ACCIDENT CLAIM FORM / HOSPITALISATION CLAIM FORM

Transcription

1 ACCIDENT CLAIM FORM / HOSPITALISATION CLAIM FORM Important te: Please note that, under the policy terms and condition, the policy may be void if any information provided in this claim form are made knowingly by you that it is materially false or misleading. The issue of this form is in no way an admission of liability. claim can be considered unless the medical specialist report section is furnished at the expense of the claimant. Mandatory Required documents for claim submission: 1. Accident & Hospitalisation Claim Form and Medical Specialist Report 2. Clinical Abstract Application Form (3 copies) 3. Please refer to the section on Benefit Type for additional documents SECTION 1 (This section is to be completed by the Life Assured who is at least 18 years old or the Policyowner if the Life Assured is below 18 years old.) LIFE ASSURED S PARTICULARS Full Name NRIC. Address of birth Contact. Occupation POLICY DETAILS Please indicate the policy number for the benefit(s) you would like to claim. BENEFIT TYPE (Please tick the appropriate box for the benefit type you are claiming.) Accidental Dismemberment / Permanent Medical Reimbursement Disablement Newspaper article (if available) Police Report (if available) Letter from your employer (If accident happened at work place) Weekly Income / Temporary Disablement Original final hospital / medical bills & receipts Weekly Hospital / Hospital Cash / Medical Cash A copy of the Medical Certificates (MC) A copy of the final hospital / medical bills DECLARATION I hereby declare that all the information given by me in this form, is to the best of my knowledge and belief, true and complete. I authorise Prudential Assurance Company (Pte) Limited ( Prudential ) to: a) seek medical information from any doctor who, at any time, has attended to the life assured concerning anything that affects his/her physical or mental health; b) seek information from any insurance office to which an insurance proposal has been made; c) seek information from any other sources (including employer, government authorities) in connection with this claim; and d) disclose information including medical information about me to other insurers, reinsurers or other third parties assisting with my claim, for the assessment of my claim. I understand and agree that Prudential should have full access to the information stated above and a photographic copy of this authorisation shall be as valid as the original. Name & Signature of Life Assured if above 18 years old Name & Signature of Policyowner(s) Prudential Assurance Company Singapore (Pte) Limited 30 Cecil Street #30-01 Prudential Tower Singapore Postal Address: Robinson Road P.O. Box 492 Singapore Telephone: Fax: Website: Part of Prudential Corporation plc Reg Z ID CMAHCLM Accident & Hospital v 2013 Page 1 of 10

2 1. Details of Illness 1.1. Describe fully the extent and nature of illness symptoms first started 1.3. first treated 1.4. Is the illness still being treated? (Please circle) If YES, please state nature of ongoing treatment and approximate date of completion If NO, please state date of last treatment or appointment Has the illness been treated previously? (Please circle) If YES, please state date of previous treatment Please state name and address of attending doctor for previous treatment. 2. Details of Accident 2.1. of Accident 2.2. Time of Accident 2.3. Place of Accident 2.4. Describe in detail how the accident happened and the injuries sustained. (Please enclose a copy of the police report, if any) 3. Other Information 3.1. of hospitalisation 3.2. of medical leave From (dd/mm/yy) To (dd/mm/yy) From (dd/mm/yy) To (dd/mm/yy) 3.3. Was surgery performed? If YES, please provide details below. (Please circle) Surgical Operation / Procedure (s) of Operation / Procedure (dd/mm/yy) Name & Address of Doctor(s) / Hospital(s) Page 2 of 10

3 3.4. Are you claiming Medical Expenses from other sources? If YES, please provide details below. (Please circle) Name of Insurance Company, Employer, Third Party etc. Nature of Claim Amount Claimed Policy Number (if applicable) 3.5. Please provide details of doctor(s) or hospital(s) admitted for this disability. Name of Doctor Name & Address of Clinic / Hospital s of Consultation / Admission Reason for Visit 3.6. Please provide details of doctor(s) you consulted for any disorder on or before this hospitalisation. Name of Doctor Name & Address of Clinic / Hospital s of Consultation Reason for Visit Declaration I declare that the above answers given by me in this form are true and complete and that no material information has been withheld or any relevant circumstances omitted. Name & Signature of Life Assured if above 18 years old Name & Signature of Policyowner(s) SECTION 2 MEDICAL SPECIALIST REPORT Accident & Hospitalisation Claim This section is to be completed by the life assured s attending medical specialist. Name of Specialist MCR. Field of Specialty Name of Medical Institution Name of Patient NRIC. Patient s Occupation Details of Illness / Accident 1. Please circle the conditions to which this medical report relates. Illness Accident Page 3 of 10

4 2. Was patient admitted to a hospital? Please circle. If, please provide the details below. a. Name of hospital patient was admitted to b. and time of admission c. and time of discharge d. Please indicate how the patient was admitted. Please circle. Emergency admission Doctor referral i. If admission is via a doctor referral, please provide name & address of the referring doctor. ii. Please state the clinical basis for the referral and to enclose a copy of the referral letter. e. Was surgery performed for this condition? Please circle. If, please provide details below. Surgical Operation / Procedure (s) of Operation / Procedure (dd/mm/yy) f. What is the period of medical leave issued? If further medical leave will be required after this end date, please state the reason. From (dd/mm/yy) From (dd/mm/yy) g. What is the usual period of recovery for an injury of this severity? h. When is the patient expected to recover? 3. of diagnosis of illness / of Accident Signature & Practice Stamp of the Medical Specialist who filled up Section 2 Page 4 of 10

5 4. Cause of illness / Cause of injury 5. Details of diagnosis of the illness / Details of injury including nature and extent of injury 6. Was the patient informed of the diagnosis? Please circle. If yes, please state date patient was informed. 7. Did the patient s injuries result in permanent and total loss of use of the organ or limb? Please circle. If, please provide details in the following sections where appropriate. Description Please tick and elaborate Sight a) Left eyes Power: Please state the power of vision. b) Right eye Power: 7.2. Speech a) Speech 7.3. Hearing Please state power of hearing. a) Hearing in left ear Decibel: b) Hearing in right ear Decibel: 7.4. Limbs a) Upper limb Please circle which limb: Please indicate the anatomical site involved. b) Lower limbs Please circle which limb: Signature & Practice Stamp of the Medical Specialist who filled up Section 2 Page 5 of 10

6 7.5. Arm a) Arm at shoulder Please indicate the anatomical site involved. b) Arm between shoulder and elbow c) Arm at elbow d) Arm between elbow and wrist 7.6. Hand a) Hand at wrist Please indicate the anatomical site involved. b) Thumb Please circle which arm: Please circle which arm: Please circle which arm: Please circle which arm: Please circle which hand: c) Index finger d) Middle finger e) Ring finger f) Little finger 7.7. Foot a) All toes of one foot Please indicate the anatomical site involved and number of phalanx b) Great toe Please circle which foot: c) Other than the great toe, each toe Number of toes: Signature & Practice Stamp of the Medical Specialist who filled up Section 2 Page 6 of 10

7 Description 7.8. Leg a) Leg at hip Please indicate the anatomical site involved. b) Leg between knee and hip c) Leg below knee d) Fractured leg or patella with established non-union e) Shortening of leg by at least 5cm Please tick and elaborate. Please circle which leg: Please circle which leg: Please circle which leg: Please circle which leg: Please circle which leg: 7.9. Other injuries a) Third degree burns covering at least 25% of the body surface b) Permanent and incurable insanity c) Total and permanent loss of tooth Number of tooth: d) Removal of the lower jaw by surgical operation 8. Is the above condition associated with the following: a. Any condition resulting from pregnancy, childbirth or miscarriage or abortion or pre & post natal care b. Any form of dental care of surgery c. Any treatment for obesity, weight management program d. Eye test, refractive errors of eyes, photo refractive keratectomy, cosmetic or plastic surgery and the provision of appliances, including spectacles lenses, hearing aids, artificial organs or joints, wheelchair & prosthesis e. Any elective surgery, cosmetic or plastic surgery not necessitated by injury f. Routine health check-up, custodial or rest care g. Mental illness, personality disorders, and psychiatric disorders h. Infertility, impotence, contraception, sterilization, circumcision i. Human Immunodeficiency Virus Infection, AIDS or any sexually transmitted diseases Signature & Practice Stamp of the Medical Specialist who filled up Section 2 Page 7 of 10

8 j. Food poisoning k. Illness or diseases as a result of bite inflicted by, and/or contact with, animal or insect, which animal or insect is infected by, or is a carrier of, such illnesses or diseases l. Birth defect, including hereditary conditions and congenital anomalies m. Alcohol, drug abuse or the use of unprescribed drugs where such drugs are required by law to be prescribed by a registered doctor n. Self inflicted injury e.g. voluntary causing hurt, suicide or attempted suicide, o. Vaccination 9. If your answer to any of the conditions listed under Question 8 is, please provide details. Past History 10. For the current injury / illness, were there any underlying illnesses or past injury that could have contributed to the current condition? a. If yes, please give details below. Diagnosis of diagnosis (dd/mm/yy) Name & address of doctor(s) consulted b. How has the past or pre-existing illness contributed to the injuries or prolonged the period of disability? 11. Were you the first doctor who attended to this patient about this illness / injury? Please circle. a. you were first consulted for the injury / illness. b. Main complaints at this first consultation. 12. Has the patient previously consulted or been treated for the condition mentioned in Q5? a. If, please state the date of first consultation. Signature & Practice Stamp of the Medical Specialist who filled up Section 2 Page 8 of 10

9 b. Please indicate approximate date from which the patient first noticed symptoms of condition. c. In your view, if the condition existed before symptoms became apparent to the patient, please indicate when this condition began to develop. d. Was patient informed of the diagnosis? Please circle. e. patient was informed of the diagnosis. f. Please state name and practice address of the doctor whom the patient has consulted or received treatment for this condition. Name and Signature of the Medical Specialist who filled up Section 2 Practice Stamp of the Medical Specialist Page 9 of 10

10 SECTION 3 Attachment of Laboratory Reports To enable us to proceed with the claim, it is mandatory to enclose all relevant clinical, radiological, histological, operation and laboratory reports by attaching them to this page. Prudential Assurance Company Singapore (Pte) Limited 30 Cecil Street #30-01 Prudential Tower Singapore Postal Address: Robinson Road P.O. Box 492 Singapore Telephone: Fax: Website: Part of Prudential Corporation plc Reg Z Page 10 of 10