Claim Form Medicare International
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1
2Please complete and return to:
MediCare International Limited
Minster House, 42 Mincing Lane
London EC3R 7AE, United Kingdom
Telephone:
+44 (0) 20 3418 0496
Facsimile:
+44 (0) 20 7118 1178
Email:
info@medicare.co.uk
Claim Form
Website:
PLEASE COMPLETE IN BLOCK CAPITALS AND TICK RELEVANT BOXES
FAILURE TO COMPLETE THE FORM FULLY WILL DELAY SETTLEMENT OF YOUR CLAIM
PLEASE ENSURE YOU HAVE READ THE CLAIMS PROCEDURES PRIOR TO MAKING A CLAIM
How to make a claim
Written notification of claims must be provided within 90 days
4. ALL routine dental treatment must be supported with
of the initial consultation, even where original invoices are not yet
confirmation of an annual check up.
available. To help us deal with your claim promptly, please:
5. When calculating claims, the exchange rate at time
1. Complete a separate claim form for each illness/accident/dental
of adjudication is used.
treatment/maternity or wellness benefit claim and each
6. Original accounts for treatment received must be submitted.
Insured Person
7. Important: all inpatient claims and any other claim likely
2. Ensure that the doctor or dentist who treats you fully completes
to exceed £2,500 /$4,250/l3,250 from the outset must be
the sections overleaf
pre-authorised by CEGA. Failure to do so will result in the
3. ALL questions must be answered in full (ticks or dashes will
insured person being responsible for £1,000 /$1,700/l1,300
not be acceptable)
of treatment costs.
Section A – Patient Information
TO BE COMPLETED BY THE INSURED PERSON OR HIS/HER LEGAL REPRESENTATIVE
1. Full name:
5. Full mailing address of claimant:
Title:
Mr
Mrs
Miss
Ms
Other
Surname:
Postcode:
Forenames:
Country of residence:
2. Date of birth:
Telephone:
3. Certificate number:
Facsimile:
4. Sex:
Male
Female
Email:
Section B – Claim Information
TO BE COMPLETED BY THE INSURED PERSON OR HIS/HER LEGAL REPRESENTATIVE
6. State the nature of illness and the date upon which symptoms
8. How long have you had these symptoms before consulting
first occurred:
your doctor?
7. Have you ever received treatment (including prescription drugs)
9. If the cause of the illness relates to an accident, state the date
for this condition or any related condition before this episode.
of the accident and give brief details of the circumstances and
Please provide dates and details of previous treatment.
injuries received:
10. Do you have any other insurance that provides cover for
healthcare benefits?
11.
Date of
List Expenses for Which
State Currency
State in Full, to Whom you
Currency of
Treatment
Reimbursement Claimed
and Amount Paid
Wish Settlement Paid
Settlement
(Original accounts will be required)
Section B Cont’d over...
Please note that MediCare has authority from your insurers to handle claims on their behalf subject to certain limitations. If you do not wish us to act on this
claim as agent of both yourself and insurers, you should advise us by return and we will arrange for handling of your claim to be managed by insurers themselves.
DATA PROTECTION: The information you have provided will become part of the personal data held by MediCare International Limited and will be used for the
provision and administration of insurance products and services. MediCare International Limited may disclose your personal data to insurance companies and to
their agents for underwriting, claims handling and fraud prevention purposes. In addition, it may seek information from insurance companies to check the answers
you have provided. Full details of MediCare International Limited’s processing of personal data appear in the register maintained by the Information Commissioner.
SEPTEMBER 2013
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