In-patient Claims

In order to ensure that you receive the best possible claims service the procedures noted below should be followed in the event of treatment being required by you or one of your dependants. Members are recommeded to submit claims via email (stated at bottom of this page).

MEDICAL HELPLINE

Our medical helpline is available 24 hours a day, 365 days a year and is staffed by multi-lingual operators who can arrange admission to hospital, ambulance transfers and air evacuation where necessary. To obtain medical assistance, please use the medical helpline number nearest to you as shown on your membership card. You will need to provide your name, reference number, telephone and/or fax number, location and medical condition. In any given situation, if you are unsure what to do, contact the medical helpline.

DEFINITION

We/Our/Us: Aetna Global Benefits

DAY-PATIENT and IN-PATIENT TREATMENT

Day-patient and in-patient treatment are those that are received in a hospital, and where it is medically necessary for you to be admitted to a hospital bed, whether or not you need an overnight stay. We require that our prior approval (pre-authorisation) be obtained for all planned day-patient and in-patient treatment.

For emergency admissions you, the hospital or a family member are recommended to contact us to obtain a pre-authorisation prior to you leaving the hospital. Failure to pre-notify your in-patient or day-patient treatment will mean that you may only be eligible for reimbursement of a proportion of the costs incurred.

Outside the USA: When we have been pre-notified of an eligible day-patient/in-patient stay we will attempt to arrange direct billing with the hospital, medical practitioners or specialists concerned. We will send the provider a ‘Guarantee of Payment’ to the value of the estimated cost of treatment advised to us by the relevant facility/provider, which will confirm to them that the treatment is covered under your policy.

We cannot place a guarantee of payment without the following documents, so please ensure that the hospital confirms with you that this has been sent to us.

Release of Medical Information Form: You will be required to complete a ‘Release of Medical Information’ form which you should forward to us as soon as possible. Delays in completing this document may result in delays in receiving your treatment.
Pre-certification Medical Form: The hospital is required to complete a ‘Pre-certification Medical Form’ outlining details of the medical condition and the treatment to be undertaken.

We will verbally confirm with you should your treatment be covered under the terms of the policy. However, completion of pre-authorisation is conditional on the submission of our ‘Guarantee of Payment’. We will notify you as soon as possible if the condition or treatment required is not covered under the terms of your policy.

It may be that we are unable to implement a ‘Guarantee of Payment’ before your treatment is undertaken. This may be due to delays in the hospital providing us with the appropriate medical information for us to be able to confirm coverage. It is therefore important to contact us as soon as possible prior to your treatment taking place to ensure we are able to place a ‘Guarantee of Payment’ in due time. We would recommend that you do not delay your treatment if a guarantee is not in place at the time your treatment is due.

Inside the USA: Some policies allow for treatment to be undertaken in the USA. Please check your policy to ensure that you have the appropriate coverage before undertaking any treatment in the USA.

Treatment received within the provider network will be billed to us directly. Our claims department will determine what portion of the invoice is applied to your excess and any co-insurance applicable and which portion is payable by us. We will send you and the provider copies of the ‘Explanation of Benefits’ (EOB) detailing how the bill was settled and what amount you are responsible for.

We will notify you as soon as possible if the medical condition or treatment required is not covered under the terms of your policy.

USA Provider Network: We have made arrangements with many medical provider networks in the USA which, when you receive treatment at these facilities will mean that your costs for treatment can be settled directly by us.

You can find the Provider Network facilities in your area by visiting the Network area of our web site. Click on the link to the ‘DocFind’ search engine. From there you can perform a search by address, name, speciality, and/or Tax ID number. If you are unable to find details of your preferred provider from this search facility or have any problems with the search engine please call +1 866-545-3252 (Toll Free within USA) for assistance.

Pre-Authorisation: We require members to obtain prior approval (pre-authorisation) from us before commencing the following treatments:

Planned in-patient or day-patient treatment (hospitalisation).

Any pregnancy or childbirth treatment.

Planned surgery.

Evacuation.

Second medical opinions.

Psychiatric treatment, in-patient, day-patient and out-patient.

Home nursing charges.

Planned MRI and CT scans.

Evacuations are supervised by your medical practitioner or specialist at the place of incident and by our medical helpline and must be agreed by us before the evacuation takes place.

Referral from a Medical Practitioner: We will require a doctor’s referral to be included whenever filing a claim for the following treatments:

Physiotherapy (medical practitioner referral accepted).

Medical practitioner or specialist referral required:

......Chiropractic treatment.

......Acupuncture treatment.

......Osteopathic treatment.

......Homeopathic treatment.

......Paediatric treatment.

Claim Form: When submitting any claim forms and any other documents pertaining to the claim, please ensure that:

the first page of the claim form has been completed in full by you for each medical condition treated. The declaration must be signed by the insured person and dated to enable the claim to be validated.
you attach to your claim form, the copies of paid receipts and any other documents pertaining to the claim (or other proof of payment) for all treatment for which you are making a claim.
where your treatment has been provided by a registered physiotherapist, chiropractor, osteopath, homeopath, podiatrist or acupuncturist, please ensure that you attach to your claim form a copy of the ‘referral letter’ that was provided by your medical practitioner.
where applicable laboratory tests results and/or x-rays were provided, please include the test results with your claim.
for all claims under US$200 per medical condition, you need only complete sections A, B and C and return your claim form with a copy of the original receipt(s) showing the diagnosis and a full breakdown of costs for each condition being claimed for. All sections MUST be completed in full for hospitalisation claims and all claims over US$200. A ‘referral letter’ from your specialist should be attached when you are claiming for diagnostic tests.

The settlement of your claim may be delayed if you fail to complete your claim form properly.

Please note that any charges that may be made by an attending medical practitioner for completing your claim form are not eligible for reimbursement under the terms and conditions of the policy and you will be responsible for settling these costs.

Where it is not possible to have the claim form completed by the medical practitioner, specialist or dental practitioner, we will accept the claim for assessment provided your receipt(s) for treatment include the date of service, the diagnosis of your medical condition, the treatment provided, the amount charged and the stamp of the facility concerned.

To ensure prompt settlement of any eligible claims please ensure that you submit all necessary documents at the time of the claim. We accept copies of original receipts for claim processing and to facilitate the assessment of your claim, however do keep your originals properly as we may require them under certain circumstances. When submitting claims via email, please adhere to the procedure stated on this link.

Note: Should a member make a claim and receive reimbursement (of any size), their NCB discount will revert to a level two years below their current level at their next renewal. However, if their reimbursement exceeds US$15,000 the NCB discount will drop all the way down to the standard premium, i.e., no discount.

General Claims Information: We reserve the right to reject any claim which is not submitted within 90 days of the date that treatment took place. All documents and materials (including, but not limited to original accounts, certificates and x-rays) that we require to support a claim, shall be provided without expense to us (including, if requested by us, a medical report from your medical practitioner or specialist and details of the your medical history).

In cases where medical information is required by us for consideration of a claim, but it is not made available to us, it is your responsibility to obtain such information from your current or previous medical practitioner, as appropriate. Claims may only be made for treatment actually given during a Period of Cover and benefit will be available only for expenditure incurred prior to expiry or termination of such cover.

An insured person must, without delay, give us written notification of any claim or right of action against any third party arising out of circumstances which gave rise to a claim under this policy and must continue to keep us fully informed in writing and take all steps we reasonably require in making a claim upon that other party. We shall be entitled to take legal action in any insured person's name for our own benefit and claim for indemnity or damages or otherwise which relates to any benefits and costs paid or payable under this policy. We shall have full discretion in the conduct of any such proceedings and in the settlement of any such claim.

If You have any questions concerning the above or any other aspect of your policy please do not hesitate to contact your local Aetna claims office.

Contact Details: For all pre-authorisation, claims or benefit queries please contact the Aetna Worldwide claims office closest to you. Please ensure you have your policy number at hand prior to calling, as this will be required to verify your cover:

Britain

Tel: + 44 870 442 4386

Fax: + 44 870 442 4387

Hong Kong

Tel: + 852 2104 7486

Fax: + 852 2866 2555

Dubai

Tel: + 971 4 438 7600

Fax: + 971 4 428 7100

America

Tel: + 1 813-775-0220-------------Toll Free (inside the USA only): + 1 866-545-3252

Fax: + 1 860-262-9111

Email: claims@talent-trust.com