975711 3/2024
CRITICAL ILLNESS CLAIM FORM INSTRUCTIONS
Please complete the claim form in its entirety, including supporting medical documentation.
Have your Physician complete Section 7: Physician Statement. This is the preferred option
for the fastest claim processing time.
All medical records related to the covered Critical Illness, including pathology if applicable.
File this claim form using one of these methods:
Mail Cigna Supplemental Health Solutions
P. O. Box 188028
Chattanooga, TN 37422
Email
OR
Note: the claim review process will start once we receive all documentation supporting your claim.
Additional documentation is required if you qualify for one of these special situations:
• If the claimant was hospitalized, also provide a UB-04 Form (can be requested from the hospital billing
department) or documentation outlining room and board charges OR observation stay (with hospital
arrival and discharge times) and Medical documentation with procedure and diagnosis codes
associated with the date(s) of treatment.
• If claimant is a child dependent who is 26 or more years old and has a mental or physical handicap that
requires employee support, also include the SSDI Award letter.
• If you are filing a claim on behalf of an insured claimant who is deceased, also provide the death
certificate AND a disclosure authorization for the deceased, which can be obtained from the employee's
Human Resources department.
SECTION 1: EMPLOYEE INFORMATION
Was the employee considered actively at work on the date of the
incident?*
If no, what was the reason the employee was not actively at work?*
Group Policy Number:
Date of Birth (mm/dd/yyyy):*
Name of Employer (at time of claim):*
If adult child is disabled, please provide
the SSDI Award Letter.*
If Child is not a full-time student, is he/she
totally disabled?*
Relationship to Insured:*
Name (First & Last):*
SECTION 4: CHILD'S ADDITIONAL INFORMATION: (Complete for Child claim only)
SECTION 3: CLAIMANT DEMOGRAPHIC INFORMATION (Complete for Spouse or Child claim only)
Unpaid Leave of Absence
Paid Leave of Absence
Family Leave (FMLA)
Other:
Name (First & Last):*
Yes
No
Is the Child a full-time student?*
SECTION 5: DESCRIPTION OF YOUR CRITICAL ILLNESS
Does the employee have health care coverage with Cigna?
Email Address:*
Daytime Phone Number:*
Date of Birth (mm/dd/yyyy):*
Social Security Number:*
SECTION 2: EMPLOYER INFORMATION
SSN:
Does not have SSN
Yes
No
Yes
No
Yes
No
Does the claimant have health care coverage with Cigna?
Yes
No
City:* State:* Zip Code:*
City:* State:* Zip Code:*
Address:*
Address:*
Note: Claimant must complete Sections 1-6.
Have your Attending Physician complete Section 7 as proof of diagnosis for fastest claim processing.
We will contact you if we need additional information to process the claim.
Cigna Healthcare Supplemental Health Solutions
Critical Illness Intake Form
This document is confidential and proprietary to Cigna Healthcare
Note: * = Required field
975711 03/2024
Page 1 of 10
CLEAR FORM
SECTION 6: LIST OF HOSPITALS, CLINICS OR PHYSICIANS
Address:
Treatment Period:
Phone Number:
Physician/Facility Name:
Specialty: Fax Number:
Address:
Treatment Period:
Phone Number:
Physician/Facility Name:
Specialty: Fax Number:
SECTION 7: CRITICAL ILLNESS PHYSICIAN'S STATEMENT
Cancer (Please attach pathology report)
Did the patient have a malignant tumor which has not yet become invasive but is confined only to the superficial layer of cells from which it arose?
Yes
No
Initial diagnosis date:
Any subsequent diagnosis dates:
Carcinoma in Situ** (continued on next page)
History (must fill out for any condition)
Yes
No
Cancer
• Carcinoma in Situ
• Invasive Cancer
• Skin Cancer
Vascular Condition
• Advanced Heart Failure
• Aortic & Cerebral Aneurysm
• Coronary Artery Disease
• Heart Attack
• Stroke
Nervous System Condition
• Parkinson’s Disease
Infectious Condition
• Severe Sepsis
Other Specified Condition
• Advanced Obesity
• Benign Brain Tumor
• Blindness
• Crohn’s Disease
• End-Stage Renal (Kidney)
Failure
• Major Organ Failure
• Paralysis
• Pulmonary Embolism
Note: If the patient has a condition that is not listed in the section above, please supply all medical documentation necessary to
verify the diagnosis and associated diagnosis date.
Fax Number:Specialty:
Physician/Facility Name:*
Phone Number:*
Treatment Period:
Address:*
When did the current symptoms first appear?
Confirmed Diagnosis Date:
Has the patient ever had the same or a similar condition? (If “yes,” provide date and description.)
Note: Only the conditions listed below may be covered. If the patient does not have one of the specific illnesses listed below, the
claim may not be eligible.
Below is a list of all conditions outlined in this form (please fill out the applicable section):
Note: The patient may or may not have coverage for all listed conditions. Patient may also have coverage for additional conditions
not listed. Coverage is determined by the patient’s policy.
For Any Condition Not Listed
Confirmed Diagnosis Date:
Diagnosis (include ICD 10 Code):
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SECTION 7: CRITICAL ILLNESS PHYSICIAN'S STATEMENT (cont'd)
**FOR GROUPS SITUSED IN OREGON - Does NOT include:
1. Pre-malignant conditions or conditions with malignant potential;
2. Carcinoma in situ;
3. Basal cell carcinoma;
4. Squamous cell carcinoma of the skin, unless metastatic disease develops;
5. Melanoma that is diagnosed as Clark's Level I or II or Breslow less than 0.75mm, or melanoma in situ; or
6. A prostate tumor that is classified as T-1a,b, or c, N-0, and M-0 on a TNM classification scale.
Did the patient have prostate cancer that is classified as T-1a, b, or c, N-0, and M-0 on a TNM classification scale?
Yes
No
**Does NOT include pre-malignant conditions or conditions with malignant potential, skin cancer or invasive cancer.
Invasive Cancer**
Did the patient have a disease involving an organ of the body which is identified by the presence of malignant cells or a malignant tumor
characterized by the uncontrolled and abnormal growth and spread of invasive malignant cells?
Yes
No
FOR GROUPS SITUSED IN OREGON – Was there a disease involving an organ of the body which is identified by the presence of malignant cells or a
malignant tumor characterized by the uncontrolled and abnormal growth and spread of invasive malignant cells?
Yes
No
Is the diagnosis the recurrence or spread (metastasis) of a previously diagnosed cancer where the patient has not undergone any form of
treatment for the previously diagnosed invasive cancer for a period of 1 year?
Yes
No
**Does NOT include pre-malignant conditions or conditions with malignant potential, carcinoma in situ or skin cancer.
Carcinoma in Situ** (cont'd)
Skin Cancer
Did the physician take a tissue specimen that shows basal cell carcinoma, squamous cell carcinoma or melanoma that is diagnosed as Clark’s Level
I or II or Breslow less than 0.75mm?
Yes
No
Advanced Heart Failure**
Did the patient have one of the following diagnostic tests that shows abnormal left ventricular function consistent with advanced heart failure -
echocardiogram, nuclear scan, or catheterization?
Yes
No
Procedure Date:
Vascular Conditions (Please attach associated operative report, lab report, or test results)
Did the patient have a blood test showing elevated BNP of 400 or greater consistent with advanced heart failure?
Yes
No
Does the physician confirm that the patient displays the clinical signs of advanced heart failure and recommends the patient be inpatient in a
hospital?
Yes
No
Did the patient show signs of fluid overload such as lower extremity edema?
Yes
No
Did the patient show signs of accumulation of fluid in the abdomen (ascites) and/or lungs (pulmonary edema)?
Yes
No
In the event of death, does the autopsy confirmation and/or death certificate identify cardiomyopathy as the cause of death?
Yes
No
**Does NOT include heart attack, coronary artery disease or arrhythmias.
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SECTION 7: CRITICAL ILLNESS PHYSICIAN'S STATEMENT (cont'd)
Aortic & Cerebral Aneurysm**
Was there a localized, blood-filled dilation of a natural blood vessel caused by weakening of the vessel wall in the aorta or cerebral blood vessels
for which a physician has prescribed repair?
Yes
No
In the event of death, does the autopsy confirmation and/or death certificate identify non-traumatic aortic or cerebral aneurysm as the cause of
death?
Yes
No
**Does NOT include any surgical repair of complications resulting from prior repair of an aneurysm.
Coronary Artery Disease
Did the patient have a narrowing or blockage of the inner lining of the coronary arteries by lipid-bearing plaques, which restricts blood flow to the
heart by at least 70% for any one occlusion or 50% for any two or more?
Yes
No
Heart Attack
Was there an ischemic death of a portion of the heart muscle confirmed by diagnostic testing through:
1. Electrocardiographic (EKG); and,
2. Elevation of cardiac enzyme markers of myocardial injury?
Yes
No
In the event of death, does the autopsy confirmation and/or death certificate identify cardiomyopathy as the cause of death?
Yes
No
Stroke**
Was there a cerebrovascular event resulting in damage of brain tissue as a result of ischemia or hemorrhage and confirmed by findings on
neuroimaging studies, including brain CT, MRI, MRA or similar diagnostic study, or a lumbar puncture (spinal tap)?
Yes
No
At least 96 hours after the event, was there:
i. Clinical evidence of persistent neurological deficits diagnosed by a physician; or
ii. Confirmatory findings on neuroimaging studies, including Brain CT, MRI, MRA, or similar diagnostic study, or lumbar puncture (spinal tap)
consistent with a cerebrovascular event?
Yes
No
In the event of death, does the autopsy confirmation and/or death certificate identify stroke as the cause of death?
Yes
No
**Does NOT include transient ischemic attack, brain injury related to trauma or infection, brain injury associated with hypoxia or anoxia, vascular
disease affecting the eye or optic nerve and ischemic disorders of the vestibular system.
Nervous System Conditions
Was there a loss of the neurotransmitter dopamine that lead to at least three of the following signs?
a. Tremors at rest
b. Slowed, physical movement (bradykensia) or difficulty initiating movement
c. Difficulty with speech (monotone voice, lack of inflection, etc.)
d. Muscular rigidity
e. Inexpressive face
f. Festinating gait
g. Rapid, persistent blinking (blephoraspasm)
Yes
No
Parkinson’s Disease
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SECTION 7: CRITICAL ILLNESS PHYSICIAN'S STATEMENT (cont'd)
Infectious Conditions**
Was there a severe bacterial infectious disease that has spread to the bloodstream resulting in both of the following:
1. Organ dysfunction (failure of the respiratory, kidney, renal, cardiovascular, gastrointestinal tract, central nervous or blood coagulation systems to
perform their normal functions); and
2. Blood pressure of less than or equal to 100 systolic?
Yes
No
Severe Sepsis
**Does NOT include relapse of the underlying bacterial infection causing the severe sepsis.
Other Specified Conditions
Was there a metabolic disorder that led to excess body fat for which a physician has prescribed:
Primary bariatric surgery; or
Date of diagnosis for primary bariatric surgery is the date when all of the following criteria have been met:
1. Is the individual is ≥ 18 years of age or has reached full expected skeletal growth and has evidence of either of the following:
a. A BMI (Body Mass Index) ≥ 40; or
b. A BMI (Body Mass Index) 35–39.9 with at least one clinically significant obesity-related comorbidity as well as any other medically recognized
condition adversely affecting the patient’s health. Clinically significant obesity-related comorbidity includes any of the following: i.
symptomatic degenerative joint disease in a weight bearing joint; ii. Type II diabetes mellitus; iii. systolic blood pressure at least 140 mm Hg
or diastolic blood pressure 90mm Hg or greater, despite medical management; iv. hyperlipidemia; v. coronary artery disease; vi. lower
extremity lymphatic or venous obstruction; vii. obstructive sleep apnea or pulmonary hypertension; viii. evidence of nonalcoholic fatty liver
disease or nonalcoholic steatohepatitis?
Advanced Obesity
Yes
No
2. Has the physician, physician’s assistant/nurse practitioner or registered dietician, other than the requesting surgeon, provided a statement that
the patient has failed previous attempts to achieve and maintain weight loss by medical management?
Yes
No
3. Has a thorough multidisciplinary evaluation by a metabolic and bariatric surgery accreditation and quality improvement program (MBSAQIP)
accredited bariatric program been performed within the previous 6 months which includes ALL of the following:
a. A description of the proposed primary bariatric procedure(s)
b. A separate medical evaluation and/or a recommendation for primary bariatric surgery from a physician/physician’s assistant/nurse
practitioner other than the requesting surgeon or associated staff
c. unequivocal clearance for bariatric surgery by a mental health provider
d. A nutritional evaluation by a physician or registered dietician
Yes
No
A revision or conversion of a prior primary bariatric surgery for the patient?
Yes
No
A physician prescribes primary bariatric surgery. The date of diagnosis for a revision or conversion of a prior primary bariatric surgery is the date
the physician prescribes the revision or conversion of the prior bariatric surgery due to inadequate weight loss in accordance with the following
criteria:
1. Is there evidence of full compliance with the previously prescribed postoperative dietary and exercise program?
Yes
No
2. Due to a technical failure of the original bariatric surgical procedure, has the individual failed to achieve adequate weight loss, which is defined
as failure to lose at least 50% of excess body weight or failure to achieve body weight to within 30% of ideal body weight at least two years
following the original surgery?
Yes
No
In the absence of a technical failure or major complication, individuals with weight loss failure greater than two years following a primary bariatric
surgery procedure must meet the initial criteria for primary bariatric surgery.
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SECTION 7: CRITICAL ILLNESS PHYSICIAN'S STATEMENT (cont'd)
Was there a localized mass of abnormal cells in the brain that is non-cancerous, non-inflammatory, and non-infectious?
Yes
No
Has a biopsy been performed to confirm diagnosis? (Attach biopsy test results)
Yes
No
Benign Brain Tumor
Was there a clinically proven irreversible reduction of sight in both eyes, due to a disease or sickness resulting in sight in the better eye reduced to
a best corrected visual acuity of less than 6/60 (Metric Acuity) or 20/200 (Snellen or E-Chart Acuity)?
Yes
No
Blindness
Was there visual field restriction to 20 degrees or less in both eyes?
Yes
No
Was there a chronic inflammation disease of the digestive tract?
Yes
No
Crohn’s Disease**
**Does NOT include irritable bowel syndrome or ulcerative colitis.
Was there a chronic irreversible failure of the function of both kidneys, such that regular hemodialysis or peritoneal dialysis is required to sustain life?
Yes
No
End-Stage Renal (Kidney) Failure
FOR GROUPS SITUSED IN IDAHO – Was there a chronic irreversible failure of the function of both kidneys, such that the patient’s kidneys will no
longer sustain life?
Yes
No
Was there a life-threatening inability or lack of function of organs that is the result of sickness or disease and is not the result of physical Injury or
trauma?
Yes
No
Major Organ Failure
Did the physician recommend or prescribe that the patient undergo a human to human transplantation of the organ?
Yes
No
Was there a complete, irreversible and permanent loss of the use of two or more non-severed limbs, as a result of a disease or sickness?
Yes
No
Paralysis**
**Does NOT include paralysis as a result of stroke, multiple sclerosis and cerebral palsy.
Was there an obstruction of the pulmonary artery or its branches by thrombus that originated elsewhere in the body?
Yes
No
Pulmonary Embolism**
In the event of death, does the autopsy confirmation and/or death certificate identify pulmonary embolism as the cause of death?
Yes
No
**Does NOT include a blood clot confined to the lower extremities or pelvis.
Physician Information / Signature
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Attending Physician Name (First & Last):* Degree:*
Fax Number:*
Phone Number:*Street Address:*
City:*
State:*
Zip Code:*
Date Signed*
Attending Physician Signature*
CAUTION: Any person who, knowingly and with intent to defraud any insurance company or other person: (1)
files an application for insurance or statement of claim containing any materially false information; (2) conceals
for the purpose of misleading, information concerning any material fact thereto, commits a fraudulent
insurance act. For residents of the following states, please see the last page of this form: Alaska, Alabama,
Arizona, Arkansas, California, Colorado, District of Columbia, Florida, Kansas, Kentucky, Louisiana, Maine,
Maryland, Minnesota, New Hampshire, New Jersey, New Mexico, Ohio, Oklahoma, Pennsylvania, Puerto
Rico, Rhode Island, Tennessee, Texas, Virginia, Washington, West Virginia.
New York Residents: FRAUD WARNING: 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
$5000 and the stated value of the claim for each such violation.
If Section 7: Physician’s Statement is not filled out, include proof of diagnosis.
We will contact you if we need additional information to process the claim.
Date Signed*
Claimant’s Signature*
(or Parent/Guardian if Claimant is under 18 years old)
The issuance of this form is not the admission of the existence of any insurance nor does it recognize the
validity of any claim and is without prejudice to the company’s legal rights.
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Disclosure Authorization
AUTHORIZATION
NOTE: This authorization is designed to comply with HIPAA and relates to information necessary to administer coverage and services
under your employer’s employee health and welfare plan(s) ("the Plan") and similar or coordinating governmental benefits. You are
not required to sign the authorization, but if you do not, the Plan, insurers or other providers of services or coverage under the Plan
may not be able to process your request for Plan benefits, coverage or services.
Company Names: Cigna Health and Life Insurance Company, Life Insurance Company of North America (LINA), and New York Life Group
Insurance Company of NY (NYLGICNY) (formerly Cigna Life Insurance Company of New York).
Guardian, or Conservator, please attach a copy of the document granting authority.
(indicate relationship). If Power of Attorney Designee,I signed on behalf of the claimant as
Claimant’s Name (can be Employee, Spouse, or Child):*
I authorize any physician, medical professional or other health care provider, hospital or other medical facility; pharmacy; health plan;
other medically related entity; rehabilitation professional; vocational evaluator; employee assistance plan; insurance company,
reinsurer, health maintenance organization, third party administrator, broker or other insurance service provider, or similar entity; the
Medical Information Bureau; the Association of Life Insurance Companies, which operates the Health Claims Index and the Disability
Income Record System; government organization or agency, including the Social Security Administration; any of your social security
disability advocates or representatives; financial institution, accountant or tax preparer; consumer reporting agency; and employer or
group policyholder that has information about my health, prescriptions, financial, earnings or employment history, or other insurance
claims and benefits to provide access to or copies of this information to the Plan and to any individual or entity who provides services
to or insurance benefits on behalf of the Plan, including but not limited to the requesting company(ies) named below ("Company"). To
the extent I may be eligible for governmental benefits similar to or that coordinate with those available to me under the Plan, I also
authorize disclosure of information necessary to apply for or determine my eligibility for such benefits to the relevant government
agency and/or vendor providing application assistance.
For any claim for insurance benefits, this authorization is valid for the shorter of 24 months or the duration of my claim. For all other
permitted disclosures, this authorization is valid for one (1) year from the date below. I am entitled to a copy of this authorization and a
photographic or electronic copy of it is as valid as the original.
I understand that any information obtained with this authorization will be used for evaluating and administering my coverage,
including any claim for benefits, or otherwise providing services related to or on behalf of the Plan, which may include, but is not
limited to assisting me in returning to work and Plan administration. With respect to governmental benefits similar to or that
coordinate with benefits available to me under the Plan, I understand that the information will be used to help determine my eligibility
for any such benefits and may include assisting me in applying for the benefits. I understand that the information disclosed under this
authorization is subject to redisclosure and may no longer be protected by certain federal regulations governing the privacy of health
information, although it will continue to be protected by other applicable privacy laws and regulations.
Information about my health may relate to any disorder of the immune system including but not limited to HIV and AIDS; use of drugs
or alcohol; and mental and physical history, condition, advice or treatment, but does not include psychotherapy notes.
If my employer, union, and/or group association sponsors any other plans, whether or not underwritten or administered by a Cigna
company, the information and/or records obtained may also be shared with the underwriting company (insurer) or administrators of
those other plans, including their internal or external health management, disease management, wellness, employee/member
assistance program or other similar programs, for the purpose of administering any service, benefit or feature described in those plans.
Date Signed*
Claimant’s Signature*
(or Parent/Guardian if Claimant is under 18 years old)
Print Name*
Date of Birth (mm/dd/yyyy):*
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IMPORTANT CLAIM NOTICES
Alaska Residents: A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim
containing false, incomplete, or misleading information may be prosecuted under state law.
Alabama Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who
knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or
confinement in prison, or any combination thereof.
Arizona Residents: For your protection Arizona law requires the following statement to appear on this form: Any person who
knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.
Arkansas Residents: 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.
California Residents: For your protection California law requires the following statement appear on this form: Any person who
knowingly presents false or fraudulent information to obtain or amend insurance coverage or to make a claim for the payment of a
loss is guilty of a crime and may be subject to fines and confinement in state prison.
Colorado Residents: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance
company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of
insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete
or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the
policyholder or claimant with regard to settlement or award payable from insurance proceeds shall be reported to the Colorado
division of insurance within the department of regulatory agencies.
District of Columbia Residents: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of
defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance
benefits if false information materially related to a claim was provided by the applicant.
Florida Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or
an application containing any false, incomplete or misleading information is guilty of a felony of the third degree.
Kansas Residents: Any person who knowingly and with intent to defraud any insurance company or other person (1) files an
application for insurance or statement of claim containing any materially false information; or (2) conceals for the purpose of
misleading, information concerning any material fact thereto, may be guilty of insurance fraud determined by a court of law.
Kentucky Residents: Any person who knowingly and with intent to defraud any insurance company or other person files an
application for insurance 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.
Louisiana Residents: 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.
Maine Residents: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the
purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.
Maryland Residents: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or
who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines
and confinement in prison.
Minnesota Residents: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.
New Hampshire Residents: Any person who, with a purpose to injure, defraud, or deceive any insurance company, files a statement
of claim containing any false, incomplete, or misleading information is subject to prosecution and punishment for insurance fraud, as
provided in RSA 638:20.
New Jersey Residents: Any person who knowingly files a statement of claim containing any false or misleading information is
subject to criminal and civil penalties.
New Mexico Residents: 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 civil fines and criminal penalties.
Ohio Residents: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an
application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
Oklahoma Residents: Warning: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any
claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
Pennsylvania Residents: 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 subjects such person to
criminal and civil penalties.
975711 03/2024
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Puerto Rico Residents: Caution: Any person who knowingly and with the intention of defrauding presents false information in an
insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other
benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned
for each violation by a fine of not less than five thousand dollars ($5,000) and not more than ten thousand dollars ($10,000), or a fixed
term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances be present, the penalty thus
established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may be reduced to a
minimum of two (2) years.
Rhode Island Residents: 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.
Tennessee Residents: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for
the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
Texas Residents: 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.
Virginia Residents: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the
purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.
Washington Residents: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for
the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.
West Virginia Residents: 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.
THESE POLICIES PAY LIMITED BENEFITS ONLY. THEY ARE NOT COMPREHENSIVE HEALTH INSURANCE COVERAGE AND DO NOT COVER ALL
MEDICAL EXPENSES. THIS COVERAGE DOES NOT SATISFY THE “MINIMUM ESSENTIAL COVERAGE” OR INDIVIDUAL MANDATE
REQUIREMENTS OF THE AFFORDABLE CARE ACT (ACA). THIS COVERAGE IS NOT MEDICAID OR MEDICARE SUPPLEMENT INSURANCE.
Product availability may vary by location and plan type and is subject to change. All group insurance policies may contain exclusions, limitations,
reduction in benefits, and terms under which the policy may be continued in force or discontinued. For costs and details of coverage, review your
plan documents or contact a Cigna representative.
All Cigna Healthcare products and services are provided exclusively by or through operating subsidiaries of The Cigna Group. The Cigna Healthcare
name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. LINA and NYLGICNY are not affiliates of The Cigna Group.
© 2023 Cigna. Some content provided under license
975711 03/2024
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