Hospital Indemnity Claim Form - Gtl
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5HOSPITAL INDEMNITY CLAIM FORM
Please read the important
r Please send the completed claim form,
signed authorization, and itemized bills to:
information below:
r Please be sure your policy number(s) is/are
Guarantee Trust Life Insurance
written on the claim form.
P.O. Box 1144
r The claim form must be completed and
Glenview, Illinois 60025
signed by the Insured.
OR Fax to: (847) 699-1048
OR Email to:
• If your policy has been in force less
than two years from when your claim
r If you signed an “Assigment of Benefits” with
was incurred, a completed claim form,
the hospital and you have a balance still due,
signed authorization and the billing
we will have to pay benefits directly to the
statements mentioned below.
provider; otherwise, benefits will be sent to
• If your policy has been in force more
you.
than two years from when your claim
r NOTE: Your Policy may have a 6 Month
was incurred, a claim form only needs to
Pre-Existing Conditions Limitation and a
be completed for a claim involving an injury
2 Year Policy Contestability Period. If your
r The HIPAA Authorization to Permit Use and
claim happened during one of these periods,
Disclosure of Health Information must be
additional information may be required. If
signed, dated and included with your
we need to request any additional informa-
submission, so that we can contact your
tion and we have your signed HIPAA Authori-
medical provider on your behalf if additional
zation, we will handle these requests directly
information is needed.
with your medical provider(s) and will notify
you of our action and any delays.
r For faster processing of your hospital
benefits, ask your medical provider to
r We suggest you make photocopies of any
print a UB-04 form along with an itemized
information sent for your own records.
bill (for hospital expenses).
• Processing delays may result if you do
A UB-04 form with itemized bill are
not provide the above information.
statements that indicate:
1. The date(s) of treatment,
2. The type(s) of service,
3. The diagnosis,
4. The medical provider’s name and address,
5. The individual charge for each expense.
For assistance, please contact our Customer Service Department (800) 338-7452
HICF 07/16
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