HOSPITALISATION CLAIM FORM

Transcription

1 HOSPITALISATION CLAIM FORM Dear Claimant, We are sorry to learn of your hospitalisation. In order for us to process your claim, we require the following: 1) Claimant s Statement. 2) 1 Clinical Abstract Application Form. 3) Doctor s Statement (refer to Note I & II below). 4) Original Final Hospital Bills & Medical Bills (refer to Note III below). 5) Police Report (If hospitalisation is due to an accident). Once we have received all the above required documents, we will process your claim and inform you of the outcome as soon as possible. If you need any help, please call our Customer Service hotline at or us at claims-sg@greateasternlife.com. Note: I) For claims more than $2,000, the Doctor s Statement must be completed by the attending doctor and submitted to us. For SupremeHealth/ MaxHealth / Premier Health Plan (with deductible) claim, the Doctor s Statement is required only if the claim amount exceed the deductible amount. The Doctor s Statement is furnished at the expense of the claimant. II) For claims less than $2,000 or less than the deductible amount for SupremeHealth / MaxHealth / Premier Health Plan (with deductible), the Company may waive the medical report if there is sufficient documentary evidence to show the cause of hospitalisation / disability and period of disability. For example, Doctor s Memo certifying the date of accident, the injuries sustained and diagnosis. III) For the documents mentioned in item (4) above, copies of the hospital bills will be accepted for Hospitalisation Benefit, Lifetime Hospital Benefit claim, stand-alone Hospital Cash Protector (HCP) claim, Premier Medicash claim and Hospital Income Benefit Rider. Original final hospital bill is required for all Hospital & Surgical Benefit claim for the reimbursement of Surgeon s fee, Anaesthetist s fee, stand-alone Hospital & Surgical Protector ( HSP), Premier Health Plan ( PHP) claim, SupremeHealth claim and MaxHealth claim. IV) Please continue to pay the premiums to keep your Policy in force. V) Authorisation letter from the claimant has to be submitted if the case is not handled by the Servicing Life Planner/Representative. VI) The Company does not admit liability by the mere issue of the claim forms. VII) "The Company" refers to The Great Eastern Life Assurance Company Limited And/Or The Overseas Assurance Corporation Limited. Submission of Documents Please submit all claim documents personally at our Customer Service Centre at the ground floor, Great Eastern Centre or, through your Servicing Life Planner or, by post to: The Great Eastern Life Assurance Company Limited 1 Pickering Street Great Eastern Centre #13-01 Singapore The Great Eastern Life Assurance Company Limited (Reg. No G) The Overseas Assurance Corporation Limited (Reg No W)

2 AUTHORISATION LETTER For Claimant s completion : I would like the claim cheque (if claim is approved) to be : posted to me via my correspondence address. collected by my Servicing Life Planner, (NRIC No.: ) Signature of Claimant : Policy No. : Name of Claimant. : Handphone/ Contact No. of Claimant. : NRIC of Claimant : : For Servicing Life Planner s completion (if Claimant has authorised you to collect the cheque) I would like the claim cheque to be: - Collected at Customer Service Reception Counter at Ground Floor, Great Eastern Centre. (Please note that the cheque will be posted to the Claimant if it is not collected by the next working day after the collection date.) Dropped into my GSM Box No. at GE@Changi.* Dropped into my GSM Box No. Dropped into my GSM Box No. at GE House.* at Nankin Row.* * Notes:- 1. Option is available only if there are no outstanding documents to be submitted. Cheque will be delivered to your GSM Box the next working day after 12pm. 2. For Life Planners who have opted for collection of cheques at Customer Service Reception Counter at Great Eastern Centre, will contact you when the cheque is ready. Signature of Servicing Life Planner : Agent No. : Name of Servicing Life Planner : Contact No. : For Official Use : Claim Officer : Extension No. : Pending documents / comments : Cheque / Letter released by:- Signature : Name : : Cheque / Letter received by:- Signature : Name : : The Great Eastern Life Assurance Company Limited (Reg. No G) The Overseas Assurance Corporation Limited (Reg No W) Oct 2012

3 CLINICAL ABSTRACT APPLICATION Important Note: (i) This form is required for the application of medical report from hospital/clinic and should be completed by the patient or the patient s parent (if patient is below 21 years of age) or the patient s next-of-kin (if patient is deceased). (ii) For request of medical report from hospital, this form is to be submitted to the Medical Records Department of the hospital. * Please delete accordingly : Dear Sir Name of Patient : NRIC No.: Re : Application for Medical Report I hereby authorise you to furnish THE GREAT EASTERN LIFE ASSURANCE COMPANY LIMITED/ THE OVERSEAS ASSURANCE CORPORATION LIMITED with a detailed medical report on the above named patient (including without limitation all of my personal data contained therein) for purposes reasonably required by any of the aforesaid companies to evaluate, admit, process and/or administer my insurance claims. I agree and confirm that a photocopy of this executed Clinical Abstract Application form is as valid and effective as the original Clinical Abstract Application form. Yours faithfully [ ] [ ] Signature of *Patient / Patient s Parent / Patient s Spouse / Next-Of-Kin [ ] [ ] Signature of witness Name : Name : NRIC No : NRIC No : Address : Address : The Great Eastern Life Assurance Company Limited (Reg. No G) The Overseas Assurance Corporation Limited (Reg No W) CCLMCAA

4 HOSPITALISATION CLAIM CLAIMANT S STATEMENT Important Note: * Please delete where appropriate (1) The Great Eastern Life Assurance Company Limited And/ Or The Overseas Assurance Corporation Limited hereby referred to as The Company. (2) The Company does not admit liability by the mere issue of this or any other form. (3) The Doctor s Statement must be furnished (at the expense of the Policyholder) if the claim amount exceeds S$2,000 or the deductible amount for SupremeHealth / MaxHealth Claim / Premier Health Plan (with deductible). (4) To be completed by the Policyholder. 1 POLICY (IES) ISSUED BY THIS COMPANY Great Eastern Life Policy No(s).: Overseas Assurance Corporation Policy No(s).: 2 DETAILS OF POLICYHOLDER (Please complete in BLOCK letters) Name (According to NRIC/ Passport): NRIC/ Passport No.: of Birth (dd/mm/yyyy): Gender: M / F * Residential Status at the point of treatment: Singaporean / Singapore PR / Foreigners* Occupation: Home Tel: Office Tel: HP No.: Address: Claims Acknowledgement Update via SMS : YES / NO* (Kindly note that this SMS facility is available for Great Eastern Life policies only). 3 DIRECT CREDITING OF CLAIMS (Excludes OAC Claims) Name of Bank Branch of Bank Bank Account Number Account Holder s name Important Notes: - Direct Crediting will only be applicable for claims (excluding reimbursement to CPF Board) up to S$10,000 to a local bank account. Claim amounts will only be direct credited to the Policyholder s bank account. A cheque will be issued if claim is above S$10,000. The Company will continue to credit all further claim benefits payable for the same event to the above bank account, unless otherwise notified by the Policyholder. 4 DETAILS OF LIFE ASSURED (if different from (2)) (Please complete in BLOCK letters) Name (According to NRIC/ Passport): NRIC/ Passport No.: of Birth (dd/mm/yyyy): Gender: M / F * Residential Status at the point of treatment: Singaporean / Singapore PR / Foreigners* Home Tel: Office Tel: HP No.: Address: Signature of Policyholder The Great Eastern Life Assurance Company Limited (Reg. No G) The Overseas Assurance Corporation Limited (Reg No W) CCLMCLAHOS Jul 2014

5 5 DETAILS OF LIFE ASSURED S OCCUPATION Occupation: Name of Employer: Address of Employer: Postal Code: Description of Duties: 6 CONDITION (IF DUE TO ILLNESS OR INJURY) (a) Describe fully the symptoms for which the Life Assured consulted a doctor. (b) When did the Life Assured have the symptoms before he/ she consulted a doctor? (c) when the Life Assured FIRST consulted a doctor: (d) Name and address of the doctor whom the Life Assured first consulted for the illness or injury: (e) Describe fully the extent and nature of the illness or injury. (f) What is the hospital/ doctor s diagnosis? (g) Was surgery performed for this condition? YES / NO* If YES, please specify. Nature of Surgical Operation(s) (s) Performed (D/M/Y) Surgical Table Signature of Policyholder Jul 2014

6 7 ACCIDENT (IF APPLICABLE) (a) of Accident: (b) Time of Accident: (c) (d) Place of Accident: Detailed description of Accident: (e) Name(s) and telephone no(s) of witness(es): Name of Witness Telephone No. 8 HOSPITALISATION (a) How was the Life Assured admitted to the hospital? [ please tick ] Referral by a General Practitioner/ Specialist/ Other Hospital* Please provide the name and address of doctor/ hospital: A & E department 9 DETAILS OF REGULAR DOCTOR(S) (a) Name(s) and address(es) of the Life Assured s regular/ company doctor(s): Name(s) Address(es) (s) of Consultation Reason(s) for Consultation (b) (i) Does the Life Assured have the same medical condition previously or any other medical conditions not stated above?yes / NO* (ii) If YES, please state: of Onset: of Diagnosis: Medical condition: Medical treatment received: Signature of Policyholder Jul 2014

7 10 OTHER INFORMATION Has the Life Assured or the Claimant been bankrupt or insolvent or has executed any deed or transfer for the benefit of creditors since becoming interested in the policy? YES / NO* 11 OTHER INSURANCE Is the Life Assured claiming for medical expenses from any other sources (e.g. employer, other medical insurances)? If YES, please provide the following information. YES / NO* Name of Employer, Insurance Company, etc of Issue Type of Plan Claim Amount Claim Notified (YES/ NO) DECLARATION I hereby declare that the information, answers and statements provided above are in every respect true, complete and correct, and that no material information has been withheld nor is any relevant circumstances omitted. I hereby agree and consent to Great Eastern, its related corporations (collectively, the Companies ), as well as their respective representatives and agents collecting, using, disclosing and sharing amongst themselves my personal data, and disclosing such personal data to the Companies authorised service providers and relevant third parties for purposes reasonably required by the Companies to process and administer my claims. These purposes are set out in Great Eastern s Privacy Statement, which is accessible at and which I confirm I have read and understood, including without limitation: (a) (b) the Companies, their representatives, agents, authorised service providers and other relevant third parties ( Requesting Parties ) may collect medical information concerning me from any persons possessing the same (such as doctors whom I have consulted), and I hereby authorise those persons to release the same to any of the Requesting Parties for the purpose of my claims, and the Requesting Parties may disclose any relevant information concerning me (including my medical information) to other parties, which any of the Requesting Parties deems necessary for the purpose of my claims. I further agree that this declaration shall form part of my proposed application for the relevant insurance benefits, and a copy of this form shall be treated as valid and binding as if it were the original. By providing the details of my bank account in Section 3 above, I hereby authorise Great Eastern to credit any claim proceeds of not more than S$10,000 into the aforesaid bank account. Signature of Policyholder Name: NRIC/ Passport No: : Jul 2014

8 HOSPITALISATION CLAIM DOCTOR S STATEMENT * Please delete where appropriate For Official Use _ G E L S _ O A C S Name of Life Assured: NRIC/ Passport No.: of Birth (dd/mm/yyyy): Gender: M / F * 1. (a) Has the Life Assured consulted any other doctors/ hospitals prior to first consultation with you? YES / NO* If YES, please provide name and address of the doctor(s)/ hospital(s). (b) Are you the Life Assured s usual medical doctor? YES / NO* If YES, since when? 2. (a) of first consultation for the current condition: (b) (c) (s) of subsequent consultation: Please state symptoms presented and date symptoms first appeared. Symptoms Presented at First Consultation Symptoms First Started (DD/MM/YY) What is the source of this information? Life Assured/ Referring Doctor/ Others* If Others, please specify the name of the person and relationship to the Life Assured: (d) Diagnosis: (e) of FIRST Diagnosis: (f) (g) Diagnosis was first made by (name of doctor): diagnosis was made known to the Life Assured: (h) What was the exact information conveyed to the Life Assured? Signature of Doctor The Great Eastern Life Assurance Company Limited (Reg. No G) The Overseas Assurance Corporation Limited (Reg No W) Oct 2013 CCLMDOCHOS

9 (i) Is the condition a result of an accident? YES / NO* (i) If YES, describe in detail how the accident happened. (ii) of accident: (iii) Was the Life Assured under the influence of alcohol/ drugs at the time of accident? YES / NO* If YES, please state the blood alcohol content/ drug type and quality consumed: (iv) Did the injuries result from a self-inflicted act? If YES, please give full description. YES / NO* (j) Type of treatment/ medication given and the response. (k) Please tick if the following were done/ will be done. Gamma Knife Radiotherapy Stereotactic Radiotherapy Erythropoietin Chemotherapy Kidney dialysis Cyclosporin Immunotherapy (l) Is the current treatment related to the following conditions? YES / NO* If YES, please tick the box(es): Infertility Subfertility Abortion Birth control Sterilisation Impotence test or treatment Pregnancy, childbirth, miscarriage or their sequelae Complications of Pregnancy or childbirth Alcoholism Drug addiction Drug abuse Routine eye examination Refractive errors of the eyes Depression Mental disorder Functional disorder Hereditary conditions Birth defects Congenital sickness or abnormalities Obesity Weight reduction Weight improvement AIDS or any illness caused by or related to HIV Sexually-transmitted disease Signature of Doctor Oct 2013

10 If you have ticked any of the boxes, please give full details. (m) Is the Life Assured still on follow-up treatment? If YES, please specify the type of treatment/ medication. YES / NO* (n) How frequent does the Life Assured seek treatment since discharge from hospital? (o) What is the expected length of follow up? 3. Please state the periods of hospitalisations. Name of Hospital Period(s) of Hospitalisation Period(s) of Intensive Care From To From To 4. (a) Was surgery performed for this condition? YES / NO* If YES, please specify. Nature of Surgical Operation(s) (s) Performed (DD/MM/YY) Surgical Table No. (b) Is further surgery likely to be required? YES / NO* If YES, (i) please specify the tentative date of surgery: (ii) please specify the type of surgery to be performed: Signature of Doctor Oct 2013

11 (c) Is the surgery performed an elective cosmetic or plastic surgery? YES / NO* If YES, please provide details. 5. (a) Has the Life Assured previously suffered from the same illness in respect of which he/ she is claiming now? YES / NO* If YES, please state: (i) when illness was first diagnosed: (ii) Name and address of the doctor who first treated him/ her. (iii) Has the Life Assured fully recovered from the previous illness before the current episode? YES / NO* (b) Has the Life Assured been admitted to any hospital before, either for the same or different cause? YES / NO* If YES, please state. Period(s) of Hospitalisation Diagnosis Hospital Name(s) of Attending Doctor(s) (c) Is the Life Assured suffering or has suffered from any other significant illnesses? YES / NO* If YES, please state. Brief Description of Illness(es) (s) of First Diagnosis (DD/MM/YY) Name & Address of Attending Doctor 6. Please provide us with any other additional information that will enable the Company to assess this claim. Signature & Official Stamp of Doctor Oct 2013