert; and
- the right to name and change a beneficiary.
We will recognize any absolute assignment made by You under The Policy, provided:
- it is duly executed; and
- a copy is acknowledged and on file with Us.
We and the Policyholder assume no responsibility:
- for the validity or effect of any assignment; or
- to provide any assignee with notices which We may be obligated to provide to You.
You do not have the right to collaterally assign Your rights and interest under The Policy.
When can legal action be taken against Us?
Legal action cannot be taken against Us:
- sooner than 60 days after the date Proof of Loss is furnished; or
- more than 3 years after the date Proof of Loss is required to be furnished according to the terms of The Policy.
How does The Policy affect Workers’ Compensation coverage?
The Policy does not replace Workers’ Compensation or affect any requirement for Workers’ Compensation coverage.
How does the Company deal with fraud?
Insurance fraud occurs when You and/or Your Employer provide Us with false information or file a claim for benefits that contains any false, incomplete or misleading information with the intent to injure, defraud or deceive Us. It is a crime if You and/or Your Employer commit insurance fraud. We will use all means available to Us to detect, investigate, deter and prosecute those who commit insurance fraud. We will pursue all available legal remedies if You and/or Your Employer perpetrate insurance fraud.
What happens if facts are misstated?
If material facts about You were not stated accurately:
- the premium may be adjusted; and
- the true facts will be used to determine if, and for what amount, coverage should have been in force.