ဥវᗁᒚ৶ᐺܑॾ
Group Medical Claim Form
‫ܝ‬෧৶ᐺ!OUTPATIENT CLAIM
Ϥ‫ܲצ‬ˠ๱ᆷ!To be completed by Insured Member
Ͱࡊ৶ᐺ!DENTAL CLAIM
!)υื๱ᆷ!Must be provided*
ဌ͹ЩჍ
Employer Name:
ဥវܲಏበཱི
Group Policy No.:
ဌࣶࡻ͛‫ؖ‬Щ
Employee English Name (In Full):
ܲᐍ෠በཱི
Certificate No.:
ঽˠࡻ͛‫ؖ‬Щ
Patient English Name (In Full)
छᛳበཱིĞтዋϡğ
Dependent No. (If applicable) :
ů
ů
ϒώќፂ૟̙ᒔ൴ᔘĄтᅮ‫פ‬аќፂ۞८၁ઘώĂኛ‫̰ॾ͞ٺ‬ΐ˯!#✓#!Ą
Original receipt will not be returned. Please "✓" this box for return of certified true copy of receipt.
A.
‫ܝ‬෧৶ᐺ!OUTPATIENT CLAIM
෧াƟ‫ڼ‬ᒚ͟ഇ Date(s) of
෱ϡ
෧াᙷҾĞυื̏Е‫ܲٺ‬ಏ۞ܲᅪቑಛ̰ğ
Consultation /Treatment
Amount Charged Type of Treatment (Should be covered under the policy)
(͟Ɵ͡Ɵѐ) (DD / MM / YY)
* ኛ઻΍ЪዋᙷҾ Please circle the appropriate type
ঽˠҋҖᓏ‫ځ‬ঽা Self Declaration of Diagnosis
Ϊዋϡ‫ٺ‬ᗁგԊᔑ˭۞ᗁੰ‫ܝ‬෧ొٕ߆‫ܝع‬෧ (ռछ̈́̚ᗁাੵγ)
For Claims Incurred at Outpatient Dept. under Hospital Authority /
Government Clinics Only (Except for private and chinese medicine case)
1.
* GP / SP / CMP / Others:
ঽা Diagnosis
2.
* GP / SP / CMP / Others:
ঽা Diagnosis
3.
* GP / SP / CMP / Others:
ঽা Diagnosis
4.
* GP / SP / CMP / Others:
ঽা Diagnosis
* GP = ೼఼ࡊ General Practitioner SP = ૞ࡊ Specialist
CMP = ̚ᗁ Chinese Medical Practitioner
‫ ΁׎‬Others = ‫ۏ‬ந‫ڼ‬ᒚ PhysiotherapistƟਖᗁ ChiropractorƟXЍ X-rayƟ̼រ Lab testsƟּҖᑭߤ Routine CheckupƟҝੰ݈̝෧া Pre-hospitalisation consultationƟ
ҝੰ‫̝ޢ‬෧া Post-hospitalisation consultationƟඈ etc
B. Ͱࡊ৶ᐺ!DENTAL CLAIM
!
ᅍϹͰࡊ৶ᐺ݈Ăኛቁܲᅦ˭̝ܲಏѣ೩ֻͰࡊܲᅪĄ!Please ensure you are covered under the dental benefit before submitting dental claims.
ืቁܲ‫ڼ‬ᒚีϫ,෱ϡ̈́͟ഇ୻຾Е‫ٺځ‬ќፂ˯Ą
Please ensure particulars and amount charged with date clearly marked on the receipt.
ኛ‫ٺ‬Πဦො‫ځ‬ঽˠତ‫ڼצ‬ᒚ۞Ͱጎ
ٕ˾ටҜཉĄ
Please mark teeth treated or area of
oral treatment on the right chart.
ࣼ LABIAL
Π RIGHT
Ҏ LINGUAL
ࣼ LABIAL
ν LEFT
ᘪཌ͟ഇ
Date Signed
ᓏ‫̈́ځ‬଱ᝋ३!DECLARATION AND AUTHORIZATION
I hereby DECLARED, UNDERSTOOD and AGREED that:
1. All information provided by me in this form is complete and true to the best of my knowledge and belief.
2. I authorize any physician, medical practitioner, hospital, clinic or other medically related facility, insurance
company or other organization, institution or person that has any records or knowledge of me or my
dependent to provide to Manulife any such information. Such authorization shall survive me and shall be
irrevocable. A photocopy of this authorization shall be as valid as the original.
3. Information collected from me and in respect of me and/or my dependent can enable Manulife to carry on its
insurance/financial business and may be:
i) used by Manulife or its associated companies for the purpose of (a) approving and administering the policy
or any alterations, cancellation or renewal of it; (b) underwriting and any claims or analysis of it; (c) statistical
or actuarial research of Manulife, Manulife's associated companies or the insurance/financial industry; and/or
ii) transferred to (a) any related company or other company carrying on insurance or reinsurance related
business or an intermediary or a claims or investigation or other service provider providing services relevant
to insurance business or any regulatory bodies, association or federation of insurance companies that exists
or is formed from time to time; (b) any person/organization to fulfill any of the above purposes and/or for the
purpose of data verification by way of matching procedures or otherwise; and/or reinsurance of the policy.
All data processes may involve a transfer of information to places either within or outside the Hong Kong
Special Administrative Region/Macau Special Administrative Region.
4. I agree Manulife to transfer back all supplied information from me to the policyholder (i.e. the Employer)/ the
insured employee (where applicable). I have obtained the necessary authorization from my dependent to (a)
supply their information to Manulife; and (b) transfer back all supplied information from them to the
policyholder (i.e. the Employer) and me if my dependent (if applicable) is to be covered. I also understand that
the information requested in this form is required in order for Manulife to process this claims.
5. By writing to the Privacy Officer of Manulife - Employee Benefits, I can request access to and correction of
my personal data (if appropriate).
6. All information may be treated by Manulife in the same manner as mentioned in the "Notice to Customers
relating to the Personal Data (Privacy) Ordinance" ("Notice") (for Hong Kong policy) / Manulife Personal
Information Collection Statement (“Statement”) (for Macau policy) (where applicable). In case I have not read
the Notice / Statement (where applicable) before, I can obtain such Notice / Statement (where applicable) from
my Manulife's intermediary or through Manulife’s website at www.manulife.com.hk.
7. Manulife has the right to reverse / claim back any incorrect payment caused by incorrect information provided
by me.
8. I have read and understood the information and content provided in this entire "Group Medical Claim Form",
including the Claims Instructions and General Exclusions provided overleaf.
GC01
ώˠ‫ځ‬ϨĂТຍ֭ᖰѩᓏ‫ځ‬Ĉ
2/! ώˠ‫ٺ‬ώܑॾٙ೩ֻ۞˘̷ྤफ़ࠎώˠٙۢ۞Бొ̈́ࠎৌቁ൑ᄱĄ
3/! ώˠ଱ᝋЇңᗁϠăᗁጯࠧેຽˠ̀ăᗁੰă෧ٕٙ‫΁׎‬ᄃᗁᒚѣᙯ۞፟
ၹăܲᐍ̳Φٕ‫΁׎‬௡ᖐă፟ᙯٕˠ̀Ă૟‫׎‬ٙѣᙯ‫ٺ‬ώˠ̈́‫ܲצ‬छᛳ۞
੃ᐂٕઉ૵‫ྤڶې‬फ़Ă೩ֻ̟ԈӀĄѩ଱ᝋ३ߏ̙Ξၣዚ۞ĂӈֹώˠΝ
͵Ăѩ଱ᝋ̪൒Ϡड़Ąѩ଱ᝋ३۞ᇆОώ૟ᄃϒώТᇹѣड़Ą
4/! ଂώˠќะ̈́ᙯ‫ٺ‬ώˠ̈́0ٕ‫ܲצ‬छᛳ۞ྤफ़ĂўдቁܲԈӀ۞ܲᐍٕ‫ܛ‬Ꮙ
ຽચ଀ͽึӀྻүĂ҃ྍඈྤफ़Ξֻ
! j*! ԈӀٕ‫׎‬ᓑᒉ̳Φүͽ˭ϡ౉Ĉ)b*Բ८̈́გநώܲಏĂٕ‫ޢ׎‬ซҖЇ
ң࣒ࢎă‫פ‬ঐܲಏٕᜈְܲ‫آ‬ć)c*८ܲă̶‫̈́ژ‬఍நኪᐺϦኛć)d*ֻ
ԈӀăᓑᒉ̳Φٕܲᐍ0‫ܛ‬Ꮙຽү௚ࢍٕჟზࡁտϡ౉ć̈́0ٕ
! jj*! ᖼϹ̟)b*Їңѣᙯా̳Φć‫΁׎‬ଂְᄃܲᐍٕГܲᐍѣᙯຽચ̝̳Φć
ٕ̬̚ˠă೩ֻநኪăአߤٕ‫ܲ΁׎‬ᐍຽ࠹ᙯ‫ڇ‬ચֻ̝ᑕથٕனॡ̏х
дٕ͟‫ޢ‬௡ј̝Ⴞგ፟ၹăܲᐍ̳Φᓑົٕ௡ᖐć)c*Їңˠ̀0፟ၹͽ
ү˯ࢗϡ౉̈́0ٕͽ੨၆ٕ‫ڱ͞΁׎‬८၁ྤफ़ćᄃ̈́щଵГܲᐍĄ
! ٙѣྤफ़఍ந࿅඀ٕົঘ̈́ྤफ़ொᖼҌࢶപপҾҖ߆ડ0፫‫ܝ‬পҾҖ߆ડ̈́
ͽγгડĄ
5/! ώˠТຍԈӀ૟ѣᙯϤώˠ೩ֻ۞ٙѣྤफ़็аගܲಏ޺ѣˠĞӈဌ͹ğ0
‫ܲצ‬ဌࣶĞтዋϡğĄώˠ̏Шٙѣ‫ܲצ‬छᛳ‫଀פ‬଱ᝋĞтዋϡğĂΞ)b*Ш
ԈӀ೩ֻ‫ྤ׎‬फ़ć̈́)c*૟ٙѣ‫׎‬೩ֻ۞ྤफ़็аගܲಏ޺ѣˠĞӈဌ͹ğ‫׶‬
ώˠĄώˠϺ‫ځ‬Ϩώܑॾ̰೩ֻ۞ྤफ़ߏឰԈӀү఍நώˠ৶ᐺ̝ϡĄ
6/! ώˠѣᝋͽ३ࢬ఼ۢԈӀဌࣶ჊Ӏొ̝࣎ˠྤफ़͹ЇĂࢋՐ৶ዦ̈́ՀԼ࣎
ˠྤफ़ĞтᅮࢋğĄ
7/! ԈӀΞ޷‫ٺ‬ĮѣᙯIJ࣎ˠྤफ़Ğռᔳğ୧ּij۞‫఼ۢ͗މ‬įĞĶ఼ۢķğĞዋϡ‫ٺ‬
ࢶപܲಏğ0ĮԈӀ࣎ˠྤफ़ќะᓏ‫ځ‬ĞĶᓏ‫ځ‬ķğĞዋϡ‫ٺ‬፫‫ܲܝ‬ಏğĞтዋϡğ
ٙࢗĂ఍நѣᙯྤफ़Ą઄тώˠϏѣ௟ዦྍ఼ۢ0ᓏ‫ځ‬ĞтዋϡğĂώˠΞଂώˠ۞
ԈӀ̬̚ˠٕ౅࿅ԈӀშӬxxx/nbovmjgf/dpn/il‫఼ۢྍ଀פ‬0ᓏ‫ځ‬ĞтዋϡğĄ
8/! ώˠ‫ځ‬Ϩ֭ТຍԈӀѣᝋࢋՐ‫ܲצ‬ˠĂЯྤफ़̙ቁ҃ੜа̏ኪᐺ̝‫ܛ‬ᗝĄ
9/! ώˠ̏གྷ௟᝝̈́‫ځ‬ϨѩĶဥវᗁᒚ৶ᐺܑॾķ̝ٙѣྤफ़̰̈́टćΒ߁ࡦ
ࢱٙ೩ֻ̝৶ᐺ޽͔̈́˘ਠ̙‫ีܲצ‬ϫĄ
ঽ۰/‫ܲצ‬ဌࣶᘪཌĞтঽ۰̙֖18໐Ă‫ܲצื݋‬ဌࣶᘪཌğ
Patient's/Insured Employee's Signature (For patient whose age is below 18, insured employee's signature is required)
Manulife (International) Limited (Incorporated in Bermuda with limited liability)
ԈӀˠုܲᐍĞ઼ᅫğѣࢨ̳ΦĞ‫ٺ‬Ѻᇍ྿ොΊјϲ̝ѣࢨయЇ̳Φğ
͟ഇĞ͟Ɵ͡Ɵѐğ
Date (DD / MM / YY)
ISO
9001
EB LH-CLAIM (01/2017) 1 of 2
C.
Ͱᗁᘪཌ̈́෧ٙОౢ
Signature of Dentist and Clinic Chop
Certified to Manulife
Employee Benefits
৶ᐺ޽͔Ĉ
Claims Instructions:
ኛ๱ԁ̈́ᘪཌѩܑॾĂ֭Ϲаෳ̳Φˠְొٕѣᙯ࢑య
ˠĄ
1
3
‫˯ܢ‬ϒώᗁᒚќፂ֭୻೽Е‫ྤ˭ͽځ‬फ़Ĉ
•! ঽ۰‫ؖ‬ЩĞኛ޷໰ࢶപ֗ЊᙋٕᄮΞ֗Њᙋ‫!ځ‬
! ͛І̝‫ؖ‬Щ๱ᆷğ
•! ঽাЩჍ
•! ෧াƟ‫ڼ‬ᒚ͟ഇ
•! ќ෱̶ᙷĞт෧‫ܛ‬ăᘽ෱ă̼រ෱ඈğ
•! ᗁϠОᝥᄃᘪཌ
2
4
тѣᙯϦ৶ঘ̼̈́រٕYЍᑭߤĞኛ‫̼˯ܢ‬រྤफ़ͽүણ
҂ğă‫ۏ‬ந‫ڼ‬ᒚă૞ࡊ‫ڼ‬ᒚٕᗁϠ఍͞ҘᘽĂኛ‫˯ܢ‬ᗁ
Ϡᖼ̬३Ą̼រٕYЍᑭߤᖼ̬३ѣड़ഇࠎ൴‫ܫ‬ഇ̰̱࣎
͡Ă֭Ϊਕֹϡ˘ѨĄ‫ี΁׎‬ϫ̝ᖼ̬३‫ٺ‬൴‫ܫ‬ഇ̰̱
࣎͡ѣड़Ą
3
5
৶ᐺܑ̈́ќፂυื‫ٺ‬෧া͟‫̰࣎͡ˬޢ‬૙аဥវܲᐍந
ኪొĄ࿈ഇ೩΍Ϧኛٕٙᅮྤफ़̙БĂ৶ᐺϦኛ૟̙‫צ‬
நĄ
4
6
тᅮ৶ᐺĂٙѣᗁᒚ‫ڇ‬ચυืϤ޺ѣࢶപેຽٕ༊гᄮ
Ξྤॾ̈́ેຽൕ໰̝ˠࣶтᗁϠăͰᗁă૞ࡊᗁϠă̚
ᗁरăਖᗁ̈́‫ۏ‬ந‫ڼ‬ᒚरඈ೩ֻĄ
5
7
ϒώќፂ૟̙ᒔ൴ᔘĄ҃൴ᔘќፂ८၁ઘώ۞Ϧኛυื
‫ٺ‬ᅍϹѩܑॾ۞ˬ˩̰͟ϹᄃԈӀĂӎ‫ྍ݋‬ќፂ૟ົ̟
ͽዚ໑Ą
8
ЇңЯ৶‫פ‬ᗁᒚಡӘ҃ᅮᘳ;۞෱ϡӮ̙Β߁дܲಏ۞
ኪᐺቑಛ̰Ą
9
৶ᐺͰࡊܲᅪĂืϤᑕ෧Ͱᗁ๱ᆷBొЊĄ
:
тଋ۞ဥវܲಏ̏ଳϡ࿪̄೩ϯ‫ڇ‬ચ̈́‫ܲצ‬ဌࣶϺ̏‫ٺ‬ԈӀ
൳੃࿪ฎгӬĂԧࣇдԆј৶ᐺϦኛ‫ົޢ‬൴΍࿪̄೩ϯҌѩ
޽‫۞ؠ‬࿪ฎгӬĂ‫ܲצ‬ဌࣶΪᅮ൳ˢwww.manulife.com.hk!
e-GLHშ˯‫ڇ‬ચߤྙ৶ᐺྎଐ̈́ዦᜓ৶ᐺኪഠ఼ۢĄࡶ
‫ܲצ‬ဌࣶ֭՟ѣ೩ֻ࿪ฎгӬĂ৶ᐺኪഠ఼ۢ૟ͽฎ૙
͞ё̟ܲಏ޺ѣˠĞӈဌ͹ğࠁ൴Ą
6
7
8
9
Send this completed and signed form to your Human Resource Department or
plan administrator.
Attach all original medical receipts (not bill or invoice) with clear information
provided as follows:
• Full name of the patient (must be identical with HKID card or other recognized
personal identification)
• Diagnosis of condition
• Date of consultation / Treatment Date
• Breakdown of charges (consultation fee, medication, laboratory fee etc.)
• The attending Doctor's signature and chop.
Attach Doctor's referral letter for the diagnostic laboratory test or X-ray (attach
details of laboratory tests taken for reference), physiotherapy treatment,
Specialist consultation or Prescribed Medication from outside Clinic. The referral
letter for laboratory tests or x-ray is valid once within 6 months from the date of
issuance. Referral letter for other services is valid for 6 months from the date of
issuance.
Claim(s) must be submitted to Group Claims Department within 3 months from
the date of consultation / treatment. No reimbursement will be made for claims
submitted late or with insufficient information.
All medical services must be rendered by a person who has professional
qualifications pursuant to the relevant Registration Ordinance of Hong Kong or
equivalent, and being authorized and registered in the geographical area of his
practice and as a qualified medical practitioner, dentist, Specialist, Chinese
medicine practitioner, chiropractor, physiotherapist etc.
Original receipt will not be returned. Written request of certified true copy of
receipt should be submitted within 30 days after submission of this claim to
Manulife. Otherwise, the medical receipts will be disposed.
Medical report fee will not be covered under the medical policy.
For dental claim, please have your attending dentist to complete Part B.
If your Group Policy has already subscribed the e-Alert service and the insured
employee has registered his/her email address with Manulife, an e-Alert will be
sent to this designated email address upon claim processed. Insured employee
can check the claim result and view the Payment Advice via our e-GLH Online
Service at www.manulife.com.hk. If no insured employee’s email address is
provided, Claim Payment Advice will be delivered by mail and sent to the
policyholder (i.e. the Employer) for distribution.
˘ਠ̙‫ีܲצ‬ϫĈ
General Exclusions:
ώ̳Φ૟̙ົ၆˭ЕЧีฟ͚ү΍ЇңኪᐺĂ‫ܲٺ‬ᅪܑ̰পҾ
ො‫ੵ݋ځ‬γĈ
The Company shall not reimburse expenses incurred as a result of the following
unless specified in the valid Benefit Schedule:
1 Routine physical examinations, health check-ups or tests not incidental to
treatment or diagnosis of an insured sickness or injury or any treatment which is
not medically necessary unless otherwise provided for in the Clinical Benefits
Schedule.
2 Congenital anomalies, infertility, sterilization.
3 Dental care and treatment unless otherwise provided for in the Dental Benefit
Schedule.
4 Cosmetic surgery, treatment on refractive errors or hearing aids except as
necessitated by injuries wholly occurring during the period of insurance.
5 Childbirth (including surgical delivery or pregnancy related).
6 Injury or sickness arising directly or indirectly from war or any act of war,
declared or undeclared, riots, insurrection, or civil commotion.
7 Vaccination and immunization injections.
8 Drug addiction or alcoholic treatment.
9 Treatment of functional disorders of the mind and psychological treatment.
10 Suicide, attempted suicide or intentionally self-inflicted injury, whether sane or
insane.
11 Treatment of Human Immunodeficiency Virus (AIDS) or ARC (AIDS-related
Complex).
12 Pre-Existing Conditions.
13 Expenses that have been recoverable from Employees' Compensation Law, any
government or public programmes of medical benefits', other group or individual
insurance.
2
ᄃ‫ܲצ‬ˠЯ়ঽٕ‫ื๋҃צ‬ତ‫ڼ̝צ‬ᒚٕ෧ᕝ൑ᙯ̝‫ؠ‬ഇ֗
វઉ૵ᑭߤٕᑭរĂٕ֭‫ܧ‬υื̝ᗁᒚ‫ڇ‬ચĄ
3
Аّ͇ள૱ăѣᙯ̙ֈ̝‫ڼ‬ᒚă඗ֈ͘ఙĄ
4
Ͱࡊ᜕ந̈́‫ڼ‬ᒚĄଘܲಏѣ೩ֻͰࡊܲᅪੵγĄ
5
ፋट͘ఙăෛ˧۬ϔ́ӄ᝘ጡĂ̈́ѣᙯ఍͞Ą‫ܲצ‬ˠ‫ܲצٺ‬
ഇมЯຍγ‫๋҃צ‬υืତ‫ڼ̝צ‬ᒚ‫ੵ݋‬γĄ
6
̶ओĞΒ߁࣠ཛயٕ̄Яᘃθ͔࡭۞‫ڶې‬ğĄ
7
ۡତٕมତϤ‫̙ٺ‬ኢ‫ކ‬ጼᄃӎ̝Їңጼ‫ۋ‬ăᄃጼ‫ۋ‬ѣᙯ̝
Җજăᇷજă‫ݔ‬ใٕϔிᛢજጱ࡭̝‫়๋ٕצ‬ঽĄ
8
࿰֨ࠪࡺ‫ڦ‬डĄ
9
ᘽ‫̈́ۏ‬੧ჟ‫ڼ‬ᒚĄ
:
ჟৠᅪᘣٕ͕ந‫ڼ‬ᒚĄ
21 ‫ܲצ‬ˠҋ୭ăྏဦҋ୭ٕᄊຍҋԧ๋च҃٢࡭̝Їң෱ϡĄ
22 ‫͇ޢ‬Һࠪ˧৿ͻাĞຑൄঽğ̈́ᄃ‫͇ޢ‬Һࠪ˧৿ͻাѣᙯ̝
‫׀‬൴াĄ
23 ‫݈̏ܲצ‬хд̝‫ڶې‬Ą
24 ౻̍ܲᐺăܲᐍ̳Φٕ‫΁׎‬ᗁᒚܲᅪࢍထĂ̏ᒔ଀ኪᐺ̝ᗁ
ᒚ෱ϡĄ
ͽ˯Чี֭ϏБᇴЕ΍ٙѣ̙‫ีܲצ‬ϫĂྎଐኛણዦѣᙯܲᅪ
୧ഠĄ
This is not a comprehensive list of Exclusions, please refer to the specific Benefit
Provision for details.
ኛֹϡԈӀ‫ཱི͗މ‬ቅ̈́ռˠ૜ቅĂ൳ˢშӬ www.manulife.com.hkĂ
Please use your Manulife Customer Number (MCN) & PIN to check the claim status by login at
website www.manulife.com.hk.
ߤྙЧ৶ᐺְี۞‫ڶې‬Ą
Please return the completed form and original receipts to ኛ૟๱ԁ۞ܑॾాТќፂϒώϹĈ
For Hong Kong policy - Employee Benefits, Manulife (International) Limited, P.O. Box 70302, Kowloon Central Post Office.
For Macau policy - Manulife (International) Limited, Macau Administration Office, Avenida De Almeida Ribeiro No. 61, Circle Square, 14 andar A, Macau.
ዋϡ‫ࢶٺ‬പܲಏ!.!˝ᐷ̚δฎ߆Ԋฎ߆‫ܫ‬ቐ81413ཱིԈӀˠုܲᐍ)઼ᅫ*ѣࢨ̳Φဌࣶ჊Ӏొ!Ą
ዋϡ‫ٺ‬፫‫ܲܝ‬ಏ!.!፫‫ܝ‬າ੺ྮ72ཱིϖЍᇃಞ25ሁBԈӀˠုܲᐍ)઼ᅫ*ѣࢨ̳Φ፫‫̶ܝ‬ҖҖ߆ొĄ
ώܑॾ̝͛̚ᛌώΪֻણ҂ϡ౉Ăࡶᄃࡻ͛‫ۍ‬ώѣளâໄͽࡻ͛‫ۍ‬ώࠎ໤Ą
The Chinese version of this form is for reference only. In the event of discrepancies between the Chinese and English versions, the English version shall prevail.
EB LH-CLAIM (01/2017) 2 of 2
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