submit a claim

Disability Claim 

 We provide the disability benefit in life and cancer insurance policies as disability income or waiver of premium payments. It is important that you send any medical evidence that supports the disability as a result of studies, progress notes, etc., aside from the medical and employer certifications that appear in the disability claim form.

 Requirements to claim total physical disability policies due to disease or accident: 

• Fully completed disability claim form, including employer and medical CL-0285-10 (R-0414) certifications. 
• Claim Acceptance Form – Notice of Anti-Fraud Act, Law No. 230 of August 9, 2008, in case it is not included in claim form CL-0807-122 (R-1012) (Spa.) 
• If you were treated by the State Insurance Fund Corporation (SIFC), include copy of medical appointments (Form 2000,1082) from said agency, Medical Certificate (Form 1021), “Manager’s Decision on Medical Treatment” (Form 395), and Employer’s Report (Form 373), which the employer completed at the time of the accident 
• Copy of records of private physician certifying the disability, including copy of studies and laboratory results. 

• Documents that must be submitted with all policy claims with less than two years of enforcement as of the date of the loss: 
• Authorizations to request medical information signed by the insured POS-0190-42 (R-0606) (Spa.) (Eng.) 
• Copy of insured’s (patient’s) photo ID and signature 
• Additional Requirements Form to list the names of physicians and hospitals, including addresses, telephones, and specialties of the physicians CL-0501-106 (R-0103) who have treated you in the past three years

For more information on disability insurance, click here. 

Claim for Cancer Policies or Their Riders 

You are only required to fully complete the claim form when you submit the claim for the first time for the same cancer or critical disease.  When you file a cancer claim, the medical certificate included in the form must be completed by the physician who treats your cancer condition, not the surgeon or any other physician who is not directly involved in the treatment. 

Requirements to claim cancer policy benefits 

(Please review the benefits contained in your policy contract) 

Documents to be submitted in cancer and dreaded/critical disease and hospitalization claims for any disease with losses incurred six (6) months or less from the policy’s effective date. 

In claims for the rest of the supplements or riders, if the losses occur during the contestability period (2 or 3 years), the documents must be submitted as stated in the policy: 

• Three (3) original authorizations to request medical information, signed by the patient older than 21 years of age POS-0190-42 (R-0606) (Spa.) (Eng.), or signed by the guardian if the patient is a minor 
• Copy of the patient’s photo ID and signature if of legal age, or of their guardian. 
• List of the names of physicians and hospitals, including telephones, addresses, and specialties of the physicians (last 2 years) 
• Copy of the record of the past two (2) years, prior to the issuance of the policy, of the physician who started treating you for the condition you are claiming 
• Detailed health insurance use certificate with the dates of medical services received, including the diagnosis codes, two years prior to when the policy was issued 

When the claim is for your dependent child, who is older than 21 but younger than the maximum age indicated in the policy: 

• Full-time enrollment certification from a duly approved academic institution (with date close to the period claimed) 
• For children who are neither natural nor adopted, but who depend on you, you must submit a copy of the income tax return; for legally adopted children, submit the final decree of adoption 

Claim Form: 

Cancer policy claim form CL-0801-108 (R-0614) completed and signed by: 

• Claimant – primary policyholder named in the insurance application, to whom all payments will be made, including claims from his or her dependents or, in his or her death, the beneficiary designated in said application 
• Claimant – Notice of Anti-Fraud Act, Law No. 230 of August 9, 2008, (in case it is not included in the claim form) 
• Claimant – Authorization for bank deposit of claim payment, if made 
• Hospital certification – Document by a hospital medical record official certifying the admission into a regular room or intensive care unit. 
• Primary care physician certification – In cancer or dread/critical disease claims, complete only in the first claim 

Waiver of Premium Payment 

• Be the primary insured 

Hospital, Drugs, and Prolonged Hospitalization Coverage 

• Admission sheet and discharge summary 
• Or a certification by a medical record official with hospitalization dates and diagnoses 

Disability or Loss of Income Indemnification during Hospitalization 

• Be the primary insured and employed 

Intensive Care 

• Medical records department certification that includes diagnosis, date and time of admission and discharge. 
• Or nursing notes of admission to the intensive care unit 

Nursing Home 

• Medical order requiring stay in a nursing home 
• Hospital discharge sheet 
• Bill for nursing home stay 

Personal Physician 

• Personal physician’s visit notes during hospitalization 
• Bill for hospital visits, not including postoperative visits 

Private Nursing Services 

• Medical order justifying the need for private nursing services at the hospital 
• Payment receipt for services showing the date and costs 

Second Opinion per Surgery 

• Second medical opinion consultation sheet 
• Surgeon’s bill for second opinion 

Blood and Plasma 

• Hospital bill for blood and/or plasma charges 
• Transfusion record 

Radiotherapy, Chemotherapy, and Experimental Therapy 

• Bill or receipt with name, cost, code, and date of chemotherapy, radiotherapy, or experimental therapy service 
• Or pharmacy certificate with the cost of the drug 

Ambulance 

• Having been admitted to a hospital 
• Ambulance bill 

Air Transportation of the Insured 

• Medical order certifying treatment in an institution outside the country by a hematologist-oncologist 
• Receipt for purchase of airfare at regular rate 

Air Transportation and Lodging for the Relative Companion 

• Receipt for purchase of airfare at regular rate for the companion 
• Payment receipt of lodging for adult companion 

Breast Prosthesis and other Prostheses 

• Bill for prosthesis acquisition 

Breast Reconstruction 

• Surgery report 
• Surgeon’s bill 

Skin Cancer 

• Medical certification 
• Report of positive pathological exam 
• Surgery report 
• Bill from dermatologist 

Terminal Cancer Home Confinement 

• Medical order with the reason for home confinement 

Funeral Expenses 

• Death claim form completed by the claimant (primary insured in case of deceased dependent or beneficiary in case primary insured dies) CL-0586-58 (R-0414) 
• Copy of claimant’s Social Security card 
• Copy of claimant’s identification 
• Original death certificate (form RD-77) with the cause(s) of death 
• Funeral service payment receipt 

In case the funeral service has not been paid, you must include: 

• Funeral home bill 
• Notice of Law No. 230, Anti-Fraud Act (signed by funeral director) 
• Designation of benefits authorizing pending payment to the funeral home, signed by the beneficiary (primary insured in case of deceased dependent or the beneficiary in case the primary insured dies) 
• Copy of the identification with signature of the person who signs the designation 

Postmortem Diagnosis 

• Cancer policy claim form completed and signed by the claimant CL-0801-108 (R-0614) 
• Copy of claimant’s identification with signature 
• Original death certificate (form RD-77) 
• Medical certificate completed by the primary care physician that is neither the surgeon nor the oncologist 
• Admission and discharge summary of the last hospitalization period prior to the date of death, or a certification made by a medical record official that includes hospitalization dates and diagnoses 
• Admission medical record 
• Hospitalization bill 

Good Health Maintenance 

• Bill or result with date of mammograms, PAP smears, prostate specific antigen (PSA), and other services with a similar purpose, according to the policy. 

Housekeeping 

• Medical order justifying the need for housekeeping services 
• Payment receipt for services showing the date and costs 

Psychological Support 

• Medical order justifying the need for psychological services 
• Payment receipt for services showing the date and costs 
• Evidence of medical visits 

Quality of Life 

• Medical order justifying the need for the items or services itemized in the policy 
• Receipt for payment of items or services received, with dates and costs 

Additional Compensation for Working Parents 

• Employer’s certification with exhausted leave periods or copies of paystubs 

Erectile Dysfunction 

• Medical order justifying the need for a surgical procedure or drugs to treat erectile dysfunction 
• Payment receipt with date and costs 

Drugs for Chemotherapy-related Nausea 

• Payment receipt with date and costs of drugs for nausea caused by chemotherapy 

X Rays, CT Scan, and MRI 

• Bill or payment receipt of the conducted test, including the date of said test 
• Medical order justifying the need for the test 

Legal Services 

• Payment receipt with date and fees of the attorney who rendered services as a result of the insured’s death 

Transfer of Remains to Puerto Rico 

• Payment receipt from the funeral home that transported the insured’s remains 

Ground Transportation 

• Medical order certifying treatment in an institution outside the country by a hematologist-oncologist 
• Car rental payment receipt 

Human Papilloma Virus Vaccine 

• Payment receipt with vaccine date and cost 
• Pediatrician’s certification 

For more information on cancer insurance, click here. 

Additional Benefits Claim 

Verify your policy’s additional benefits beforehand:

Accidental Death 

• Death claim form completed by the claimant CL-0586-58 (R-0414)

Note: the documents to be submitted for certain situations related to this benefit are found in the back of the death claim form. 

• Copy of claimant’s Social Security card 
• Copy of claimant’s photo ID and signature (legible) 
• Original death certificate (form RD-77) with the cause(s) of death 
• Police report (if applicable) CL-0586-58 (R-0414) 

Hospitalization due to Accident 

• Accident benefit claim form completed and signed by claimant CL-0801-107 (R-0614) 
• Police report, if applicable 
• Admission sheet and discharge summary or a certification by a medical record official with hospitalization dates and diagnoses 

Accidental Dismemberment 

• Accidental dismemberment claim form completed and signed by the claimant CL-0208-127 (R-0813) 
• Medical certification and/or surgery report with the details of the loss(es) 
• Police report, if applicable 

Hospitalization due to Accident 

• Accident policy claim form completed and signed by the claimant CL-0801-107 (R-0614)
• Police report, if applicable 
• Admission sheet and discharge summary or a certification by a medical record official with hospitalization dates and diagnoses 

Emergency Medical Treatment due to Accident 

• Detailed bill or payment receipt that includes the date of service and the payment made 
• Emergency room patient assessment form 
• Triage nurse’s notes 
• X Ray results 
• Medical certificate from the State Insurance Fund Corporation (SIFC) (form CFSE-1021), if applicable 
• Bill for medical visits, if applicable 
• Police report, if applicable 

Burns, Fractures, Tendons and Ligaments, Bruises, Dislocations, and Mutilations 

• Accident claim form completed and signed by the claimant CL-0801-107 (R-0614) 
• Medical assessment form (in case of burn, state the degree and percentage of affected body surface area) 
• Triage nurse’s notes 
• X-Rays results and any other test (in case of fractures) 
• Medical certificate from the State Insurance Fund Corporation (SIFC) (form CFSE-1021), if applicable 
• Police report, if applicable 

Hospitalization due to Illness 

• Cancer policy claim form completed and signed by claimant CL-0801-108 (R-0614) 
• Admission sheet and discharge summary or a certificate by a medical record official with hospitalization dates and diagnoses 

Total Physical Disability 

• Disability claim form completed and signed by claimant CL-0285-10 (R-0414) 
• Employer certification with date of last day of work and date on which insured resumed work, with company seal or stamped paper. If you are self-employed, complete the employer certification in the back of the form 
• Medical certification indicating the disability period and diagnosis(es) 
• Medical certificate from the State Insurance Fund Corporation form CFSE-1021, if applicable 

Organ Transplant 

• Cancer policy claim form completed and signed by claimant CL-0801-108 (R-0614) 
• Medical certification 
• Transplant medical report 

After indemnification, we will pay 100% of the expenses incurred and paid by the insured which exceed the indemnification benefit, subject to the terms and limits of the supplement. You must submit the following: 

• Breakdown of payments not covered by another health insurance or insurance coverage 
• Deductible or copayment receipts 

• Bill from the hospital where the transplant was performed 
• Total of services paid and not covered by Medicare (submit Medicare breakdown) 
• Proof of transportation, lodging, and food expenses 
• Payment receipt for private nursing services 

Intensive Care 

• Cancer policy claim form completed and signed by claimant CL-0801-108 (R-0614) 
• Certificate by a medical record official indicating diagnosis(es), date, time of admission and discharge, or the intensive care unit admission nursing notes 

Home Health Care due to Accident

• Accident policy claim form completed and signed by claimant CL-0801-108 (R-0614) 
• Medical certification including convalescence period 
• Medical certificate from the State Insurance Fund Corporation (SIFC) (form CFSE-1021), if applicable 
• Admission sheet and discharge summary or a certificate by a medical record official indicating accident-related hospitalization dates and diagnoses, if applicable 

First Heart Attack Diagnosis and First Major Heart Surgery 

• Illness policy claim form completed and signed by claimant and primary care physician CL-0801-108 (R-0614) 

• Surgery report, if applicable 
• Discharge summary, if applicable 

First Cancer Diagnosis 

• First cancer diagnosis policy claim form completed and signed by claimant and primary care physician CL-0801-108 (R-0614) 
• Report of positive pathological exam 

Life Insurance Claim 

The claimant is the beneficiary(ies) designated in the insurance application signed by the insured or the last beneficiary change made by the insured.  The benefit of ordinary life insurance policies can be partly or fully transferred by the beneficiaries to the funeral home, in accordance with the insurance amount acquired by the insured and the contract with the funeral director. 

Requirements to claim Accidental or Natural Death benefits 

• Life or Funeral Claim Brochure AGY-0722-194(R-0523)
• Fully completed claim form provided by Triple-S Vida CL-0586-58 (R-0414)  
• Claim Acceptance Form – Notice of Anti-Fraud Act, Law No. 230 of August 9, 2008, in case it is not included in claim form CL-0807-122 (R-1012) (Spa.)
• Original death certificate (form RD-77, preferably) 
• Birth certificate of insured (deceased) 
• Claimant’s (beneficiary[es]) photo ID and signature 
• Copy of claimant’s (beneficiary[es]) Social Security card 
• Marriage certificate or copy of birth certificate of children in common (if the claim is filed by a dependent) 

*If the claim is filed by a child claimed as a dependent in the policy, include copy of birth certificate. If filed by a child older than 21 years of age, include evidence of full-time studies at the time of death. If filed by an adopted minor, submit copy of legal custody papers.

Special Situations: 

• If the death results from homicide or an accident, please submit the following: 
  • Initial and final police report
  • Autopsy and toxicology report (in case of accident)
  • Authorization to request autopsy and toxicology report (in case of homicide) 

   

• If the beneficiary or one of the beneficiaries is a minor, please submit the following: 
  • Minor’s birth certificate 
  • Certified copy of the document through which the minor’s guardian is appointed. 
  • Minor’s name and mailing address 

   

• If at the time of the insured’s death, the designated beneficiary has not survived, and there is no other designated beneficiary, please submit the following: 
  • Beneficiary’s original death certificate 
  • Insured’s original declaration of heirs 

   

• If at the time of the insured’s death, the beneficiary dies subsequently and there is no other designated beneficiary, please submit the following: 
  • Beneficiary’s original death certificate 
  • Original declaration of heirs of insured 

   

• If at the time of the insured’s death, the primary beneficiary has not survived, and the contingent beneficiary is alive, please submit the following: 
  • Primary beneficiary’s original death certificate 

   

For more information on Life Insurance, click here.