Instructions for Completing the Medical Expense Claim Form

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1 Instructions for Completing the Medical Expense Claim Form Read the form carefully and answer all of the pertinent questions as completely as possible. An incomplete form may delay the processing of your claim. Benefits are paid for eligible medical expenses which are not eligible for reimbursement by your primary medical insurance. Claims must be filed with your primary medical insurance first, after they have made their decision attach the explanation of benefits or the denial to your claim. All Claimants should fully complete the Medical Expense Claim Form; Please make sure you attach a copy of your primary medical insurance card if you have one; Include the originals of the medical and pharmacy bills along with the original paid receipts, (unless they have been sent to your primary insurance then you can send copies) without the receipts for payment we will not be able to reimburse you; If any bill or invoice exceeds $500.00, provide proof of payment such as credit card statement. If you have obtained any medical records, please attach those for review; Attach a copy of your flight itinerary and a copy of your passport with the travel dates and ID to support where your home country is and when you traveled. Your completed claim form and all supporting documentation should be submitted to the following address: It will take approximately 14 to 30 days to process the claim once all the required documentation is received. UnitedHealthcare Global Assistance P.O. Box Atlanta, GA 30348

2 Underwritten by ACE American Insurance Company Medical Expense Claim Form Please fully complete this Claim Form and return it along with the signed Authorization and all original cash, credit card receipts and original invoices to the address below. To verify that you were traveling, we also require a copy of your flight itinerary and copies of the front page of the passport and the dates traveled that are stamped on the passport. IMPORTANT NOTICE: Pan American Life Insurance Company has contracted with MEDEX Insurance Services to provide claims administration services for this insurance. For coverage verification, to report a claim or inquire about your claim status, please contact: MEDEX Insurance Services, P.O. Box Atlanta, GA 30348, ( or between 8:00 A.M. and 5 P.M. Monday through Friday Eastern Time. Part A: To be completed by insured person Claimant s Name Mailing Address Home Phone No. Male Female Date of Birth / / Policy ID No. Address Does the claimant alone or through a family member have any other medical insurance individually or through an employer, school or other organization? Yes No If yes, please provide the name and phone number of the company, and your policy number and attach a copy of the medical card: Part B: Complete this section if claim is the result of an injury 1. Was the MEDEX Emergency Response Center notified? Yes No If yes, when? 2. Date and location of the injury: 3. Describe the injury and how it occurred: 4. Name and address/fax number of the physician or hospital where you were treated:

3 5. What date did you first seek treatment for this injury? 6. What is the name and address/fax number of your primary care physician in your home area? Part C: Complete this section if claim is the result of an illness 1. Was the MEDEX Emergency Response Center notified? Yes No If yes, when? 2. Date you first noticed the symptoms that led you to seek treatment: 3. Describe the illness and give the actual diagnosis of the condition: 4. Name and address/fax number of the physician or hospital where you were treated: 5. What date did you first seek treatment for this illness? 6. Have you ever had this illness or similar condition before? Yes No If so, when and where did the injury occur and what was the name and address of the treating physician? 7. What is the name and address/fax number of your primary care physician in your home area? Any person who knowingly presents a false or fraudulent claim for payment of loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. CALIFORNIA RESIDENTS: For your protection, California law requires the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for payment of a loss is guilty of a crime and may be subject to fines and confinements in state prison.

4 COLORADO RESIDENTS: 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 RESIDENTS: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. NEW YORK RESIDENTS: 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 material fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. OKLAHOMA RESIDENTS: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. OREGON RESIDENTS: Any person who knowingly, and with intent to defraud any insurance company or other persons 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, may be subject to prosecution for insurance fraud. PENNSYLVANIA RESIDENTS: 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. RHODE ISLAND: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. VIRGINIA RESIDENTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

5 AUTHORIZATION and ASSIGNMENT OF BENEFITS I, the undersigned authorize any hospital or other medical-care institution, physician or other medical professional, pharmacy, Insurance support organization, governmental agency, group policyholder, Insurance company, association, employer or benefit plan administrator to furnish to the Insurance Company named above or its representatives, any and all information with respect to any injury or sickness suffered by, the medical history of, or any consultation, prescription or treatment provided to, the person whose death, injury, sickness or loss is the basis of claim and copies of all of that person s hospital or medical records, including information relating to mental illness and use of drugs and alcohol, to determine eligibility for benefit payments under the Policy Number identified above. I authorize the policyholder, employer or benefit plan administrator to provide the Insurance Company named above with financial and employment-related information. I understand that this authorization is valid for the term of coverage of the Policy identified above and that a copy of this authorization shall be considered as valid as the original. I agree that a photographic copy of this Authorization shall be a valid as the Original. I understand that I or my authorized representative may request a copy of this authorization. I understand that I or my authorized representative may revoke this authorization at any time by providing the insurance company with written notification as to my intent to revoke. Signature of Insured or Authorized Representative Dated Address Underwritten by PanAmerican Life Insurance Company

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