Accident Insurance
Instructions for Filing a Claim
The accident insurance plan is designed to cover all students of the policyholder while they are on
campus or participate in policyholder sponsored and supervised activities. Full time students are
also covered off campus. The plan will reimburse claimants for eligible expenses which are not
payable by your healthcare plan or any other insurance plan providing reimbursement for medical
expenses. Therefore, prior to filing a claim against the accident insurance policy, you must first
file the claim with your own healthcare plan. If you are covered under the student accident and
sickness plan or Medicaid/Medicare this plan is primary coverage.
Please observe the following claim filing procedures:
1. Obtain a claim form from the Health Center. Only one form is needed for each accident,
regardless of the number of expenses incurred for the particular accident.
2. The claim form should be completed and signed by the student. Please note the first section
1-4 is the student’s information.
3. The second section of the claim form should be completed by the student and requires a
College official signature.
4. Submit copies of itemized bills that provide the dates of service, the procedure codes, the
diagnosis and the charge(s). “Balance Due” bills are not acceptable because they do not
provide all of the information needed to properly pay a claim.
5. Submit copies of the Explanation of Benefits (EOB) statements from your own healthcare
plan. The EOB’s will show how much your healthcare plan paid for the services rendered and
the amount which is your responsibility. There should be an EOB for each Itemized Bill you
have submitted for reimbursement. Please note you may receive a denial from your health
carrier this must also be submitted. (This step is not required if you have the Student Accident
and Sickness Plan)
6. Mail the fully completed claim form, each Itemized Bill and the corresponding EOB to the
following address:
HealthSmart, Inc.
3320 West Market Street Suite 100
Fairlawn, Ohio 44333
MAIL FORM TO:
HealthSmart
____________________________________________________________
United States Fire
____________________________
___________________________
Insurance Company
____________________________________________________________
Benefit Consultant and Administrators
____________________________________________________________
3320 West Market Street, Suite 100
____________________________________________________________
Fairlawn, OH 44333
____________________________________________________________
Tel 800.331.1096
_____________________________________________________TO BE COMPLETED BY STUDENT________________________________________________________
1.
Iona College
School Name: ________________________________________________
UIL4979A
Policy #: ____________________________________________________________
2.
Insured Student: _____________________________________________
SF725P5
Group #: ____________________________________________________________
3.
Plan Member ID: ____________________________________________
Patient Status:
4.
Local Address:
_____________________________________________________________________________________________________________________
5.
Date of Birth:
_____________________________________
6.
Is this Claim for a dependent?
Yes
No
Male
Female
Single
Married
Local Phone: _________________________________________________________
If yes, give name: ____________________________________________________________________
Relationship: ________________________________________________
Date of Birth: ________________________________________________________
COMPLETE THIS SECTION FOR ACCIDENT CLAIM _______________________________________________________________________________________________
7.
Is this claim the result of an accident?
Yes
No
Is this claim the result of a work-related injury?
Yes
No
Is this claim the result of sports participation?
Yes
No
If yes, give date of accident: __________________ Time of Accident: ____________
Is this claim the result of an auto accident?
If “yes”
intercollegiate
intramural
Yes
club
No
other
Name of Sport: ______________________________________________________________________________________________________________________
8.
Where did the accident occur? ________________________________________________________________________________________________________
How did the accident happen? _________________________________________________________________________________________________________
COMMENTS/REMARKS BY SCHOOL AUTHORIZED ADMINISTRATOR_____________________________________________________________________________
____________________________________________________________________________________________________________________________________
Policyholder/School Signature:__________________________________________________________
Date:_________________________________________
COMPLETE THIS SECTION FOR SICKNESS CLAIM _______________________________________________________________________________________________
9.
Name of physician: ___________________________________________________________________
Date of initial service: __________________________
10.
Description of Illness: _________________________________________________________________________________________________________________
11.
Has the patient been treated for the above condition(s) in the last 12 months?
Yes
No
If “yes” give condition(s) treated for and date(s) of treatment: _______________________________________________________________________________
COMPLETE THIS SECTION FOR ALL CLAIMS (ACCIDENT OR SICKNESS) __________________________________________________________________________
12.
Is patient covered for benefits by any Group Health, Employer, Union,
Welfare Plan or Parent Health Plan (including Medicare)?
Yes
No
N/A
N/A
Other coverage provided through: Name of Person ___________________________________________
Relationship __________________________________
N/A
N/A
If answered “yes” please complete the following: Insurance Co. or Benefit Plan:__________________________
Employer or Sponsor: __________________
N/A
Address : _______________________________________________
Policy #:
N/A
_______________________________________________
Telephone: _________________________________________________________________
Please include a photocopy of other plan identification card, if available.
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 be subject
to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
Signature of Insured Student ________________________________________________________________________
Date ________________20 ______
Patient’s or Authorized Person’s Signature _____________________________________________________________
Date ________________20 ______
COMPLETE THIS SECTION ONLY IF YOU WISH THE BENEFITS TO GO DIRECTLY TO THE PROVIDER(S)
Authorization to Pay Benefits: I hereby authorize payment directly to: any physician or provider of service for which I am submitting attached billings and charges.
For the expenses provided under my Group Medical Expense Benefits, I understand I am financially responsible for charges not covered by this authorization.
Signature