For a First Occurrence diagnosis of cancer, please complete the printable claim form. Complete the Patient/Claimant section, have your physician complete the Physician Statement, and provide a Pathology Report positively diagnosing cancer (click here for Pathology Report Examples.)
If a Pathology Report is not available due to a clinical diagnosis of cancer, please include copies of all applicable medical records confirming the positive cancer clinical diagnosis and treatment. Examples of medical records include reports indicating the results of a CT scan, ultrasound or an MRI, and consultation reports verifying the cancer diagnosis and treatment.
For filing cancer treatment claims after the First Occurrence claim has been processed (e.g., surgery, chemotherapy/radiation treatments, hospital stays, etc.), please submit copies of the following if applicable:
- Complete, itemized hospital bill
- Physician bills
- Surgery bill from the surgeon/physician’s office and the corresponding pathology report for each surgery (the bill should include the 5 digit CPT procedure code)
- Itemized chemotherapy/radiation bills and pharmacy/prescription bills/receipts (these should include the patient's name, drug name and charges/costs, and the dates of each treatment or the date the prescription was filled)
- Any other itemized bills (see below for examples)
- The printable claim form (for inpatient hospitalizations). Complete the Patient/Claimant section and have your physician complete the Physician Statement.
Please also include a copy of the 1500 HEALTH INSURANCE CLAIMS FORM or UB-04 form (only associated with hospital visits) and any itemized medical bills you would like to have considered for payment. These forms are completed by and obtained from the provider in which the treatment was sought. The form numbers can be found at the bottom of the page. The following examples are for illustration only.
For transportation claims, complete the printable travel log. Include copies of all applicable itemized bill(s) and consultation report(s).
Please do not send any Explanation of Benefits (EOB) forms from other insurance companies. We are not able to use these documents to process claims. Itemized bills are required to process claims and are available from the providers of service.
Please mail or fax the completed documentation to the following address:
Family Heritage Life Insurance Company of America
Attn: Claims Department
P.O. Box 470608
Cleveland, OH 44147
Fax: (440) 922-5152
Please note: We will examine each covered person(s) for our consideration of each person(s) pending claim. If at any time during the review of your claim we find that we need additional information, we will notify you in writing.
If you have questions or need assistance with filing your claim, please contact our customer service department online or by calling (440) 922-5151.