Claim Form - Medical Gap Cover Policy

Transcription

1 Claim Form - Medical Gap Cover Policy Return address and Zestlife contact details: info@zestlife.co.za or fax: or post to Private Bag X1005, Claremont, 7735 Claim enquiries and queries Zestlife tel: Mandate to obtain medical information I hereby authorise my medical aid to furnish Zestlife with any information with respect to any illness or injury, medical history consultation, prescriptions, treatment, PMB investigations including copies of all medical records. This authorisation relates not only to me but also to all my dependants on my medical and covered under this policy and will continue until written instruction is received from me to cancel this mandate. Signature of principal insured To ensure we are able to process your claim promptly Please read carefully We require all the following documents which we refer to as the Claim Pack: 1. Completed claim form, ensuring: a. All relevant sections are fully completed. b. The inclusion of the Patient s ID number. c. The policyholder s bank account details have been provided. d. It s signed and dated by the policyholder. 2. Hospital account (all pages). 3. Doctors accounts. 4. Detailed medical aid statements reflecting payment to all providers and the shortfall which is being claimed for. 5. If you are claiming a co-payment, proof that the co-payment was levied (i.e. medical aid pre-authorisation and medical aid statement reflecting the co-payment)and proof that the co-payment was paid (receipt or credit card slip). Please only submit your Claim Pack once you have all the listed supporting claim documents and submit one Claim Pack per claim incident. You must notify us of a claim within six months from the date admitted to hospital or the date of the out-of-hospital or casualty procedure or the date diagnosed in the event of a lump sum cancer claim. If we have closed a claim due to long outstanding documentation, and you subsequently submit the relevant documentation, we will re-open and process your claim provided this documentation is submitted within 12 months from claim incident date. Principal insured Full names Surname of birth ID number Policy number 1

2 Postal address Postal code Work telephone number Cell phone number address Medical aid name Medical aid plan type Medical aid membership number Total number of people on your medical aid Policyholder bank account details Please provide the bank details of the principal insured. By law no benefit can be paid to a third party. Name and surname of account holder Bank name Branch code Account number Account type Claimant details Patient full names Patient surname Patient date of birth Patient ID number Relation to insured Self Spouse Child Adult dependant Reason for claim Illness Accident Childbirth Routine/Preventative examination not due to illness or injury admitted to hospital discharged from hospital Name of hospital/day clinic Procedures undertaken 2

3 To be completed if you have held the policy for less than 12 months: When did the medical condition leading to your claim start First consultation with a Doctor for this condition Name of doctor and telephone number Details of medical treatment received in last 12 months If the procedure was due to an accident: of accident Details of accident Gap Benefit/shortfalls being claimed (please tick the relevant boxes and you only need to complete the sections A to I that are relevant to your claim) Medical practitioner cost shortfalls Complete section A Co-payment Complete section B Internal prosthesis shortfall Complete section C Casualty unit shortfalls Complete section D Accident tooth fracture benefit Complete section E Dental Extender benefit Complete section F Lump sum benefit for first time cancer Complete section G Cancer Extender benefit Complete section G Oncology treatment programme co-payment Complete section H Non-affected breast reconstruction benefit Complete section I Please request a special claim form if you want to claim for: - Medical premium waiver death or disability benefit. - Lump sum accidental death or disability benefit. - Accidental emergency transportation, trauma counselling or life support equipment. CAIM DETAILS Section A (Medical practitioner cost shortfalls) The procedure was In-hospital Out of hospital 3

4 1. Detailed medical aid statements reflecting payment to all providers a shortfall is being claimed for. 3. Doctors account/s. 4. Hospital account (all pages). Section B (Co-payment) Service provider R R Co-payment amount 1. Medical aid statements reflecting the co-payment. 2. Medical aid pre-authorisation letter. 3. If the claimant is not the policyholder, a medical aid letter stating the claimant is a dependant of the policyholder. 4. Account on which co-payment was applied. 5. Hospital account (all pages). 6. Proof that co-payment was paid (receipt or credit card slip). Section C (Internal prosthesis shortfall) 1. Medical aid statements reflecting payment to all providers a shortfall is being claimed for. 3. Doctors account/s. 4. Hospital account (all pages). Section D (Casualty unit shortfalls) 1. Medical aid statements reflecting payment to all providers a shortfall is being claimed for. 3. Doctors account/s 4. Casualty unit account Section E (Accidental tooth fracture benefit) Number of teeth damaged 1. Dentist motivation of accidental injury and invoice reflecting damaged tooth number. 4

5 Section F (Dental Extender benefit) Dentist name Dentist Practice number of visit Diagnosis Possible Treatment Cover Mark with X Tooth numbers Impacted wisdom tooth Surgical tooth removal R per tooth Periodontitis Gum surgery R per event Jaw fracture Surgery R per event Dental Emergency Emergency Root Canal, temporary crown, temporary filling. R per event Accidental tooth fracture Crown, splinting, bridge R per tooth Severely decayed or damaged tooth Crown R per tooth Impaired function due to loss of teeth Removable denture R per jaw Occlusal instability Implant or bridge R per tooth 1. Dentist quote or invoice for the procedure. 2. Dentist X-ray for tooth. 3. If the claimant is not the policyholder, a medical aid statement confirming that the claimant is a dependant of the policyholder. 4. If a Periodontitis claim then also a copy of the Periodontitis treatment plan. Section G (Lump sum benefit for first time cancer diagnosis and Cancer Extender benefit) Give full details of type of cancer Name of attending doctor Telephone number Address of diagnosis Is this a first time diagnosis? Yes No 5

6 1. Medical reports to be completed by Medical Practitioner (refer to the form on the last page of this document). 2. Histology reports. 3. Test results. 4. If the claimant is not the policyholder, a medical aid statement confirming that the claimant is a dependant of the policyholder. Section H (Oncology treatment programme co-payment) Give full details of type of cancer Name of attending doctor Telephone number Address of diagnosis 1. Treatment plan. 2. Medical aid statements reflecting payment to all providers a shortfall is being claimed for. 3. If the claimant is not the policyholder, a medical aid letter stating the claimant is a dependant of the policyholder. 4. Any relevant specialist accounts. Section I (Non-affected breast reconstruction benefit) 1. Medical reports supporting the illness as well as copies of any relevant test results. 3. Proof of the single mastectomy of the affected breast due to cancer a copy of the histopathology report. 4. Proof of the breast reconstruction surgery performed to the non-affected breast a copy of the hospital account and relevant specialist accounts. 5. Proof that your medical aid did not cover or pay for the cosmetic reconstruction costs of the non-affected breast a copy of preauthorisation confirmation from your medical aid. 6. The full detailed medical aid statement reflecting all the transactions to the service providers in respect of this surgery including the reason codes. 7. Doctor accounts. 8. Hospital account (all pages). 6

7 Declaration by policyholder and permission to share information with a third party I declare that the above particulars are true in every respect and I attach copies of all required supporting documents. I hereby authorise my medical aid and any hospital, physician or other person who has attended to me or my dependants, or examined me or my dependants, to furnish to Zestlife, Guardrisk or their authorised representative any information with respect to any illness or injury, medical history consultation, prescriptions or treatment and copies of all hospital or medical records. Such information could relate to medical information (i.e. PMB details, chronic conditions, claims transaction history, hospital procedures, health records etc.) or benefit information (i.e. plan type, limits, waiting periods, co-payments, self-payment gap etc.). I further authorise Zestlife, Guardrisk or their authorised representative to share any information obtained as referred to above with my appointed Medical Gap Cover Financial Advisor. A photocopy of this authorisation shall be considered as effective and as valid as the original. By giving this authority I agree that any of the parties providing Zestlife, Guardrisk or their authorised representative with information will not be held responsible for any claim that results from the wrongful use or disclosure of information by Zestlife, Guardrisk or their authorised representative. Full names of principal insured Signature of principal insured 7

8 MEDICAL REPORT FOR CANCER LUMP SUM BENEFIT (Required for lump sum cancer benefit claims) To be completed by the claimant s attending Medical Practioner only Full names of claimant When were you first consulted by the claimant in connection with his/her condition? On what date was the claimant diagnosed with cancer? Is this the claimant s first diagnosis of any type of cancer? Yes No If no, when was the claimant first diagnosed with cancer? Please provide details of any previous diagnosis of cancer Please provide full details of current diagnosis of cancer Please clarify the severity of the current diagnosis Stage Local Regional Benign Malignant Medical Practitioner Declaration I hereby certify that the above statements are true in every respect. Name Qualifications Physical Address: Telephone No: Practice No. Signature 8