Global Health Plans Corporate Application Form

Transcription

1 Global Health Plans Corporate Application Form Please complete this form in BLOCK CAPITALS using black ink, and return it to us by , fax or post. You can find our contact details at the end of this form. Broker/intermediary details If you were introduced to us by an intermediary or broker, please state their name, company and PHIR number. Name of broker:... Name of company:... PHIR no.:... Company details Company name:... Type of business:... Address: Telephone number:... Contact(s) at company Contact 1: Position in company: Telephone number: Contact 2: Position in company: Telephone number: Start date required When would you like your Global Health plan to start? On acceptance of your application Specific date:... Please note that your application is only valid for 28 days from the date we receive it. Cover cannot be backdated. Eligibility for cover for your plan Cover must be provided and paid for by the company on a compulsory basis. The company must apply for cover for ALL employees, or ALL employees of a certain category (e.g. managers, executives, expats). If cover for dependants of employees is required, the company must apply for cover for ALL eligible dependants. Total number of employees in your company:... Total number of employees to be covered in this plan:... If cover is required only for a certain category of employees, or if different levels of cover are required for different categories of employees, please define those categories below. Category Eligibility criteria Level of cover Cover required for all eligible dependants? Choose your health insurance plan Please choose either A) an Elite plan or B) a Foundation plan, then select the optional benefits you require. If you have one, please state the quote illustration ID for the quote you wish to accept:... 1

2 A) Elite plans Plan: Excess required: GOLD Nil $15 or AED 55 per visit $30 or AED 110 per visit SILVER Nil $15 or AED 55 per visit $30 or AED 110 per visit Neuron medical network required Comprehensive (widest network of medical facilities) General Plus (excludes some of the more expensive facilities) Optional benefits available with the Elite plans Medevac plus only available with Area One cover. Dental plus available with Silver only if Dental basic is also selected, and on Gold. Dental basic only available with Elite Silver. $5,000 or AED 18,350 maternity care benefit only available with Elite Silver $7,000 or AED 25,690 maternity care benefit only available with Elite Silver $10,000 or AED 36,700 maternity care benefit only available with Elite Silver Optical care benefit Choose your Elite area of cover Area One Area Two Worldwide cover, excluding the USA. Worldwide cover, with cover in the USA limited to $100,000 during temporary trips of not more than 45 days. This limit is increased to $250,000 for unforeseen emergency treatment. Area Three Worldwide cover, with cover in the USA limited to $250,000 during temporary trips of not more than 90 days. B) Foundation plans Plan: FOUNDATION FOUNDATION PLUS A nil excess applies to the Foundation plans. Neuron medical network required General Plus (wider network of medical facilities) The Foundation areas of cover General (basic network of medical facilities) The Foundation plan provides cover in the UAE and the Indian Subcontinent (India, Pakistan, Sri Lanka, Bangladesh, Nepal & Bhutan). Insured persons are not covered for treatment received in their home country if that country is not stated above. The Foundation Plus plan provides worldwide cover, excluding the USA, Canada, Caribbean Island & Countries, and the London area. Cover is restricted in the following countries and regions: all countries within the European Union, Andorra, Channel Islands, Gibraltar, Iceland, Liechtenstein, Monaco, Norway, San Marino, Switzerland, Australia, Bali, China, Hong Kong, Japan, Macau, New Zealand, Singapore, and Taiwan. By restricted we mean that the cover we provide is restricted to emergency treatment you receive whilst on a temporary trip of up to 90 days to one of the restricted countries or regions stated above. The maximum benefit we will pay in respect of all emergency treatment you receive in restricted countries or regions during an annual period of cover is $50,000. 2

3 Add-ons available with your health insurance plan GLOBAL TRAVEL PLAN You Spouse/partner Family GLOBAL PERSONAL ACCIDENT PLAN You Spouse/partner Please answer the following questions ONLY if you have opted for Personal Accident cover. If you have opted for cover for your spouse/partner, we also require details of their occupation and any hazardous activities. Please select level of Personal Accident benefit you require: $75,000 or AED 275,250 $150,000 or AED 550,500 $225,000 or AED 825,750 $300,000 or AED 1,101,000 $375,000 or AED 1,376,250 Underwriting options The following medical underwriting options are available: Fully underwritten Medical history disregarded (10+ employees only) Health declaration (please skip this section if you require cover for more than 50 employees) 1 In the past three years, have any of your employees or their dependants: a) Been admitted to hospital? Yes No b) Suffered from any serious health problems?* Yes No *By serious, we mean conditions such as cancer, heart conditions, strokes, back problems, depression, serious injuries or disabilities, multiple sceloris, or liver or kidney problems. If you are in any doubt as to what constitutes a serious medical condition, please declare it. 2 Are any of your employees or their dependants: a) Currently undergoing a course of medical treatment? Yes No b) Currently pregnant? Yes No 3 Are all employees actively at work at the time of application? Yes No If NO, please make a full declaration (e.g. name, date last worked, reason for absense):... Paying for your plan Please select the currency in which you would like to pay your premiums: US Dollars Dirhams Your plan benefits and excess will be denominated in the currency in which you pay your premiums. 3

4 Please select your payment method and frequency: Bank transfer Annually Half-yearly^ Quarterly Monthly* Cheque** Annually Half-yearly^ Quarterly Monthly* *Monthly payments are only possible if you are paying in US Dollars. ** Cheques are payable to Dubai Insurance Company psc., and must be drawn on a UAE bank account. ^ Half-yearly premiums are subject to a 3% surcharge. Quarterly or monthly premiums are subject to a 5% surcharge. How we use your employees information By submitting this application, you consent to Dubai Insurance Company psc. processing the personal data of each employee named in this application, including sensitive medical information. We will use this data for the purposes of underwriting, administering your plan, and processing claims only. In certain cases, it may be necessary to pass your employees data to the insurers and reinsurers of your plan, cost control agents, banks, our claims service, your appointed intermediary (if any), and our emergency assistance service providers. If required, we will pass your employees data to legal or regulatory bodies, and to relevant parties in the interests of fraud prevention. We will never share your employees data with a third party not strictly necessary to the administration of your plan or the processing of your employees claims. Declaration for your Global Health plan Please read this section carefully and sign below. We understand that this application is subject to written acceptance by Dubai Insurance Company psc. We declare that to the best of our knowledge and belief the above information supplied in respect of our employees and their dependants is true and complete. We understand that we must inform Dubai Insurance Company psc., in writing, of any changes in the facts provided in this application, including any change in health of any employees and dependants occurring before the start date of the plan. We confirm that membership of the corporate Global Health plan is compulsory, with all eligible employees and their eligible dependants being insured in accordance with the eligibility criteria we have provided in this application form. We understand that our company data will be held and processed for the purposes of processing any claims submitted under the plan and providing other related services. This may include sharing our company data with the re-insurers of the plan, doctors and other medical professionals involved in the treatment or care of the employees insured under the Global Health plan, medical network providers, third party administrators, emergency assistance providers, and other agents. We also understand that our company data may be disclosed to any regulatory body that may require Dubai Insurance Company psc. to disclose it and that, in the event of fraud or suspected fraud, our company data may be disclosed to other parties including, but not limited to, the appropriate law enforcement agencies. We authorise Dubai Insurance Company psc. to send all insurance documents as PDF files to the address we have provided on this form. If we have applied through a broker or intermediary, we give consent for these documents to be sent via to that broker or intermediary. We understand that telephone calls to and from Dubai Insurance Company psc. may be recorded and monitored. We understand that, upon receipt of the insurance documents, if we are not entirely satisfied, we can cancel the application from inception and receive a full refund of the premium paid, provided we notify Dubai Insurance Company psc. within 30 days of the plan start date, and provided no claim has been made. Important notes Your completed application form is valid for 28 days from the date you signed the form. If cover is not commenced within 28 days, we reserve the right to request that you complete a new application form. If the health of any employee named on this form changes after you submit this form, but before your plan starts, you must let us know immediately. We are unable to accept electronic signatures below. 4

5 Please provide the following documentation with your application: Photographs of all insured persons in JPEG format A full census of all insured persons, including passport numbers, Emirate ID numbers, and UID numbers A copy of your company s trade license Name of authorised company representative:... Position in company:... Signature of authorised company representative:... Date:... The Global Health plans are designed by William Russell Limited and insured by Dubai Insurance Company psc., who are licensed by the UAE Insurance Authority, registration number 4. The claims service for the Global Health plan range is administered by Neuron LLC. The Global Travel plans and Global Personal Accident plans are designed by William Russell Limited and insured by Dubai Insurance Company psc., who are licensed by the UAE Insurance Authority, registration number 4 Global Plans Team Dubai Insurance Company, PO BOX 3027, Dubai, UAE DIC/2017/group_h_app/v1 5 T: F: E: enquiries@globalplans.ae globalplans.ae

6 Global Health Plans Application for Neuron Services Please complete this form in BLOCK CAPITALS using black ink, and return it to us by , fax or post. You can find our contact details at the end of this form. Important information about the Neuron claims service Neuron LLC administers the claims service for the Global Health plans. All insured persons receive a network membership card from Neuron, which allows them to receive eligible treatment from the medical facilities in Neuron s extensive network. By eligible treatment, we mean treatment covered under the Global Health plans, subject to any applicable benefit limits. When an insured person presents their network card to a medical facility within their chosen Neuron network, the medical facility will request a form of identification in order to verify that the person is indeed insured. Once verified, the medical facility will only ask the insured person to pay the excess amount displayed on the network card. Treatment will be provided without the insured person having to make any other form of payment. The bill for the medical treatment will be sent straight to Neuron, who will settle directly with the medical facility. Neuron is obliged to settle all bills received from medical facilities within their network. This means that insured persons have an obligation only to use their network card for eligible treatment covered under their Global Health plan. If an insured person is in any doubt about what is eligible, they should contact Neuron or our Claims Team before they receive treatment. It is very important that you and all insured persons understand the obligations of using the Neuron claims service. When an employee leaves your company When an employee leaves your company, you must retrieve their Neuron network card and all cards issued to dependants as soon as possible. If you do not retrieve the cards, they could be used to claim for medical treatment. Your company will be liable for any costs incurred by an employee (and any dependants) after the date they leave your employment. As such, we will only cancel an employee s cover from the date on which we receive their returned network card(s) from you. We can accept torn copies of the Neuron cards. The cards need to be sent to us by mail in order for us to proceed with the cancellation of cover. Our address can be found at the end of this form. You will be charged a premium for the employee (and dependants) until the network card(s) are returned to us. Dubai Insurance Company psc. are entitled to recover from your company all costs and/or liabilities incurred after the date your employee (and dependants) leave your employment. When an insured person claims for treatment not covered by your plan When an insured person presents their Neuron network card for a treatment or service that is not covered by your Global Health plan, you will be liable for any costs incurred. For example, this situation could arise if an insured person uses their network card to pay for the treatment of a medical condition that is not eligible for benefit under your Global Health plan, or if the treatment costs incurred exceed any applicable benefit limits. Your company will be responsible for any ineligible claims made by an insured person. As soon as we are made aware of an ineligible claim, we will write to the insured person and ask them to repay to us the ineligible costs. If that person fails to repay those costs, we will require their network card immediately. Your company agrees to indemnify fully Dubai Insurance Company psc. if we are unable to obtain repayment of ineligible costs from the insured person within 30 days. If an insured person makes more than one ineligible claim, we will require their network card immediately along with any cards issued to dependants. Future claims must be submitted to our Claims Team for consideration. Requirement for photographic identification To produce network cards, we require a photograph of each insured person to be displayed on their card. Please submit a photograph for each insured person in JPEG format. We are unable to issue any network cards until we have received all photographs. Insured persons will not have access to the Neuron direct billing networks until this is done. In submitting these photographs, you give us permission to reproduce the images on the respective network cards. Declaration We hereby apply for membership of our chosen Neuron network. We understand that each insured person must submit a photograph in JPEG format, and this photograph will be displayed on each insured person s network card. We understand that the Global Health plan cannot commence until Dubai Insurance Company psc. has received photographs for all insured persons. 6

7 We fully understand the important information provided above about the Neuron claims service. We will inform Dubai Insurance Company psc. immediately of any employees (and dependants) who leaves the company, and we agree to retrieve the network card(s) as soon as possible. We understand that any credit issued by Dubai Insurance Company psc. in respect of any premium refund following an employee (and dependants) leaving your company will be calculated from the date that the relevant network cards are received by Dubai Insurance Company psc. We will ensure that all insured persons are fully aware of the benefits covered under their Global Health plan, as well as all treatments and conditions that are not covered, or which are subject to certain limits, to avoid incorrect claiming on their network cards. Company name:... Plan number:... Name:... Position/title:... Signature:... Date:... The Global Health plans are designed by William Russell Limited and insured by Dubai Insurance Company psc., who are licensed by the UAE Insurance Authority, registration number 4. The claims service for the Global Health plan range is administered by Neuron LLC. The Global Travel plans and Global Personal Accident plans are designed by William Russell Limited and insured by Dubai Insurance Company psc., who are licensed by the UAE Insurance Authority, registration number 4 Global Plans Team Dubai Insurance Company, PO BOX 3027, Dubai, UAE DIC/2016/group_neuron_app/v2 7 T: F: E: enquiries@globalplans.ae globalplans.ae