Medical Claim Reimbursement Form - Wehbe Insurance Services Llc printable pdf download

Medical Claim Reimbursement Form

American Life Insurance Company

GULF OPERATIONS

WILMINGTON, DELAWARE, U.S.A., INCORPORATED 1921

P.O. Box 371916, Dubai, United Arab Emirates

EMPLOyEE’S SECTION (*All Fields are Mandatory)

D M M

Employees’s Full Name*

Date of Birth

D M M

Patient’s Full Name*

Date of Birth

Employee’s Nationality*

Patient’s Nationality*

Employee Contact No.*

–

Country Code

Area Code

Policy Number*

Certificate Number*

(Mentioned on your Medical Card)

Employee E-mail Address.*

Address*

REIMBURSEMENT METHOD

Get your money FASTER:

Cheque

Wire Transfer

Use Wire Transfer

Primary Insured’s Bank Name*

Bank’s Name

Swift Code* (If not using IBAN)

& Swift Code* (If not using IBAN)

IBAN / Account No.*

(Bahrain, Kuwait,Qatar and UAE -

IBAN / Account No.

Provide IBAN for Wire Transfer)

Payment made in the name of

Employee

Employer Group

Assigned Provider

Total Amount Claimed

Currency

EMPLOyER’S SECTION

Employer’s Claim No.

Employer’s Signature & Stamp

CLAIM SUBMISSION REQUIREMENTS

To avoid any delays in the processing of your claim, please ensure that:

All fields on the form should be answered. Do not leave any blanks. Use block letters.

All original claim documents should be submitted either in English or Arabic. Documents in other languages must be translated by an official public translator prior to

submission.

All necessary original claims documents are to be submitted within 30 days of the incurred date. Subject to your policy terms and conditions, MetLife reserves the right to

deny claims that you submit after 90 days of the incurred date.

The following original documents are to be attached:

Out Patient Treatment

In-Patient Treatment

Official receipt showing the attending physician’s detailed charges along with his stamp

Itemized hospital bill supported by the official hospital receipt for the

and signature.

total amount paid.

Itemized pharmacy bill showing the date of purchase, name of patient, quantity and name

Official receipt showing Attending Physician’s or Surgeon’s charges

of drugs along with the physician’s prescription.

along with his stamp and signature.

Official receipt showing charges for each of the Lab Test, X-ray films, and other

Detailed hospital discharge report.

examinations done and supported by the respective physician’s request to undergo

examinations and copies of the results of examinations undertaken.

AUTHORIZATION STATEMENT

I hereby certify that all answers and all original documents submitted with the claim form are complete and true. I hereby authorize any doctor, hospital, or medical provider, any insurance company or any

other company, institution or any other person who has any record or information about me and / or any of my family members to provide MetLife (American Life Insurance Company) with the complete

information's, including copies of their records with reference to my sickness or accident, any treatment, examination, advice, or hospitalization. Any photocopy of this authorization shall be taken as the

original copy.

DISCLAIMER

I hereby authorize MetLife to wire transfer claim reimbursements to the account indicated above. This agreement will remain in effect until I give written notice to withdraw from wire transfer or MetLife notifies

me that this service has been terminated. If ever MetLife credits more money than the correct benefit amount to the account due to duplicate or erroneous electronic funds transfers, I authorize MetLife to revise

the Transaction and withdraw the overpayment.

MetLife will bear charges on account of claims reimbursement levied by the remitting bank. All charges that may be levied by the beneficiary’s bank / other third-party provider will be borne by the beneficiary.

We suggest confirming these charges, if any, with your banking provider”.

I verify that the documentation submitted electronically is true and unaltered and I have all the original documents that can be presented upon request of the Insurance Company. I also accept and recognize that

at the sole discretion of the MetLife, these documents may be requested at any time during a period of one year counted from the submission of the claim, which I will provide within a period not exceeding of

30 days from the request. Failing to comply could imply the claim to be declined. If the case is confirmed to be declined, I will reimburse any amount paid by MetLife to me or to any party as related to this claim.

i hereby understand no coverage and / or payment under the Policy and/or any supplementary contract (if any) will be provided / made if the person entitled to receive such payment is (i) residing in any sanctioned

country, or (ii) is listed on the Office of Foreign Asset Control (OFAC) Specially Designed Nationals (SDN) list or any international or local sanction list, (iii) the payment is claimed for any services received in any

sanctioned country, subject to the Policy and / or Supplementary contract terms and conditions.

I hereby provide MetLife my unambiguous consent to process, share, and transfer my personal data to a recipient outside the country (e.g. to the Company Headquarters in the USA and / or to other branches

or affiliates of the Insurer’s Group and Reinsurer) where the transfer, sharing, is necessary for the performance of the contract or for the compliance with any legal obligation to which the Company is subject

and where necessary transfer, share any such information with the regulators and other law enforcement agencies for the performance of its obligations related to the international sanctions and other

regulations applicable to the Company.

Employee’s Signature

Date

D M M Y

UAE

KUWAIT

OMAN

BAHRAIN

QATAR

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