Claim Procedure

A. CLAIM FILE:

MEDICAL CLAIMS:


1. Direct Billing Services Claims:

  • Please visit our website “Customer Center”– Medical Provider Network to get the list of Direct Billing Facilities which provide Cashless Services to customers of Pacific Cross Insurance;
  • Please show a valid Coverage Card issued by Pacific Cross Insurance and photographic ID (or Passport) when visiting a Clinic/Hospital which is in the list of Medical Providers for Direct Billing Services;
  • Please complete page one of the Notification of Claim Form; request a chance to check your Invoice to ensure all information is accurate and, if possible, sign the Invoice after receiving all medical services.


2. Pay & Claim:

A claim can be made with the following supporting documentation

  • Notification of Claim form: completed by Claimant and Attending Physician;
  • Medical Report: completed by Attending Physician;
  • Copy of all lab tests and/or reports;
  • Prescriptions;
  • Official original Receipts with an itemized or detailed breakdown of charges. This applies to all pay and claim situations, but is not necessary when direct billing service is used.

Further documents may be required for claims involving Accidents or Alternative Treatments. See details below:

Claims involving an Accident:

  • Police Report (for traffic accident);
  • Incident Report Form: completed by Claimant (for all other accidents);

Claims for Physiotherapy/Chiropractics/Accupunture/Chemotherapy/Radiotherapy:

  • Treatment Plan Form: completed by Attending Physician (as form);
  • Progress Report: completed by Attending Physician (when a new treatment plan is required after finishing the previous treatment plan).

In-patient Claims:

  • Discharge Certificate.

Note: Pacific Cross Insurance may require further documents which is necessary for the claim to be processed and completed.


3. Dental claims (optional benefit):

Required for submission of the first dental claim

  • An Oral Examination Report: completed by Attending Physician/Dentist, required for submission of the first dental claim;

For all ensuing Dental Claims:

  • Dental Examination Report: completed by Claimant and Attending Physician/Dentist;
  • Official original Receipts with detailed and breakdown of charges.


4. Personal Accident claim (optional health insurance policy benefit):

  • Death Claim Form: completed by the Beneficiary;
  • Attending Physician’s Statement for Death Claim: completed by Hospital/Attending Physician giving details on the nature of the injury or extent and period of disability;
  • Police Report;
  • Official original Receipts with detailed and breakdown of charges;
  •  Copy of Declaration of Death or Death Certificate.

TRAVEL CLAIMS: 

A claim file includes following documents:

  • Travel claim form: completed by Claimant;
  • Travel Certificate;
  • Boarding Pass;
  • Copy or scan of all pages of Passport;
  • Copy of air ticket booking;
  • Official original Receipts with a detailed breakdown of charges.

Further documents will be required for the following claims:

 
1. Claim for Baggage Delay:

  • Irregularity Report;
  • Luggage Delivery Report;
  • Official original Receipts with a detailed breakdown of charges.


2. Claim for Travel Delay:

  • An Official Document from the transportation Carrier clearly stating the cause, date, time and duration of the flight delay.


3. Claim for Personal Accident:

  • Police Report;
  • Incident Report: completed by claimant;
  • Attending Physician’s Statement for Death Claim: completed by Hospital/Attending Physician giving details on the nature of the injury or the extent and period of disability;
  • Copy of Declaration of Death or Death Certificate


4. Claim for Medical expenses:

  • Medical Report: completed by Attending Physician;
  • Copy of all lab tests and or reports;
  • Prescriptions;
  • Official original Receipts with a detailed breakdown of charges.


Note: Pacific Cross Insurance may require further documents which is necessary for the claim to be processed and completed.

B. TIMELINES FOR CLAIM SUBMISSION:

  • Travel Claim: within 30 days from the policy expiry date;
  • Personal Accident Claim: as soon as possible and not exceed 45 days from the incurred date;
  • Health insurance claims should be sent to us as soon as reasonably possible and in any event notification of a claim should be given within 90 days of the loss or incursion of expense. Failure to submit a claim will not affect the claim if it was not possible or reasonable to submit it on time, in any event claims must be submitted within 365 days of loss or incurred date in order to be accepted by the company.

C. TIMELINES FOR CLAIM RESPONSE:

Pacific Cross Insurance will adjudicate claims within 5 working days from the date of receiving all required documentation and information.

D. CLAIM PAYMENT:

  • In cash or by telegraphic transfer in USD;
  • Local currency reimbursement is available in some territorries, but cannot be guaranteed;
  • Claimant must show recognized photo ID or Passport to receive cash at our offices;
  • Any other authorized person must obtain Authorized Letter and copy of the passport of the Claimant to receive claim payment on behalf of a claimant.

E. REJECTION:

In case of claim payment rejection, a denial letter will be sent to the Claimant clearly stating the reason for rejection.

For scanned and imaged copies of claim files, please send to
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For any further question or clarifications, please contact us via:
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Customer Centre