myNISI | Common Claim Question

Lincoln Mutual Life
If an employee terminates employment, please draw a line through the name and product type, indicate “terminated as of date,” and deduct the amount from the total due on your bill.

If the employee is a resident of MN they have 60 days to complete a portability application

If the employee lives in anyother state they have 31 days to complete a portability application

USAble Life
To remove an Employee or to denote a rate dispute from your bill: Please fill out all columns on the “Changes and Adjustments” sheet and denote the insured name, SSN #, type of insurance, reason for change, effective date, and the correct amount. Please total the net adjustment in the field “Net Change in Premium.” Add or subtract this total amount from your “Premium Billed” amount. “Premium Remitted” should match the amount of your payment.

Items that should be included on this sheet:

Termination of Employment
On Leave
Lowering Coverage
Discrepancies between Payroll Deductions and Billed Amount

To Denote the Addition of an Employee or an Increase in Coverage: Please fill out all columns on the “Additions” sheet and denote insured name, SSN #, type of insurance, reason for change, effective date, and the projected premium for this change. DO NOT REMIT PREMIUM FOR ANY EMPLOYEE NOT LISTED ON YOUR BILL. Applications must be received and processed before coverage can be granted and premium remitted. Any additions will be reflected on future bills, once applications have been processed.

To Denote a Change of Name for Marriage or Divorce: On the “Changes and Adjustments” sheet, please fill in the original name under name of insured, the SSN #, effective date, and under reason for change, fill in the new name and that this is a name change.

Please remit your payment and documentation to:

PO Box 1861
Little Rock, AR 72203-1861

All changes and additions should be received by the last business day of the month in order to appear on your next bill. If you have any questions, please feel free to call Customer Service at 800-370-5856.

The “Changes and Adjustments” and “Additions” sheets are mailed to you with every USAble billing.

Vision and Dental
If an employee terminates employment, please draw a line through the name and product type, indicate “terminated as of date,” and deduct the amount from the total due on your bill.

How long does it take to receive policies and certificates?

If everything that is needed has been received, policies and certificates will be mailed within 20 working days of receipt at USAble Life. To order certificates please email: custserv@usable.com

How do I make changes to my group policy (waiting period, benefits, etc.)?

To make changes to the waiting period, please contact Noridian Insurance Services, Inc.

How do I file a wellness claim?

Mail an ITEMIZED bill for the covered test or service.
You DO NOT need a claim form to be reimbursed for this benefit, but you must submit the following information:

a. Insured’s name and Social Security number
b. Policy number
c. Patient’s name, date of birth and Social Security number
d. Date of service
e. Current mailing address

Mail the billing statement or receipt to:

USAble Life
Attn: Claims Department
P.O. Box 1650
Little Rock, AR 72203-1650
OR FAX: 501-399-3806

It is helpful for the insured to provide their policy number. Most wellness benefits provide a maximum payment per calendar year, based on the Schedule of Benefits, for the covered diagnostic tests listed below:

Mammography
Flexible sigmoidoscopy
Chest X-ray
Hemocult stool analysis
Pap smear
Colonoscopy
Thermography
PSA (blood test for prostate cancer)
CA125 (blood test for ovarian cancer)
CEA (blood test for colon cancer)
Any cancer screening test endorsed by the American Cancer Society.
Any cancer screening test endorsed by the National Cancer Institute.

This benefit is available without diagnosis of cancer.

Cancer and/or Specified Disease Claim

See instruction numbers 1, 2 and 3 on the front of the claim form, you will also need to fill out a Authorization for Release of Medical Information.

The Employee should complete the Insured's Statement and the Authorization to Obtain Information sections only.

The Physician should complete the Attending Physician's Statement, found on page 2 of the claim form.

Itemized bills and a copy of the pathology report diagnosing cancer should accompany the completed claim form. When submitting bills for an ongoing claim, a new claim form is not necessary, but the following information must be submitted along with the bills:

Name of Claimant
Name of Insured
Social Security Number of Claimant
Social Security Number of Insured
Current Mailing Address

Accident Claim

See instruction numbers 1, 2 and 3 on the front of the claim form (CARE, Accident Guard and Elite) or claim form (Accident Plus), you will also need to fill out a Authorization for Release of Medical Information.

The Employee should complete the Insured's Statement and the Authorization to Obtain Information sections only.

The Physician should complete the Attending Physician's Statement, found on page 2 of the claim form.

If the claim is for loss of life, the Physician should complete the “Loss of Life” section of the claim form and a certified death certificate should accompany the claim form when submitted.

An accident report is required for motor vehicle accidents. Itemized bills should accompany the completed claim form.

Hospital Indemnity and/or ICU Claim

See instruction numbers 1, 2 and 3 on the front of the claim form, you will also need to fill out a Authorization for Release of Medical Information.

The Employee should complete the Insured's Statement and the Authorization to Obtain Information sections only.

The Physician should complete the Attending Physician's Statement, found on page 2 of the claim form.

Itemized bills should accompany the completed claim form.

Short-Term Disability Claim

See instruction numbers 1, 2 and 3 on the front of the claim form, you will also need to fill out a Authorization for Release of Medical Information.

The Employee should complete the “Employee's Statement” and the “Authorization to Obtain Information” sections of the claim form only. The authorization to release medical information should be signed prior to giving the claim form to the Physician.

The Physician should complete the “Attending Physician's Statement” portion of the form, including signature.

The Employer should complete the “Employer's Statement” section of the claim form. If the employee is still disabled at the time the claim form is completed, the “Date Returned to Work” block should be left blank.

Failure to complete all sections of the claim form will prevent the claim from being processed on a timely manner.

Payment Process

If a Disability claim cannot be processed within 10 working days, a status letter should be sent to the Insured. Disability claims are processed daily. Benefits will begin on the day specified in the policy (e.g. benefits begin on the 8th day for sickness, 8th day for accident, 8th day for hospital). Once a claim is established, continuing payments will be automatically released each Saturday, as long as disability is medically supported and certified by the Physician, up to the maximum duration as defined in the Schedule of Benefits. Checks are usually mailed to the Insured on Monday (unless Monday is a holiday). If a disability has occurred and the Insured has returned to work, one check for the total period of disability will be issued and may be issued on any week day, as soon as the claim is approved for payment.

Disability payments are based on a weekly benefit amount. If your benefit amount is a monthly amount, it will be multiplied by 12 (months) and divided by 52 (weeks), to determine the weekly benefit. If disability is for a portion of a week, the benefit will be prorated based on 7 days in a week.

Medical Updates

For continuing disabilities, an Update form – Short-Term Disability (Form CL-STD-SP) is required periodically. These forms do not require an Employer's statement and are mailed directly to the Employee's home address. The Insured should have this form completed in full by their Attending Physician. The statement must be returned within 10 working days, or by the requested date, in order to avoid interruption of benefit payments. These requests are routine and are usually requested every 4 to 6 weeks, depending on the specific circumstances of the claim.

When the Employee Returns to Work

When a claim for continuing disability is approved, often benefits are set in advance to release for future benefit weeks. It is very important that the Employer notify USAble Life promptly when an Employee returns work. The "return to work date" should be reported by telephone, faxed notice, or by mail. Prompt notice helps to prevent overpayments from occurring.

Maximum Duration

When claims are paid to the maximum duration, as stated on the Schedule of Benefits, the Insured will be notified by mail at the time of the final benefit check. A copy of the correspondence will be provided to the Employer.

Medical Records

Medical records may be required if a claim is received during the first 2 years of coverage or increase in coverage. These records are requested through a medical records retrieval firm and are usually received within 4 to 6 weeks. This is a routine procedure and the records are obtained at no cost to the Employee or Employer.

Long-Term Disability Claim

Call USAble Life at 800-648-0271, ext. 25856, to request a Long-Term Disability claim form and Authorization for Release of Medical Records form.

The claim should be filed at least 30 days before end of elimination period. The Employee should complete the "Employee's Statement" and "Authorization for Release of Information." If the disability is indefinite attach a copy of the birth certificate. Attach a copy of Social Security and other income entitlement awards (or forward when received). The Physician should complete the “Attending Physician's Statement” portion of the form, including signature.

The Employer should complete the “Employer's Statement” section of the claim form. Job description (detailed duties), a copy of the enrollment card, and documentation of earnings if other than straight salary. If Workers' Compensation claim filed, include copy of First Report of Accident and the decision.

Failure to complete all sections of the claim form will prevent the claim from being processed on a timely manner.

Critical Illness Claim

A Critical Illness claim form is not available. Filing the appropriate claim form will depend on the illness. See forms listed below.

Heart and Stroke Claim

See instruction numbers 1, 2 and 3 on the front of the claim form, you will also need to fill out a Authorization for Release of Medical Information.

The Employee should complete the Insured's Statement and the Authorization to Obtain Information sections only. The Physician should complete the Attending Physician's Statement, found on page 2 of the claim form.

Itemized bills should accompany the completed claim form.

Life Claim – 10 Year Term or Universal Life Insurance Policies:

The completion of a Proof of Death claim form is required to process benefits.

For the death of an Insured Employee, the following information is required:

Employer's Statement must be fully completed.
Authorization to Obtain Information.
Beneficiary's Statement signed by the beneficiary of the policy.
An original certified death certificate.
If the loss is due to an accident, a police report is required.
If the beneficiary is deceased, we need a copy of their death certificate.
If the beneficiary is a Trust or the Estate, we need a complete copy of the Trust or Estate documents.

For the death of a Dependent, the following information is required:

Employer's Statement must be fully completed.
Employee's Statement must be fully completed.
An original certified death certificate.
If the loss is due to an accident, a police report is required.

Lincoln Mutual Voluntary Group Term Life Insurance

Claim Form and Employer’s Statement must be fully completed. Go to the Claim Forms section to find your form.

For any claims not listed, please contact Noridian Insurance Services, Inc at 800-575-9643 or 701-277-2049.