Specified Health Event Claim

Required forms (click on each form to open and print):

Sickness Claim Form (for illness related events)

Accident Claim Form (for events caused by an accident)

First determine if you need the sickness or the accident claim form. After you have downloaded or printed the correct forms just print this page and follow these instructions. For faster service fax directly to our claims department using the Claims Department fax cover sheet. If you mail anything, please keep copies of everything you mail until your claim is complete.

This policy is designed to cover treatment for specific conditions only. Those conditions are:

Heart Attack

Coronary Artery Bypass Surgery

Stroke

End Stage Renal Failure

Major Human Organ Transplant

Coma

Paralysis

Major Third Degree Burns

Please remember that this policy does not cover treatment that was received for any other reason.

It is important to follow these instructions completely. Failure to do so will result in a delay of the processing of your claim.

1. You (or the patient) need to personally complete Section A. Be sure to complete all sections.

2. Section B needs to be completed in full by the physician who treated you. Please be sure no sections are left uncompleted unless they do not apply.

3. Section C and D do not apply to your claim unless you are also claiming from an AFLAC Short Term Disability policy, however you must sign the form at the bottom of page 2.

4. Please be sure to include any of the following backup documentation that applies to your treatment.

Itemized hospital bill (if confined) [Click here to see a sample]

Operative Report (if surgery was required)

Ambulance bill

Proof of any continuing care received (see list below)

Medical records showing definite proof of your diagnosis

This type of supporting information is very important because the claim cannot be processed without it.

After you have sent your claim please deal directly with AFLAC Claims Department by calling 1-800-992-3522 from 8 a.m. to 6 p.m. Monday through Friday. Please have your policy number ready so you can be assisted promptly. Also, if you have any questions regarding your claim or if you simply want personal assistance please feel free to call me at 561-776-0098.

Reminder checklist – Please be sure you have you completed or provided the following:

· Have you completed Section A and the Authorization to Obtain

Information?

· Have you signed at the end of Section D?

· Has your physician completed Section B?

· If you were confined in a hospital have you included a copy of the Itemized

hospital bill? This bill must show a room charge in order for

benefits to be paid. Please click the following link to view a sample:

[Sample Itemized Hospital Bill] A copy of this bill should be requested

from the hospital billing or records department.

· Have you included proof of your diagnosis? (see below for details)

· If surgery was required have you included a copy of the Operative

Report? This should be requested from your surgeon.

· If you required an ambulance have you included a copy of the ambulance

bill?

· If you required any of the following continuing care after your release from the hospital please provide proof of each treatment received:

Physician Visits Home Health Care

Physical Therapy Rehabilitation Therapy

Dialysis Nursing Home Care

Speech Therapy Occupational Therapy

Extended Care Respiratory Therapy

Hospice Care Dietary Therapy/Consultation

· Have you included your policy number? If you do not have your

policy number, please call 800-992-3522 to be provided with it. It is

important to remember that each policy has a separate policy number.

· Before faxing to our Claims Department have you included your

information on the fax cover sheet?

Be sure to include proof of diagnosis from your medical records.

This should be requested from your physician or the hospital medical records department. Please review the definitions page of your policy before submitting your claim to be sure your diagnosis fits the definitions of your policy. For example, not all conditions of the heart are heart attacks. A heart attack is defined medically as a myocardial infarction, coronary thrombosis, or coronary occlusion. One of these diagnoses would need to be in your medical records if you were claiming for a heart attack. Other conditions of the heart such as congestive heart failure and angina are not medically defined as heart attacks.

[Click here to view the definitions pages from the policy]

The definitions you need are found at items B,C,D,E,J,K,L, and P.

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