| India Network Health Plan
Forms FORMS for
PRINTING and to FAX/Mail
1. Membership form InfMem.pdf
InfMem.doc
2. Insurance Enrollment Form
InsForm.pdf
InsForm.doc
3. Insurance Renewal Form
RenewalForm.pdf
RenewalForm.doc
Instructions: Print the forms
and mail completed forms to
India Network Services, 3956 Town Center Blvd #340,
Orlando, FL 32837
along with checks for correct amount of premium and
membership fee ($10), payable to 'India Network Services'. or fax
completed forms to 1-800-837-6384
4.
Cancellation Form
(Only if cancellation occurs before start date of
coverage).
5. Claims Forms - All claims must accompany a copy
of the ID card/Certificate of Insurance
Table 1: Policy Numbers for India Network Health
Plans.
| Coverage Start Date/ Policy Max |
$50,000 Max |
$100,000 Max |
$150,000 Max |
| 1997-1998
(6/1/97 - 5/31/98) |
00335720097* |
|
|
| 1998-1999
(6/1/98 -5/31/99) |
GLB9024828 |
|
|
| 1999-2000 (6/1/99 -5/31/00) |
GLB9024828 |
|
- |
| 2000-2001 (6/1/00 -5/31/01) |
GLB9024828-A |
GLB9024828-A |
- |
| 2001-2002 (6/1/01 -5/31/02) |
GLB9029520 |
GLB9029521 |
- |
| 2002-2003 (6/1/02 -5/31/03) |
GLB9100210 |
GLB9100211 |
- |
| 2003-2004 (6/1/03 -5/31/04) |
GLB9102820 |
GLB9102821 |
- |
| 2004-2005 (6/1/04 -5/31/05) |
GLB9105268 |
GLB9105269 |
GLB9105285 |
| 2005-2006 (6/1/05 -5/31/06) |
GLB9106482 |
GLB9106483 |
GLB9106484 |
*Claims are no
longer accepted for policy years in Italics.
The India Network
Health Program claims should be submitted to:
AIG Claims Services, A&H Claims Department
PO Box 15701, Wilmington, DE
19850-5701
Telephone: 1-800-551-0824/ 302-661-4176
How To File a Medical Claim:
Submit a fully completed and signed claim form to the AIG at the
above address. All bills should be itemized. A diagnosis and
procedure code needs to be clearly indicated on the bill to ensure
proper claim processing. Balance due bills are not acceptable.
Claims cannot be processed unless the claim form is signed by the
insured. If you would like to designate a family member to receive
payment for any bills you have paid, please be sure to sign and
complete the "optional limited assignment" portion of the claim
form.
Average time to review and process a claim is three weeks from
receipt. If medical records or additional information is needed,
we will request the information within the 21-day timeframe.
Contact Customer Service at 800-551-0824 if you have any
questions.
************************************************************
Fraud Statement
Residents of CALIFORNIA:
For your protection, California law requires the
following to appear on this form: Any person who knowingly
presents a false or fraudulent claim for the payment of a loss is
guilty of a crime and may be subject to fines and confinement in
state prison
GLB9106482.pdf
GLB9105268.pdf(50K)
GLB9105269.pdf
GLB9106483.pdf
(100K) GLB9105285.pdf
GLB9106484.pdf (150K)
Residents of NEW YORK:
Any person who knowingly and with intent to
defraud any insurance company or other person files an application
for insurance or statement of claim containing any materially
false information, or conceals for the purpose of misleading,
information concerning any fact material thereto, commits a
fraudulent insurance act, which is a crime, and shall also be
subject to a civil penalty not to exceed five thousand dollars and
the stated value of the claim for each such violation.
GLB9106482.pdf
GLB9105268.pdf(50K)
GLB9105269.pdf
GLB9106483.pdf
(100K) GLB9105285.pdf
GLB9106484.pdf (150K)
Residents of PENNSYLVANIA:
Any person who knowingly and with
intent to defraud any insurance company or other person files a
statement of claim containing any materially false information or
conceals for the purpose of misleading, information concerning any
fact material thereto commits a fraudulent insurance act, which is
a crime and subjects such person to criminal and civil penalties.
GLB9106482.pdf
GLB9105268.pdf(50K)
GLB9105269.pdf
GLB9106483.pdf
(100K) GLB9105285.pdf
GLB9106484.pdf (150K)
Residents of ALL OTHER STATES:
Any person
who knowingly presents
a false or fraudulent claim for payment of a loss
or benefit or knowingly presents false information in an
application for insurance is guilty of a crime and may be subject
to fines and confinement in prison.
GLB9106482.pdf
GLB9105268.pdf(50K)
GLB9105269.pdf
GLB9106483.pdf
(100K) GLB9105285.pdf
GLB9106484.pdf (150K)
Continue visiting - India Network Group
Health Program
*******************************************************
 (c) India Network Services, Inc. All Rights Reserved. |
