HOW & WHY A CLAIM IS INVESTIGATED
Why is a claim investigated prior to payment consideration?
1. To determine if the claim is eligible under the policy.
2. To determine if the condition is pre existing.
3. To determine if the provider of services is eligible.
4. To determine if the treatment is medically necessary.
How is a claim investigated prior to payment consideration?
1. IMG will request a Claim Form be completed and submitted for each condition. All
questions on the Claim Form must be completed. If not, IMG will return the Claim
Form to the insured for completion.
2. When it is determined that a pre existing condition investigation is in order, IMG will
request medical records from:
The treating physician
The referring physician(s)
The family physician
Any other physicians who treated the insured
3. As medical records are received, they will be reviewed by a Claims Examiner for:
History and physical from doctor
Completeness of information
Sources not contacted
Symptoms of conditions
Operative report history and findings
Contradictory information from a provider
In the event no medical data is available prior to the insured's effective date, the case will be
referred to IMG's Medical Director. A decision on the claim will be made using known medical
criteria for the insured's condition(s).
COMMONLY ASKED CLAIMS QUESTIONS
Insured persons and producers frequently ask the following questions. If the question you have
does not appear here, please contact the Claims Customer Service Department at IMG.
Q: I need to go to the doctor, what should I do?
A: Present your IMG Insurance I.D. Card to the doctor's office when you first visit.
The doctor's office should contact IMG to verify benefits.
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