American International Assurance Co

American International Assurance Co, Ltd Group & Credit Insurance Department : 1 Robinson Road, AIA Tower #11-00, Singapore 048542 Tel : 6530 9261, 65309708, 65309705 Fax : 6538 4340, 6538 5603 A “EXPRESS CLAIM PROCESSING” FORM ECP claim procedures : 1. Before admission, complete ECP form 2. On admission, present the ECP form, pay a deposit & sign the Medisave Authorisation form 3. Before the patient’s discharge, AIA approves or declines the claim based on the contractual terms & conditions 4. Upon discharge, the hospital collects the uninsured amount = Hospital bill - Amount paid by AIA - Medisave – Deposit 5. Upon confirmation of the CPF deduction, the hospital finalises the bill and refunds the deposit to the patient Part I (to be completed by the Employer) Name of Employer ........................................................................................ Policy No. ...................................... Name of Employee ........................................................................................ Designation ...................................... Date of birth (mm/dd/yy) ...................................... Marital Status: S / M NRIC/PP No. ...................................... Date of employment .............................……………….. Sex: M / F Room & Board ...................................... mm / dd / yy ............................. ...............................…….......... ................................. .................... Company’s stamp Employer’s name/Telephone No. Employer’s signature Date Part II (to be completed by the Patient) Name of Patient ............................................………………..……. Sex: M / F NRIC/PP No. …………..………......... Relationship to employee ............................ Date of birth (mm/dd/yy) ........................ Occupation ...........……..…............... If hospitalisation is due to accident, date of accident ................................……., place of accident .........…..................... Briefly describe what happened and state the extent of the injury ………………………………………………………………………………………………………………………………… Are you making a claim from other insurance companies? Yes / No If yes, name of the insurance company…………………………………, policy number .......................................…….. (Please submit a copy of the other insurance company’s claim settlement letter/payment voucher) Authorisation (to be signed by the Patient/Guardian) I, hereby irrevocably authorise any hospital, doctor or other person who has attended to me or any member of my family to furnish American International Assurance Company, Limited or its representatives any and all information with respect to any sickness or injury, medical history, consultation, prescriptions or treatment and copies of all hospital or medical records. I agree that a photocopy of this authorisation shall be considered as effective and valid as the original. ........................................ ........................ Signature of Patient/Guardian Date Employee’s Undertaking I understand that when my dependent/s or I utilise this Express Claim Processing form, I will be liable for settling any outstanding amount not payable under the above Medical Insurance Policy. .................................... ...................... Signature of Employee Date Part III (to be completed by the Hospital upon admission) Hospital………………………Date of admission …………............... Estimated length of stay .......................................... Admitting Diagnosis ..................................................……………………………………..…ICD Code:…………………... Name of Hospital Staff..........................……............Tel No:..............……......... Fax No/email……………….……..…….. Part IV ( To be completed by the Hospital and sent together with the final bill ) 1. Admission date : ...................................................................................... (mm/dd/yy ) 2. Diagnosis of illness : ...................................................................................... ICD Code --- --- --- --- --- --- ( If available ) ...................................................................................... 3. Type of surgical procedures : ......................................................................... Operation Code --- --- --- --- --- --- ( If available ) ......................................................................... 4. Name and Address of Attending Physician : .......................................................................................................... ( For private hospitals only ) .......................................................................................................... .......................................................................................................... Participating hospitals: Singapore General Hospital Gleneagles Hospital East Shore Hospital Changi General Hospital Mt Alvernia Hospital Mt Elizabeth Hospital National University Hospital Thomson Medical Hospital Raffles Hospital Points to note : 1. Service hours : 9.00am - 5:30p.m ( Mon - Fri ) 2. Claims that fall within the policy exclusions will be rejected 3. In the event of insufficient information, ECP will not be applicable Insured member has to settle the hospital bill first and submit the original bill and the GH&S claim form to AIA. 4. In the event of outstanding premium, ECP will not be applicable 5. In the event that resignation of staff is not reported to AIA, the Employer will be liable for the hospital expenses. 6. ECP is not applicable for Day Surgery 7. The Employer is liable for any hospital expenses that AIA is not contractually liable for Exclusions: 1. Conditions that existed prior to the effective date of insurance coverage 2. Self-destruction or intentional self-inflicted injury 3. Conditions related to mental or psychiatric cases 4. Conditions related to drug addiction or alcoholism 5. Injuries arising directly or indirectly from war 6. Special nursing care, general physical or medical check-up 7. Any dental treatment except required procedure in the event of an accident 8. Congenital anomalies 9. Treatment related to birth control, infertility; pregnancy, childbirth except ectopic pregnancy and non-elective miscarriage due to medical reason 10. Cosmetic treatment, surgery for correction of eyesight, including myopia 11. Procurement or use of special brace or garment, appliances, implants or equipment 12. Hospitalisation for the sole purpose of undergoing diagnostic test, x-ray examination or investigation, (including sleep study) 13. Conditions in relation to AIDS or any HIV.

Load more