CLAIMS PROCEDURE Anker Crew Insurance

Transcription

1 CLAIMS PROCEDURE Anker Crew Insurance cm-aci-cpt apr-2014 page 1 of 10

2 CLAIMS CONTACT DIRECTORY Office Paterswoldseweg 812 NL BM Groningen P.O. Box 8002 NL KA Groningen T F E [email protected] Contact persons Account Director Mrs. Swanhilde Henze-Bennink T M E [email protected] Account Director (internal) Mr. Willem Kenter T E [email protected] Claims Handling Mr. Erik de Vries Mrs. Martha Akkerman Mrs. Elien Zoer T M E [email protected] T E [email protected] T E [email protected] Anker Alarm Service In case of emergency 24-hours service T F E [email protected] Equian 5975 Castle Creek Parkway, Suite 100 Indianapolis, IN T: F: E: [email protected] cm-aci-cpt apr-2014 page 2 of 10

3 CLAIMS PROCEDURE 1. General Claims Procedure of Anker Crew Insurance 1.1 New claims have to be reported to Anker as soon as possible: a) Hospitalization of an insured crewmember has to be reported at least within 2 working days (preferable the same day, if possible). b) In case of hospitalization or need of medical treatment in The United States of America the procedure of Equian has to be followed (part 2 of this claims procedure). c) In case of repatriation on medical grounds Anker Crew Insurance has to be informed in order to give her approval prior to the repatriation taking place. The notification has to include: the date of the accident/the first date of disablement; name, date of birth, rank and vessel of the insured person; a (brief) description of the nature of the injury/disablement, nature of sickness or cause of accident; name and address of medical doctor/medical facility that has been consulted. For notification Anker Crew Insurance has 2 (two) forms available: A. Report of Illness / Request for medical attendance B. Accident / Incident report Ad A: If a crewmember wants to consult a medical doctor for minor complaints/injuries, the Report of Illness form is sufficient. Everyone visiting a medical doctor must make sure that this form is signed by the medical practitioner. Ad B: If it concerns a serious matter (accident or illness), the Report of Illness form also has to be completed by the medical practitioner or hospital concerned. In case of accident, the master is requested to draw up an Accident / Incident report. d) In case an insured person passed away, this has to be notified at once. In this case the following details have to be provided: full details of the deceased insured person, including passport/seaman's book number; captains report(s) and/or police report(s); death certificate (copy). In case of an emergency outside normal working hours, Anker Alarm Service can be contacted: Phone : Fax : [email protected] In case files are reported by , we advise you to also confirm this to Anker Alarm Service by phone to avoid unnecessary delays. Please state the telephone number where you can be contacted. Before treatments begins We advise you to always try and obtain an estimate of professional and hospital fees. cm-aci-cpt apr-2014 page 3 of 10

4 After treatment In order to handle your declaration of expenses properly, original invoices have to be enclosed, as photocopies are not allowed. Forms related to the treatment have to be filled in correctly and have to be sent with the original invoices to Anker Crew Insurance, all in accordance with the terms of cover. Anker Crew Insurance will handle your claim and look after reimbursement of the medical expenses At the discretion of Anker Crew Insurance a medical advisor may be appointed either to check the situation/status with the involved insured person and/or to contact the attending doctor(s) As a result of the procedure under Sub. 1.2 the medical advisor will report the status/progress on a regular basis to Anker Crew Insurance. If necessary, the insured person involved will be examined by a medical doctor who is appointed by the medical advisor Recovery of the insured person involved has to be reported to Anker Crew Insurance and/or the medical advisor within five days At all times, the insured person involved is obliged to provide all necessary information about his status and/or treatment on request of the medical advisor of Anker Crew Insurance. Note: The above mentioned claim procedure forms an integral part of the terms of cover of the taken out insurances. In case the policy holder or an insured person fails to act upon the above mentioned instructions, Anker Crew Insurance has the right to reject the claim in question. All reports / invoices have to be written in the English language or have to be properly translated in the English language. All declarations have to be submitted to Anker Crew Insurance in such a way that the declarations are clearly itemized so that it is obvious which reimbursements the Insurance Company must make. 2. Medical assistance in The United States of America Claims Procedure Equian All persons covered under the Anker Crew Insurance will receive medical care through Equian affiliated providers. 2.1 Procedure A. Actions on board 1. The master/ shipping agent will contact Equian in order to obtain the address of a preferred medical facility. 2. The master/ shipping agent will determine which medical facility is to be used for illness/injury treatment and complete the form Authorization for medical attention/examination. 3. Once in port, the master will make sure that the shipping agent is instructed to bring the insured person to the designated facility and reminds the agent not to pay the medical bill. B. Medical facility 1. The medical provider will examine the insured person and determine the course of treatment. 2. If hospitalization or special procedures/consults are required, the medical provider will contact Equian for authorization. 3. Equian will call Anker Alarm Service for coordination, final authorization for difficult medical cases and repatriation. The medical facility will send the bill(s) and accompanying medical records to Equian for payment, as indicated on the Authorization Form. cm-aci-cpt apr-2014 page 4 of 10

5 AUTHORIZATION FOR MEDICAL ATTENTION/EXAMINATION Anker Alarm Service T: F: E: Vessel: Master: Date: Shipowner: Agent: Port: Crew Member - Full Name: Date of Birth: Address: Rank: Nationality: Passport: ID No.: To: Address: Physician/Facility City/State Country This crew member requests medical attention for the reasons indicated. Kindly furnish the necessary medical care, determine and state below whether he is fit/unfit for duty and indicate a specific medical diagnosis and additional medical treatment, if required. Medical Complaint: Signature of Master Signature of Crew Member Medical report: (To be completed by examining physician) Date/Time Examined: Recommendation: Fit Unfit For Sea Duty Diagnosis: Treatment: Treatment Recommended: Prognosis: If Unfit: Rest Aboard Vessel Y N May Travel Y N Hospitalization Required Y N By Air Y N Clinic Name Address City/State Country Telephone No. Facsimile No. Signature of Physician If referral to a US based specialist or hospitalization is required, please call or fax Equian for approval and coordination. Unauthorized treatment will not be reimbursed. Please submit bills to Equian for payment: Equian 5975 Castle Creek Parkway, Suite 100 Indianapolis, IN T: F: E: [email protected] rf-aci-ame apr-2014 page 5 of 10

6 Medical consent Subject : Date : Name of patient : Date of birth : Address : Town, zip code : Country : Nationality : I,..., hereby authorize any hospital, physician or other person who has medically examined me, to furnish Anker Alarm Service any and all information with respect to any illness or injury, medical history, consultation, prescriptions or treatment that were rendered to me. A Photostat/Faxed copy of this authorization shall be considered as effective and valid as the original. I understand that this authorization will allow Anker Alarm Service to use the information obtained to investigate and adjudicate my claims. (patient signature) (witness signature) (date signed by the above & location) rf-aci-ame apr-2014 page 6 of 10

7 REPORT OF ILLNESS / REQUEST FOR MEDICAL ATTENDANCE Medical attendance is required for: (one form per crewmember) To be filled in by the master Motor Vessel Date Port Agent To be filled in by the doctor Full name: Date of birth: Master's name and signature: Nationality: Rank: Onset of illness: / / day month year Symptoms observed: Treatment on board incl. dosages (if known also mention medicines usually taken by patient): Diagnosis and treatment: Laboratory findings/ X-ray results: Medicines: How often: Admitted into hospital or repatriation? If admitted into hospital please state name / address / phone number etc. of the hospital. Unfit for duty: no / yes, for days Physician's name: NOTE TO THE DOCTOR: Address: The doctor is asked to keep one copy Place: Date: and render the original to the master. Signature: rf-aci-roi apr-2014 page 7 of 10

8 Medical consent Subject : Date : Name of patient : Date of birth : Address : Town, zip code : Country : Nationality : I,..., hereby authorize any hospital, physician or other person who has medically examined me, to furnish Anker Alarm Service any and all information with respect to any illness or injury, medical history, consultation, prescriptions or treatment that were rendered to me. A Photostat/Faxed copy of this authorization shall be considered as effective and valid as the original. I understand that this authorization will allow Anker Alarm Service to use the information obtained to investigate and adjudicate my claims. (patient signature) (witness signature) (date signed by the above & location) rf-aci-roi apr-2014 page 8 of 10

9 ACCIDENT / INCIDENT REPORT Motor Vessel Date Port Agent Abstract of ship s logbook: Injured person Full name: Date of birth: Male / female Full address: First name(s): Citizenship: Accident Date: / / Local time: day month year Port / sea: Exact location: Activity of injured person at time of accident: Ordered by: Description of accident: Accident reported at hours on / / to day month year name and rank Area of accident and/or equipment inspected by: Remarks: Injury: Name and grade of witnesses belonging to the crew: Name and address of witnesses not belonging to the crew: P&I representative informed name of representative of surveyor conducting investigation: Has the responsible party been held liable? If so, please attach copy. If not, please state name and address of responsible party: Name and signature of Master: rf-aci-air apr-2014 page 9 of 10

10 Medical consent Subject : Date : Name of patient : Date of birth : Address : Town, zip code : Country : Nationality : I,..., hereby authorize any hospital, physician or other person who has medically examined me, to furnish Anker Alarm Service any and all information with respect to any illness or injury, medical history, consultation, prescriptions or treatment that were rendered to me. A Photostat/Faxed copy of this authorization shall be considered as effective and valid as the original. I understand that this authorization will allow Anker Alarm Service to use the information obtained to investigate and adjudicate my claims. (patient signature) (witness signature) (date signed by the above & location) rf-aci-air apr-2014 page 10 of 10