Medical Insurance Services Group
251 North Illinois Street, Suite 600, Indianapolis, IN, 46204 USA
Tel: 317-262-2132 Fax: 317-262-2140 Toll Free: 800-605-2282
[email protected]
hccmis.com
DIEGO ARDILA InternationalStudentInsurance.com
VIA DEL MEZZETTA 8 http://www.internationalstudentinsurance.com
FIRENZE, 50135 877-758-4391
Italy
[email protected]StudentSecure®
THANK YOU!
IMPORTANT
Thank you for purchasing a StudentSecure insurance plan.
Please read the Description of Coverage for a full explanation This insurance coverage, offered by Tokio Marine
of your benefits and exclusions using the link at the bottom of HCC – Medical Insurance Services Group, is not
the following page. subject to and does not meet the minimum
standards required by the Affordable Care Act
In this fulfillment: (PPACA). The policy contains the plan benefits you
have selected, including a lifetime maximum. Please
Link to the Description of Coverage • Your Coverage Details •
review your choices to ensure you have sufficient
Instructional Information • ID Card(s) • Your Receipt
coverage to meet your medical needs.
Getting Medical Treatment: Filing a Medical Claim:
• Show your ID card to the medical attendant • Submit original, itemized bills, and any payment receipts, and
• Pay the deductible or copay (if applicable) claim form
• The medical office may submit bills directly • Claims must be filed within 60 days of the termination date of
• After the visit, you will need to submit a Claimant's your policy.
Statement.
http://www.hccmis.com/downloads/hccmis_claimants_statement.pdf
Student Zone Contact Us
https://zone.hccmis.com/clientzone/ • 1-800-605-2282
• Print a Visa Letter • Worldwide toll-free numbers:
• Reprint an ID card
• Extend coverage http://www.hccmis.com/docs/worldwide_numbers.pdf
• Update your info
Pre-Existing Conditions Coverage Renewals, Extensions and Cancellation
Coverage for pre-existing conditions is excluded:
• Renew up to 6 months in advance for a 12-month certificate
• During the first six (6) months of coverage period. Deductible and coinsurance must be re-satisfied as of
under StudentSecure Elite and Select, and each renewal date.
• During the first twelve (12) months of • Extend and renew policies online in the Student Zone with
StudentSecure Budget coverage. payment by credit card.
• StudentSecure Smart includes coverage for the • Free to cancel before effective date.
acute onset of pre-existing conditions ONLY. • $25 fee to cancel on or after effective date.
• Read the Description of Coverage for a full list • Monthly policies will receive a refund for unused whole
of policy exclusions and details. months only.
• Policies paid up-front must be cancelled within first 60 days,
and will receive a prorated refund on unused days only.
Tokio Marine HCC – Medical Insurance Services Group Lloyd’s, London
Tokio Marine HCC – Medical Insurance Services Group (Tokio Marine HCC – MIS Group) is a member of the Tokio Marine HCC group of companies. 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.
KHE2FFFYH6SP-152-680
StudentSecure®
ID Number: SS00210878
Participant Name: Participant Mailing Address:
DIEGO ARDILA VIA DEL MEZZETTA 8
FIRENZE, 50135
Italy
Citizenship of Participant: Colombia Effective Date: March 7, 2018
Home Country of Participant: Colombia Termination Date: August 6, 2018
Country of Assignment: Italy Length of Coverage: 5 months
Actual effective date and period may vary based on the provisions of this coverage.
®
Coverage: StudentSecure SMART - Excluding the US
Certificate Period Maximum: $ 200,000 Participant
Deductible: $ 50 per Incident / In-network or outside U.S
Medical Evacuation: $ 50,000 Lifetime Maximum
Repatriation of Remains: $ 25,000 Lifetime Maximum
Online Fulfillment: Yes
Shipping Charges: $0.00
Purchase Date: 3/6/2018
Paid By: DIEGO ARDILA
Total Paid: $ 34.00
* Monthly payments elected. Total paid reflects first months cost only. Remaining installments in the amount of $34.00
are due on the following dates: 04/07/2018 05/07/2018 06/07/2018 07/07/2018
Plan Administrator: Tokio Marine HCC - Medical Insurance Services Group
251 N. Illinois St., Ste 600
Indianapolis, IN 46204
This Declaration Page is evidence of your insurance under The Atlas/International Citizen Group Insurance Trust, Hamilton,
Bermuda. For a complete copy of the Master Policy, contact Tokio Marine HCC - Medical Insurance Services Group.
A summary of the coverage available under this plan is available at: http://www.hccmis.com/docs/4531151117.pdf.
Unique Market Ref. No. B0775RAM00217
POLICYHOLDER/CERTIFICATE HOLDER NOTICE
U.S TREASURY DEPARTMENT'S OFFICE OF FOREIGN ASSETS CONTROL ("OFAC")
It is important to note that no coverage is provided by this Policyholder/Certificate
Holder Notice nor can it be construed to replace any provisions of your plan. For
complete information on provided coverage, consult the plan itself and the Declaration
page. This Policyholder/Certificate Holder Notice is solely for providing information
concerning the possible impact on your insurance coverage due to directives issued by
OFAC, and it is necessary that this notice be read carefully. OFAC administers and
enforces sanctions policy based on national emergency declarations made by the
President and has identified numerous countries, foreign agents, front organizations,
terrorists, terrorist organizations, and narcotics traffickers as "Specially Designated
Nationals and Blocked Persons (“SDN”)". This list can be found on the United States
Treasury's web site - http//www.treas.gov/ofac. In accordance with OFAC regulations, if
it is determined that the insured or any person or entity claiming the benefits of this
insurance has been identified as a SDN or if a prohibited country as identified by OFAC
is involved, then the provisions of the insurance plan will be immediately subject to
OFAC administration. Accordingly, certain limitations on premium payments and/or
claim payments may apply.
Medical Insuranc
ce Services Group
| Filing a CClaim
• Obtainn a Claimant’s Statement & authorization form by vissiting hccmis.com or by ca alling
800-6605-2282 or 317-262-2132
• Compplete the claim form; attach h original, itemized bills; an
nd forward to
| HCC M Medical Insurance Service es. Be sure to fully comple
• If you have already paid certain expenses, attach copies o
ete your Claimant’s Statem
ment and sign it.
of payment receipts. In ma
any cases, payment will
be maade directly to the hospital//physician that treated youu.
Prrimary Insure
ed: DIEGO ARDILA F Remembber, you are responsible fo r the deductible, coinsuran
nce and any ineligible charrges.
O For geneeral questions regarding eliigibility / benefits / claims p
please call
800-605--2282 or 317-262-2132
L *Access wworldwide toll-free numbe rs online at http://hccmis..com/tollfree
Eff
ffective Date: March 7, 2018 D Mail you
ur claim form and itemize ed bills including diagnos
sis to: Electronic Payer ID: HCCMI
I.D
D. #: SS00210878 Tokio Maarine HCC MIS Group Clai ms Department
Box No. 22005
Grroup #: 061928-1 | Farmingto
ton Hills, MI 48333-2005
United Sttates
| First Health Group Co
orp. a wholly
owned subsidiary of A
Aetna
OSSESSION OF TH
PO HE CARD DOES NOT GUARANTEE COVERAGE
Payment Receipt
For Certificate: SS00210878
Paid By: DIEGO ARDILA
Payment Type: VISA
Number: xxxxxxxxxxxx4543
Amount: $34.00
Date Paid: 3/6/2018
Credit Card Payments Only
Expiration Date: 01/2020
Trans. Code: 2651265150
Auth. Code: 949117
Tokio Marine HCC - Medical Insurance Services
251 North Illinois Street, Suite 600
Indianapolis, IN 46204
