CLAIM CHECKLIST

11601006 / 11601077

Form ID MEDICAL CLAIM FORM BORANG TUNTUTAN PERUBATAN Assured / Policy Holder Pemunya Polisi Agent Name & Code Nama Ejen & Kod Agency Office Pejabat Agensi Request type : Jenis Permohonan

Policy Number(s) Nombor- Nombor Polisi Date Submitted Tarikh dokumen diserahkan Agent Telephone No. No. telefon ejen

NEW CLAIM Tuntutan Baru

PRE/POST CLAIM Tuntutan Pre/Post

OUTSTANDING REQUIREMENT SUBMISSION Submisi Dokumen Tertunggak

OTHERS Lain - Lain

Please refer to Important Notes behind for reference / Sila rujuk Maklumat Penting di belakang sebagai panduan Document required Please tick if enclosed Dokumen yang diperlukan / Sila tandakan jika dilampirkan *Circle Selection Priority Bulatkan Turutan manfaat Medical Report Laporan Perubatan Itemised Bills/ Invoice Bil-bil terperinci/Invois List of ORIGINAL receipt submitted (Including Deposit/Refund/Final Receipts) . Please paste on an A4 paper according to receipt date Senarai resit ASAL yang dilampirkan Termasuk deposit/ pulangan/ resit akhir).Sila tampal di atas kertas A4 mengikut susunan tarikh resit)

TYPE OF CLAIM / JENIS TUNTUTAN PRUMAJOR MED/ PRUGUARD MY MEDICAL 1

PRUPARENT

2

1

2

PRUSENIOR MED

1

2

PRUHEALTH

1

PRUMED/ HOSPITAL BENEFIT ( DHB & HB)

SURGICAL & NURSING LOAN (S&N)

2

Photocopy / Salinan fotokopi

Receipt Date/ Tarikh Resit

Receipt Number /No. Resit

Receipt Amount/Jumlah Resit

Total / Jumlah Other document (ie. Lab Result/ memo) / Dokumen lain (eg. Hasil Keputusan Makmal, memo) Please select your choice of mode of claim cheque delivery. / Sila tandakan pilihan kiriman cek . Counter collection at HQ (KL) Send direct to Claimant Send to Servicing Agent Pengambilan di kaunter HQ (KL) Dihantar terus kepada pomohon Dihantar kepada ejen yang berdaftar Send to Branch PIC ; Please indicate Full name & Branch Dihantar kepada pihak yang bertanggungjawab ; Sila nyatakan nama penuh & cawangan Note : In the event the servicing agent is terminated, the cheque will be sent to the Agency leader. Nota : Sekiranya ejen berdaftar telah ditamatkan, cek pembayaran akan dikirimkan kepada Ketua Agensi.

* Once this selection is completed, it shall be treated as final and no change will be accepted. /Pilihan manfaat ini akan dianggap sebagai muktamad dan tiada perubahan akan diterima. All documents must be checked by Branch PIC/Staff prior to submission./Semua dokumen perlu disemak oleh staf / pihak yang bertanggungjawab di agensi sebelum penyerahan. To be completed by Branch PIC / Staff / Untuk dilengkapkan oleh Pihak Bertanggungjawab/ Staf PIC/Staff Acknowledgement : Pihak bertanggungjawab/Staf _________________________ Full name of PIC/ Staff Nama penuh pihak bertanggungjawab/ staf

:

______________________

Date / Tarikh

: _____________

IMPORTANT NOTES Emergency and Accidental Treatment (EAT) – (Only applicable for PRUmajormed, PRUguard MY medical & PRUhealth) First consultation within 48hours from date of accident 1. Follow up within 30 days from date of the accident 2. Medical report will be waived for first consultation bill which is below RM 500.00. Attending Doctor to endorse date and time of accident, nature of accident and treatment given on the original bill. Pre Hospitalisation - (Only applicable for PRUmajormed, PRUguard MY medical, PRUhealth & PRUseniormed) 1. 30 days prior to date of hospitalisation 2. Attached copy of referral letter where applicable (eg. treatment with different clinic) Post Hospitalisation (Only applicable for PRUmajormed, PRUguard MY medical, PRUhealth & PRUseniormed ) 1. Within 90 days from date of discharge 2. Follow up with the admitting/ treating doctor 3. If follow up with other doctors : require endorsement / letter to confirm nature of treatment (Restricted to admissions at hospital in other states / countries) and supporting letters with explanation from policy holder Overseas Treatment 1. No benefit is payable if policy holder resides outside of Malaysia for > 90 days per trip 2. A copy of passport indicating entry and exit date 3. Detailed breakdown for each item in the bill Claim for excess amount not covered by employer/ other insurers 1. Policy holders may claim excess amounts not paid/ not covered by employer/ other insurers 2. This is subject to the policy conditions 3. Policy holders need to submit the following for claim processing a. Letter from employer / other insurers indicating the amount settled b. Certified true copy of bills from employer/ other insurers c. Certified true copy of medical report from employer/ other insurers d. Original Prudential Claim Form

MAKLUMAT PENTING Kemalangan dan kecemasan (EAT)(Untuk PRUmajormed, PRUguard MY medical &PRUhealth sahaja) 1. Rawatan pertama adalah dalam tempoh 48 jam daripada tarikh kemalangan 2. Rawatan lanjutan dalam tempoh 30 hari daripada tarikh rawatan pertama 3. Laporan perubatan akan dikecualikan sekiranya jumlah rawatan pertama di bawah RM 500 tetapi pengesahan daripada doktor berkenaan tarikh dan masa kemalangan, keadaan kemalangan dan jenis perawatan yang diberikan perlu dicatatkan di atas salinan bil/ resit asal Pre Hospital (Untuk PRUmajormed, PRUguard MY medical &PRUhealth sahaja) 1. 30 hari sebelum tarikh masuk hospital 2. Dilampirkan salinan surat rujukan jika berkenaan (eg: rawatan daripada klinik yang berbeza) Post Hospital (Untuk PRUmajormed, PRUguard MY medical &PRUhealth sahaja) 1. Rawatan antara 90 hari daripada tarikh keluar hospital 2. Rawatan lanjutan oleh pegawai perubatan yang sama 3. Sekiranya rawatan lanjutan oleh pegawai perubatan yang berlainan : pengesahan /surat akuan diperlukan untuk mengesahkan jenis rawatan (Syarat diketatkan kepada hospital di luar negeri/Negara dan dilampirkan surat penerangan daripada Pemunya Polisi ) Perawatan di luar Negara 1. Tiada sebarang perlindungan sekiranya hayat diinsurankan berada di luar negara melebihi 90 hari bagi setiap perjalanan 2. Satu salinan pasport untuk mengesahkan tarikh keluar dan kembali ke Malaysia 3. Disertakan data / maklumat terperinci bagi setiap item pada bil Tuntutan lebihan / baki yang tidak dibayar oleh majikan / insurans lain 1. Pemunya Polisi boleh menuntut bayaran jumlah lebihan yang tidak dibayar oleh majikan/ syarikat insurans lain 2. Situasi ini bergantung kepada syarat-syarat polisi 3. Pemunya Polisi perlu menghantar dokumen-dokumen yang disebut di bawah untuk pemprosesan tuntutan :a. Surat daripada majikan/ syarikat insurans lain dengan menyatakan perkara dan jumlah yang di bayar b. Salinan pendua bil terperinci yang disahkan oleh majikan / insurans lain c. Salinan pendua laporan perubatan yang disahkan oleh majikan / insurans lain d. Salinan asal borang tuntutan Prudential

Page/ Mukasurat 2 of / dari 4

Policy No / No Polisi :

1

Life Assured details/ Butir-butir Hayat Diinsurankan Name of life assured / Nama Hayat Diinsurankan I.C. No./ No. K/P

Age at admission / Umur sewaktu kemasukan Occupation/ Pekerjaan

Gender/Jantina Current correspondence address/Alamat surat menyurat terkini

Office/House / Pejabat / Rumah

Contact No./No. Perhubungan

Mobile No./No telefon bimbit

2

Claimant’s details ( If other than Life Assured ) /Butir-butir penuntut (sekiranya selain dari Hayat diinsurankan) Name of claimant/ Nama Penuntut I.C. No./ No. K/P Current correspondence address/Alamat surat menyurat terkini

Office/House / Pejabat / Rumah

Contact No./No. Perhubungan

Mobile No./No telefon bimbit

3

If hospitalization and/or consultation was due to accident, please furnish in your own words the following details:Sekiranya kemasukan ke hospital dan/atau rawatan disebabkan oleh kemalangan, sila kemukakan kenyataan anda sendiri perkara di bawah:(DD/MM/YY)(HH/BB/TT) (am/pm)

When did it occur/ Bila kemalangan tersebut berlaku ? Where did it occur? /Dimana kemalangan itu berlaku ?

How did the accident happen? Bagaimana kemalangan tersebut berlaku?

Nature and extent of Injury(ies) sustained / Jenis dan tahap kecederaan yang dialami.

4

If hospitalization and/or consultation was due to other illnesses /causes, please furnish in your own words the following details:Sekiranya kemasukan ke hospital dan/atau rawatan disebabkan oleh sebab-sebab lain, sila kemukakan kenyataan anda sendiri perkara di bawah:Nature of illness and symptoms/ Jenis penyakit dan simptom How long have you/ the life assured had the sign(s) and symptom(s)? Sudah berapa lama anda/ Hayat diinsurankan mengalami gejala dan tanda-tanda tersebut? What was the diagnosis informed to you by the attending doctor? Apakah diagnosis yang telah dikemukakan kepada anda oleh doktor yang merawat?

5

Name of previous doctor consulted over the past 2 years/ Nama doktor terdahulu yang telah dirujuk dalam tempoh 2 tahun yang lalu Address of the doctor/ clinic/ hospital Alamat doktor/ klinik/ hospital

Date of consultations Tarikh pertemuan

Page/ Mukasurat 3 of / dari 4

Reason for consultation/ Sebab untuk rujukan

Policy No / No Polisi :

6

Please state if you are entitled for any medical benefit from other source. Sila nyatakan jika anda berhak mendapat apa-apa kemudahan /insentif perubatan dari mana-mana sumber. Name of Company / Nama Syarikat

Policy/ Membership No/ Policy/ Keahlian Program / Scheme / Program/ Skim

Amount of Benefit / Jumlah Manfaat

Declaration & Authorization / Pengakuan & Tandatangan I / We hereby declare that the information provided in this claim form is true and that I/ the life assured have not suffered from any pre-existing conditions at the time this policy was taken up. I further declare that the current confinement to the hospital is not due to any causes which are stipulated in the Exclusion Clause of the policy. I hereby agree that if I have made or have previously made, any false or untrue statement and/ or omitted or prevented the disclosure of any material facts in respect of my / Life Assured’s health and condition, the Company shall be entitled to revoke my / Life Assured’s rights for any compensation, as well as reserve the rights to recover any amount previously paid. Saya/ Kami dengan ini mengesahkan maklumat yang diberikan di dalam borang tuntutan ini adalah benar dan saya / Hayat diinsurankan tidak mengalami apa-apa keadaan sedia ada sewaktu polisi ini diambil. Saya seterusnya mengesahkan bahawa kemasukan ke hospital ini tidak disebabkan oleh apa-apa sebab seperti yang dinyatakan di klausa pengecualian polisi ini. Saya bersetuju bahawa sekiranya saya membuat atau pada masa lalu telah membuat, sebarang kenyataan palsu atau tidak benar dan/ atau menghalang dan / atau menyembunyikan fakta material mengenai kesihatan dan keadaan saya / Hayat Diinsurankan, pihak Syarikat boleh membatalkan hak saya/ Hayat Diinsurankan bagi sebarang pampasan serta menyimpan hak untuk mendapatkan semula mana-mana jumlah yang telah dibayar sebelum ini hasil dari perkara tersebut. I/We hereby authorize any physician, hospital, clinic, insurance company, other organization, institutions or persons, that have any records or knowledge of me/ the life assured or my / life assured’s health, to disclose to Prudential Assurance Malaysia Berhad, or its representatives all information. I/we expressly waive on behalf of me / the life assured or any person who has any claim or interest in any policy issued hereunder, all provisions of law forbidding any physician or surgeon from disclosing any information acquired while attending to me/ the life assured in a professional capacity. A copy this authorization shall be as effective and valid as the original. Saya/ Kami dengan ini memberikan kebenaran mana-mana doktor, hospital, klinik, syarikat insurans, lain-lain organisasi, institusi-institusi atau orang perseorangan, yang mempunyai sebarang rekod atau maklumat mengenai saya / Hayat Diinsurankan atau kesihatan saya / Hayat Diinsurankan untuk memaklumkan kepada Prudential Assurance Malaysia Berhad, atau wakilnya, semua maklumat. Saya / Kami secara khususnya mengenepikan bagi pihak saya / Hayat Diinsurankan atau mana-mana orang perseorangan yang mempunyai apa-apa tuntutan atau kepentingan di dalam mana-mana polisi yang dikeluarkan di sini, semua peruntukan-peruntukan undang-undang yang menghalang doktor atau pakar bedah dari mengeluarkan sebarang maklumat yang ditemui sewaktu merawat saya/ Hayat Diinsurankan secara professional. Satu salinan kebenaran ini adalah efektif dan sah seperti yang asal.

Signature of Assured/ Tandatangan Pemunya Polisi

Signature of claimant / Tandatangan Pihak Menuntut

NRIC No. /No. Kad Pengenalan

NRIC No. /No. Kad Pengenalan

Signature of witness/ Tandatangan saksi Name / Nama NRIC No. /No. Kad Pengenalan

Contact Number / No. untuk dihubungi

Contact Number / No. untuk dihubungi

Contact Number / No. untuk dihubungi Address / Alamat

Prudential Assurance Malaysia Berhad (107655-U) Level 17 Menara Prudential, No. 10 Jalan Sultan Ismail, 580250 Kuala Lumpur, P.O Box 10025, 50700 Kuala Lumpur. Tel :03-20318228 Fax : 03-20323939 Email : [email protected]

Ver 08/2009

Page/ Mukasurat 4 of / dari 4

Form ID

11601007

Attending Physician's Statement To be completed by the doctor who treated the Life Assured during hospitalization. Any fees charged for this statement is payable by the claimant.

Patient Name

_______________________ Policy No _______________________

NRIC / BC/DOB ______________________ Gender 1

Admission Date (DD/MM/YYYY ) :

2

Is the hospitalization accident related? If YES, please provide the following details : a ) Date and Time of Accident : b ) Nature of Accident

:

c ) Injury (ies) sustained

:

______________

Date of Birth ____________

Discharge Date (DD/MM/YYYY ) : YES

NO

3

Presenting signs and symptoms :

4

BP _________ mmHg Temperature ______ ˚C Pulse _______ beat per minute The date on which you first saw the patient for this According to the patient, when did the signs illness/injury /medical condition. ( DD/MM/YY ) and symptoms first appear? ( DD/MM/YY )

Please advise all relevant and contributing past history pertaining to the symptoms and illness.

5

In your professional opinion, how long has the above condition existed? (DD/MM/YY)

6

Was the patient referred to you ? YES NO If YES, please enclose a copy of the referral letter ( if any) and answer the following : a) Name of doctor / clinic

7

b ) Address of the clinic

Has the patient been hospitalized for the same illness whether in this hospital or any other hospitals? YES NO UNKNOWN If YES, please state details of previous admission as below : Date of Admission ( DD/MM/YY ) Hospital Diagnosis/ Illness Treatment

8

Has the patient been hospitalized for any other illnesses whether in this hospital or any other hospitals? YES NO UNKNOWN If YES, please state details of previous admission as below : Date of Admission ( DD/MM/YY ) Hospital Diagnosis/ Illness Treatment

9

Is the patient suffering from any other underlying illnesses besides the current medical condition? YES NO UNKNOWN If YES, please provide details : Date of Diagnosis ( DD/MM/YY ) Underlying Illness Doctor’s Name/Address/Telephone No

10

What was the Final Diagnosis ?

11

When was the patient informed of the above diagnosis? ( DD/MM/YY )

12

Is the final diagnosis related to any of the following? ( Please indicate √ and circle the relevant ) Pregnancy / Childbirth / Infertility / Impotence Congenital / Hereditary diseases Alcohol or Substance Abuse/Addiction Psychotic / Mental / Nervous / Sleeping Disorder Cosmetic reason / Dental related / refractive errors correction AIDS / HIV Positive / STD / VD / Communicable Disease required quarantine by law Self-inflicted injuries / Violation of laws / Strike / Riots Routine Examination / Investigatory Purposes / Preventive Treatment / Alternative Treatment None of the above

13

What medical advice was given to the patient pertaining to the diagnosis?

14

Please state all investigations, tests or procedures which had been performed. Date( DD/MM/YY ) Name of investigation/test/procedure

15

Nature of treatment given a) b) c)

Date ( DD/MM/YY )

Test Result

16

For Surgery : Nature of operation performed Name of surgeon Date of surgery performed ( DD/MM/YY )

17

For female only : Is the patient pregnant? If YES, how long? ________weeks / months

YES

NO

Was the illness caused directly or indirectly related to pregnancy/childbirth/caesarean section/ miscarriage or any complications arising therefrom? YES NO If YES, please clarify If NO, please clarify

18

I hereby certify that I have personally examined and treated the patient for his/her medical condition/illness/injuries described above and that the facts as stated above are all true to the best of my knowledge.

Signature of Doctor : Name & Qualification of Doctor

Date : :

Name & Address of hospital clinic :

Telephone no : Hospital’s / Doctor’s Stamp :