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How can I make a claim?
All in-patient treatment requires Pre-Authorization. Your particular insurer may require you either to phone them directly to initiate this, or submit a Treatment Guarantee Form, prior to any treatment.
Please initiate Pre-Authorization of treatment at least five working days prior to treatment.
If you have emergency in-patient treatment, you need to inform your insurer about your admission as soon as possible to avoid any pre-authorization penalties by calling their Helpline. In most cases, the hospital will contact the insurer for you. It is therefore vital you always carry your insurance card as you may be unconscious at the time.
Out-patient or Dental claims
Most out-patient treatment does not need to be pre-authorized in advance, however we strongly recommend that you contact your insurer before you incur any costs to check that the course of treatment your doctor or dentist recommends is covered by your plan.
Unless your medical provider has confirmed a direct settlement arrangement, you will need to pay the medical provider for these costs at the time of treatment. You can then claim back the costs from your insurer, subject to your benefit limits, by following the guidelines on your claim form.
How long does it take to process claim?
Fully completed Claim Forms can be processed, with payment instructions issued to your bank, from 48 hours to several working days (dependant upon your insurer). Please ensure all sections of the claim form are fully completed to prevent any delay in processing and reference your claim form for instructions. The form should be returned to your insurers claims centre within their time limit which is between 90 days and 180 days (dependant upon your insurer) from the initial treatment date. Always enclose the original invoices and receipts - photocopies are not accepted. Insurers are unable to return original documents, but are happy to provide certified copies upon request.
What are some of the reasons that my claim might be denied?
Your treatment is not covered by your plan. If you have been notified by your insurer that your claim was denied in part, or in full, an explanation will be found in your policy documentation (policy wording, guide or agreement), paying attention to these sections: Definitions, Exclusions, Pre-existing Medical Conditions, Waiting Periods, and General Conditions. Many insured members see a partial denial of claim due to part of their treatment or medication not being covered by their policy due to their policy wording.
Your policy benefit limit is exceeded. Claims may also be denied as the member has used up a particular benefit limit during their policy year, and it is important to monitor your claims expenses. An example is if your policy has a limit of US$1,500 for prescribed medication each policy year, but your annual medication costs are US$4,000. You are required to pay any difference in cost as your policy benefit limit will be exceeded during your policy year. All benefits in your policy with a financial cap are reset each policy year, and it is important you choose a plan with enough cover for your needs.
Your medical file & previous insurance contradicts your insurance application. A claim may also have been denied due to your insurer identifying a misstatement, misrepresentation, or omission on your original application. In this case, the insurer may apply a retrospective exclusion to the policy, or will void the insurance, and any and all claims and benefits under the plan will be forfeited and waived. If relevant medical information may not have been provided on your application, it is important to update your insurer with any omitted information the soonest.
My claims was denied but I believe it was a mistake. What should I do?
The insurer aims to provide you with a first class standard of service at all times. Nethertheless, there may be an occasion when you may feel this objective has not been achieved by them. In the unlikely event of this happening, should you have any complaint or query regarding the service provided by your insurer under your plan, then please contact their client service advisor in the first instance. If you are difficulties with going direct, then please contact us and we will try and resolve your complaint.
What is Pre-Authorisation?
Certain insurers require some treatments to be pre-authorized in advance, and you need to contact your insurer about this, and submit a Treatment Guarantee Form where applicable. Following approval by your insurer, payments for these treatments can then be guaranteed.
This service enables the insurer to maintain their premiums at the lowest possible level for their members by helping them control the cost of medical treatment in a worldwide context. In addition, Pre-Authorization helps your insurer to provide a better service in the following ways:
1). They can ensure that proposed surgical treatments are carried out on a day-care basis where medically appropriate;
2). In the case of planned treatment, they will have time to communicate with the hospital to facilitate smooth admission and where possible, arrange for direct settlement, offering cashless access to hospitals for in-patient treatment;
3). Treatment can be overseen by your insurers Medical Team;
4). In the case of an evacuation/repatriation, they will be able to organize and co-ordinate the evacuation on your behalf;
5). They can ensure that you are admitted and discharged at times that do not attract a surcharge.