Insurance

Insurance Claims

Please see the above Claim Form and procedures for filing a claim.  You CANNOT just send in medical bills and get them reimbursed.  You have to send in the explanation of benefits with procedure and diagnosis codes along with tax id number for the medical facility.  

The accident insurance plan is designed to cover all registered participants of the policyholder while they’re engaged in policyholder sponsored and supervised activities. The plan will consider reimbursement 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. Please observe the following claim filing procedures: (Please include the policy number on all correspondence to facilitate the handling of your claim)

1. Obtain a claim form from the sponsoring organization. Only one form is needed for each accident, regardless of the number of expenses incurred for the particular accident.

2. Part I of the claim form should be completed and signed by an official from the sponsoring organization. Part I requests a description of how the accident occurred. Please check to see that a complete description is provided. For example, “Basketball” is not acceptable; however, “Twisted left ankle while playing basketball” is acceptable.

3. Part II of the claim form should be completed and signed by the claimant or the claimant’s parent or guardian if claimant is a minor. All questions in Part II must be completed in order for the company to examine your claim. Please do not leave any questions blank. Part II includes the section entitled “Authorization to Release Information.”

4. Itemized Bills must be submitted. Itemized Bills 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 examine a claim.

5. When submitting charges for Physical Therapy, the itemized bill must be accompanied by the prescription and include the frequency and the duration of the treatment.

6. 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.

7. Mail or email the fully completed claim form, each Itemized Bill (and the prescription, if applicable) and the corresponding EOB to the following address: (Please include the Policy Number on all correspondence)

NAHGA Claim Services

P.O. Box 189

Bridgton, ME 04009

claims@nahga.com

Fax 207-647-4569

Phone 800-952-4320

Please remember, the policy is an Accident insurance policy. It does not provide reimbursement for illness or for injuries that are not the result of an Accident. It is subject to exclusions and limitations. The policy may also contain a deductible which may be the claimant’s responsibility.  Please be aware that the claim form contains state mandated fraud warning language that requires your review and signature.

CLAIM PROVISIONS

Notice of Claim

Written or authorized electronic/telephonic notice of claim must be given to Us within 90 days after a Covered Loss occurs or begins or as soon as reasonably possible. If written or authorized electronic/telephonic notice is not given in that time, the claim will not be invalidated or reduced if it is shown that such notice was given as soon as was reasonably possible. Notice can be given: to Us at Our Administrative Office, One Bala Plaza, Suite 100, Bala Cynwyd, PA 19004;to such other place as We may designate for the purpose; or to Our authorized agent. Notice should include the Policyholder’s name and policy number and the Covered Person’s name and address.

Proof of Loss

Written or authorized electronic proof of loss satisfactory to Us must be given to Us at Our office, within 90 days of the loss for which claim is made. If written or authorized electronic notice is not given within that time, no claim will be invalidated or reduced if it is shown that such notice was given as soon as reasonably possible. In any case, written or authorized electronic proof must be given not more than one year after the time it is otherwise required, except if proof is not given solely due to the lack of legal capacity.

Insurance Coverage

CYW teams are covered by a general liability policy that covers slips and falls for the spectators.  For example if someone’s grandma comes to an event and falls getting to her seat and gets hurt, then the general liability policy will apply.  

CYW wrestlers and coaches are covered by a accident medical policy for injuries.  

Full Policy Application

Summary of Plan of Benefits

Accident Medical Expense Benefits Accidental Death $25,000

Maximum Benefit $25,000 Accidental Dismemberment up to $50,000

Deductible Amount $0 Accidental Paralysis $50,000

Scope of Coverage: Full Excess

Eligible Persons: Registered participants of the Policyholder, up to 16 years old. Registered instructors, referees, staff members or volunteers of the Policyholder performing their assigned duties during a Covered Activity

CONDITIONS OF COVERAGE

The benefits provided by this Policy will be paid, subject to applicable conditions, limitations and exclusions, under the following coverages.

Sports Coverage

Personal Deviations covered no

Covered activities Participation in and attendance at the following

Policyholder Supervised and Sponsored activities: Wrestling

ACCIDENT INDEMNITY BENEFITS

ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS

Each of the following Covered Losses may be included or deleted at the option of the Policyholder.

Benefit amounts are variable and may be expressed as a percentage of the Principal Sum or as a dollar amount.

Principal Sum $25,000

Loss must occur within 365 days of the Covered Accident

Schedule of Covered Losses

Covered Loss Benefit

Loss of Life 100% of the Principal Sum

Loss of Two or More Hands or Feet 200% of the Principal Sum

Loss of Sight of Both Eyes 200% of the Principal Sum

Loss of One Hand or Foot and

Sight in One Eye 200% of the Principal Sum

Quadriplegia 200% of the Principal Sum

Paraplegia 200% of the Principal Sum

Hemiplegia 200% of the Principal Sum

Loss of One Hand or Foot 100% of the Principal Sum

Loss of Sight in One Eye 100% of the Principal Sum

Loss of Speech 100% of the Principal Sum

Loss of Hearing in Both Ears 100% of the Principal Sum

Loss of Thumb and Index Finger

of the Same Hand 50% of the Principal Sum

ACCIDENT MEDICAL EXPENSE BENEFITS

Any benefit limits and Benefit Percentages for Accident Medical Expense Benefits apply, unless

otherwise specified, on a per-Covered Person per-Covered Accident basis. Any applicable Deductibles

must be satisfied within the time periods specified before benefits are payable.

Scope of Coverage Applicable to Accident Medical Benefits

Full Excess Medical Expense

Other Health Plan

Reduction 50%

Medical Expense Benefits

Total Maximum for all Accident Medical Expense Benefits $25,000

First Covered Expenses must be Incurred within 180 days after a Covered Accident

Benefit Period 1 year from the date of the Covered Accident

Deductible $0

Covered Expenses

In-Patient Hospital Services

Daily ICU or CCU Benefit 100%

Daily In-Hospital Benefit 100% of the average Semi-private room rate

Miscellaneous Services 100% per Hospital Stay

Ambulatory Medical Center 100%

Emergency Room Treatment 100%

Physician Services

Surgery Benefit 100%

Assistant Surgeon 100%

Physician's Surgical Facilities 100%

Second Opinion or Consultation 100%

Physician's Assistant 100%

Anesthesia Benefit 100%

Inpatient Visits 100%

Office Visits 100% per visit

Outpatient X-ray, CT Scan,

MRI and Laboratory Tests 100%

Outpatient Physiotherapy 100%

Nursing Services 100%

Ambulance Services 100%

Medical Equipment Rental 100%

Medical Services and Supplies 100%

Dental Services 100%

Prescription Drug Benefit

Benefit per prescription 100%

Home Health Care Benefit

Calendar Year Deductible $0

Home Health Care Visit 100%

Maximum Visits 40 per calendar year

Medical Supplies, Drugs and

Medications 100%

Tips for filing a claim

o You cannot submit medical bills

o You must send the statements of benefits

o You must provide the procedure, and diagnostics codes

o You must provide the tax id and payment address for the provide