Athletic Accident Claim Form - Sbc Insurance Page 2
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1
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4INSTRUCTIONS
You must provide all information requested; incomplete forms cannot be processed.
IMPORTANT POINTS TO REMEMBER WHEN COMPLETING
C.
HOSPITAL ROOM ACCOMMODATION
YOUR CLAIM:
Not an eligible expense
1.
Your insurer must receive notice of your accident
D.
AMBULANCE (Emergency to Hospital only)
within 30 days of the accident date and receive claim
Date of service
documentation within 90 days.
Places ambulance taken from and to
Amount charged
2.
ALL claims must be submitted with itemized
statements and paid receipts (originals are required if
E.
VISION CARE
there is no other coverage available), which indicate
If your injury received medical treatment and
Patient’s name
resulted in the loss or damage of eyewear, or
Type of purchase or service
the requirement of eyewear due to accident
Date of each purchase or service
An explanation must be submitted with your
Amount charged for each purchase or
receipt to claim the limited benefit
service
F.
SCHEDULED FRACTURE INDEMNITY
3.
A physician statement confirming diagnosis and
If your injury results in any of the fractures or
recommended treatment is required if you are claiming
dislocations listed on the policy schedule,
other than dental or ambulance expense.
there may be an amount payable to you; not
more than one amount (the largest) is
4.
Only claims in excess of the deductible specified in
payable
your plan will be considered for payment up to your
A statement completed by the licensed
maximum benefits.
physician or surgeon confirming the
fracture/dislocation
5.
Expenses eligible under any other health care plan(s)
must be submitted to that plan(s). Your sport accident
G.
MEDICAL BRACES
policy will pay only the amount of expenses that are
A letter from the licensed physician or
not eligible with any other insurer.
surgeon indicating the diagnosis, the specific
medical necessity for prescribing the brace
IF YOU ARE CLAIMING ANY OF THE BENEFITS
and the type of brace prescribed must be
LISTED BELOW, YOU MUST INCLUDE THE
submitted with your receipt
FOLLOWING INFORMATION WITH YOUR CLAIM:
Medical braces required primarily for sporting
(Please check your plan details for the conditions
type activities are not covered
under which these benefits are eligible. You must
have required and received medical/dental treatment
H.
DENTAL ACCIDENTS
commencing within 30 days of the accident date.)
Exact date of accident
Breakdown of services performed
FOR BENEFITS NOT LISTED BELOW, PLEASE
Circumstances surrounding the accident
CONTACT THE INSURER FOR CLAIMS
Is there other dental coverage? Enclose
PROCEDURE
details.
Confirmation that treatments only relate to
A.
PRESCRIBED DRUGS
the accident
Name of medication or drug
Provide other insurer’s explanation
Date of purchase
Are further treatments estimated?
Amount charged
I.
SERVICES AVAILABLE WITHIN THE
B.
SERVICES OF PHYSIOTHERAPIST,
PROVINCIAL PLAN
CHIROPRACTOR, OSTEOPATH
Your Sport Accident Policy does not make
Physician referral
payment for any services or treatment that is
Type of service
available within the provincial plan, whether
Date of each treatment
there is enrollment in the provincial plan or
Amount charged for each treatment
not
Date of treatment paid by Provincial Medical
Plan; if private fees apply, confirming
YOUR SPORT ACCIDENT POLICY MAY INCLUDE A
coverage has been exhausted
DEDUCTIBLE AND/OR PERCENTAGE OF REIMBURSEMENT.
(Example: $100 deductible or $30 per treatment up to $300 per
accident.) IF IN DOUBT, CHECK YOUR PLAN DETAILS.
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