医疗保险理赔申请书

医疗保险须知：(请详细阅读)

一、 享受条件：

员工购买广东省社保起30日后；在广州市（含番禺、花都、增城）二级或二级以上公立医院（社保定点医院）因疾病引起就医所发生的医疗费用。

二、 享受标准：

2500元；每次报销比例为70%。

20000元；每次报销比例为90%。

150000元；（重大疾病享受条件为员工购买社保起60日后）

三、理赔程序及所需资料：

1、发生医疗费用后，您需提供《医疗保险理赔申请书》、医院开据的收据原件、与收据相对应的病历复印件、处方、检验结果、门诊费用清单、化验单、身份证复印件、银行卡复印件交于公司人力资源部；

2、住院前，务必先提交身份证复印件、医院开据的诊断证明书原件到公司人力资源部作备案，否则无法进行理赔。

3、人力资源部收到您的单据后，在60天内完成保险理赔手续，报销之费用会直接转帐至您的银行帐户中。

四、 注意事项：

1、每次就医时医院开据的药量日限额为200元（包含检查费）。

2、医疗用药及费用标准均按广州市社会保险有关规定标准执行，自费药或超标药品、住院床位费不予报销。

3、因下列情况之一，公司不负给付保险责任：

A、 与生育有关费用；B、非治疗性行为；C、在康复医院、私人诊所就医；D、假牙、假肢、假眼等； E、与牙科有关疾病；F、与爱滋病、精神病有关疾病；G、投保前已有先天性疾病；H、非社保定点医院就医；I、发生住院而未经报批转院治疗；

第二篇：国寿康优全球团体医疗保险(B 型)理赔申请表

理赔申请表 国寿康优全球团体医疗保险(B型)

Claim Form China Life Goodhealth International Healthcare Plan (Type B)

(20xx年10月10日版)

(Version: Oct 10, 2009)

中国人寿保险股份有限公司

All claims under ￥1, 600 (or corresponding rates) per condition, please complete Section A, B and C and return this with 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 hospitalization claims and all claims over ￥1, 600 (or corresponding rates). A referral letter from Your Specialist should be attached when You are claiming for diagnostic tests or covered alternative treatments.

索赔金额低于1,600元人民币(或等值的其他货币),如原始#5@p已清楚写明病症并列明费用明细，请完整填写A,B,C栏。住院治疗或索赔金额高于或等于1,600元人民币(或等值的其他货币) 的，请完整填写A, B, C, D, E栏。填写完毕后请和医疗费用收据原件、医疗费用明细清单原件、诊断病历原件一起提交。如索赔诊断性检验或非常规治疗的费用，请同时提供您的治疗医师的书面介绍证明。不同的病症请分别填写理赔申请表。

保险单持有人 保险单号码

Policyholder Policy Number

栏目A：出险人详细资料 –由被保险人/附带被保险人填写 Section A: Patient’s Details - To be completed by the Insured/Supplementary Insured

姓： 住址及邮政编码：

Surname Address & Post Code

名及英文字母简写： 身份证号/护照号码：如索赔为人民币付款且大于1万元或外币

付款且大于等值美元1千元，请提供相关护照或身份证件复印件.First Name & Initials

ID No. / Passport No. : Please attach with your ID card/Passport

copy if the claim amount is above RMB10,000 for RMB

payment or above USD1,000 for Non-RMB payment

China Life Insurance Company Limited

出生日期（日/月/年）： 电邮：

Date of Birth: Day Month Year E-mail:

联系电话： 传真/

移动电话：

Contact Telephone Number: Fax/Mobile:

您本次索赔是否由于意外造成？ 您是否有其他保险？

Were your injuries caused by an accident? Do you hold any other insurance?

是□ 否□ 是□ 否□

Yes No Yes No

如果选择 “是” ，请另用纸张详细说明。 如果选择 “是” ，请另用纸张详细说明。

If Yes, please provide full details on a separate sheet. If Yes, please provide full details on a separate sheet.

栏目B：保险金给付信息 –由被保险人/附带被保险人填写

Section B: Claims Settlement - To be completed by the Insured/Supplementary Insured

发生在中国大陆的相关费用：

Receiving Treatment inside of mainland China

索赔金额合计（保险金货币固定为人民币）：

Total amount claimed (currency of claim must be RMB)

保险金将转至您投保时所指定的银行账户。

Claim payment will be remitted to your designated bank account when you applied the coverage.

索赔金额合计及货币种类：

Total amount claimed, including currency of claim

保险金给付币种：

Currency in which you wish settlement to be made

如保险金货币为‘人民币’，保险金将转至您投保时所指定的银行账户。如您投保时未指定银行账户，或给付币种为非‘人民币’时，请完整填写如下信息：（银行账户必须为被保险人本人所有，如为他人账户，需被保险人另行授权指定）

If RMB has been chosen as settlement currency, claim payment will be remitted to your designated bank account when you applied the coverage. If no bank account designated before, or the currency you wish to settle is Non-RMB, please give full details in below blank.（

注意事项： 如果希望通过支票或银行转账方式收到您的保险金，请认真填写您的开户Notes: 银行详情如下：

1.帐户名必须与开户名完全一致 If settlement is to be sent care of your bank or by Transfer, please give full Beneficiary name should be the same as bank details of your bank below:

account name. 账户名：

2.银行名称需完整，包括分行/支行/分理处 Beneficiary Name:

Bank name should include branch name. 银行名称(含支行)：

3 给付货币为非人民币时，须提供银行国际Bank Name and Branch Name:

代码 银行地址：

For Non-RMB payment, Bank Address: Swift / IBAN / Sort Code is needed.

4.给付货币为非人民币时， 需同时提供被银行账号：

Account Number: 保险人身份证/护照复印件

For Non-RMB payment, copy of passport/ID 国际代码：

card of the insured is needed. Swift/ IBAN/Sort Code:

领款通知书邮寄地址：

Address to where settlement to be sent

请注意，您接到本公司的通知时，保险金可能尚未存入您的银行账户。请您向银行查询。

Please note payment may not have been credited to your bank account at the time you receive your Advice from Us. You will need to check with your bank.

栏目C：声明及授权 - 由被保险人/附带被保险人填写

Section C: Declaration - To be completed by the Insured/Supplementary Insured

“上述各项内容，及本人提供的一切资料，均完全属实。本人授权贵公司或其指定代表向任何第三方获取处理索赔的信息, 提供有关本人此次意外或疾病的一切资料及本人既往的健康状况、病历和诊疗资料。”

“I declare that all information, to the best of my knowledge, provided on this Claim Form is truthful and correct. I also

understand that this declaration gives permission to China Life and their appointed representatives to approach any third party for information required to complete their assessment of this claim including, but not limited to, my current and previous Medical Practitioners.”

“本人允许贵公司在以下情况下使用、透露本人的个人信息（包括在本表中填写的信息和其它途径收集到的信息）①评估本次索赔或进行客户服务②因付款需要通知银行或信用卡公司③为贵公司或相关机构作与保险相关服务市场资料④处理索赔或保险研究使用。

“I declare and agree that the personal information collected or held by China Life, whether contained in this form or otherwise obtained may be used by China Life, or disclosed or transferred to any organization for the purpose to (1) assess this claim and to provide on-going insurance and customer services, (2) process and give effect to Credit Card Payment,(3) provide marketing material in respect of insurance related services of China Life or its associated companies and (4) process claims or analyze the insurance.”

“如保险金货币选择‘非人民币’，本人委托贵公司办理以所给付的保险金金额为限的购汇业务”。

“If the chosen settlement currency is not RMB, I authorize China Life to purchase foreign exchange for claim

reimbursement up to the policy benefit maximum.”

“对于发生在事先约定的医疗机构内，针对特定的或保险公司已经事先担保的医疗服务项目，我授权该医疗机构或指定的第三方代表我向保险公司提出理赔，保险公司将直接付款至该医疗机构或指定的第三方。”

“For Direct Billing case or guaranteed case which the medical treatment received in the pre-appointed provider, I hereby authorize the provider or pre-appointed third party to directly bill my insurance company which should make payment of any benefit payable to the provider or pre-appointed third party.”

出险人签名： 日期： 日 月 年

Patient’s Signature: Date: Day Month Year

（如附带被保险人未满18周岁，还需法定监护人签名）

(If patient is under 18 years of age, Parent or Guardian must sign)

栏目D：索赔信息 –由医生/牙医填写

Section D: Claims Information - To be completed by the Patient’s Medical Practitioner or Dental Practitioner

本次意外或疾病的详细诊断和治疗过程：____________________________________

Details of Medical Condition requiring Treatment: (Please provide the precise diagnosis, if known).

主要病因：

Underlying cause:

如系女性生育，请告知怀孕是否属于任何方式的人工辅助妊娠：

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If this claim is for maternity please advise whether the pregnancy is as a result of any form of assisted conception:

病情延续时间：

How long has this condition existed:

病人初次就医前何时发现病情或征兆：

When did the patient first become aware of any symptoms prior to seeking medical Advice?

病情首次就诊日期（日/月/年）：

Date of first consultation with any practitioner for this condition:

既往是否曾有相同或类似病情：

Has this, or any similar condition previously been suffered from?

预计治疗/诊断时间（如果可知）：

Please confirm the likely period of Treatment & prognosis (if known):

推荐病人前来就诊的医师的姓名和地址(如病人是由其他医生介绍)：

Name & Address of referring Doctor/Dentist (Please complete only if the patient has been referred to You):

请另附本次病情的化验检查详细报告：

Please detail any diagnostic tests performed and attach the results:

本次治疗是否属于例行牙科检查（仅由牙科医生填写）？ 是 Yes □ 否 No □

This question relates to Dental Treatment only is this claim for a routine check-up?

以上栏目如空间不足，请另用纸张详细说明。

If you have insufficient space in any section, please provide full details on separate sheet

栏目E：医生/牙医详情 –由医生/牙医填写

Section E: Medical Practitioner or Dental Practitioner Details - To be completed by the Patient’s Medical Practitioner or Dental Practitioner

医生姓名： 盖章：

Name of Practitioner: Official Stamp

地址：

Address

电话：

Tel:

电邮：

Email:

医生签名：

Practitioner’s Signature:

传真： Fax: 日期： 日 月 年

Date: Day Month Year

注意！为了保证您的索赔得到及时的处理, 请确认：

**IMPORTANT** -This will ensure that your claim is reviewed in a timely fashion. Please ensure:

1. 所有医疗费用#5@p、药品处方、费用明细清单、诊断病历的原件都已附在本表后。

All original receipts and prescriptions are attached

2. 所有栏目都已按要求完整填写。

The Claim Form is completed in full

3. 声明和授权已签名并填写日期。

The declarations are signed and dated

4. 所有化验、检查报告已附于本申请表后。

All laboratory tests are attached

5. 诊断结果和主要病因已填写。

The diagnosis and underlying cause

重要提示：请确保您的理赔申请表填写完整，并在首次治疗开始后六个月内递交我公司。否则理赔申请表将会被退回，并致您的理赔程序延迟。本公司将不会对任何由于填写理赔申请表及提供资料所引起的费用负责。本理赔申请表不作为本公司承担给付义务的证明。

Important Note - Please ensure Your Claim Form is completed in full and returned within six months of your initial Treatment. Failure to complete your form in full will result in the form being returned to you and will hold up the processing of your claim. Please note China Life is not responsible for any costs associated with the completion of this form or for any further

information/document requested by us to assess your claim. The issuing of this Claim Form is in no way an admission of liability.

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为了使您获得更及时有效的理赔服务，任何非紧急的情况下的住院、日间治疗、核磁共振(MRI)、电脑断层扫描(CT)检查在就诊前建议您首先得到本公司或本公司医疗热线服务的书面允许（包括传真/电邮/信函等方式）。如有疑问，您可以拨打您会员卡上的医疗热线电话咨询。

Please ensure that all costs for non-emergency In-Patient/Day-Patient Treatment, all MRI & CT Scans, are agreed by us, or Our Helpline, in writing (Fax/Mail/Letter) before any planned Treatment is undertaken. Planned Treatment undertaken without pre-authorization from us will not be covered. A verbal confirmation does not constitute pre-approval. If in doubt, please contact the Medical Helpline, as shown on Your Membership Card.

注意：对不同病症的索赔请分别填写理赔申请书。

PLEASE NOTE: A SEPARATE CLAIM FORM MUST BE COMPLETED FOR EACH CONDITION CLAIMED.

住院及日间治疗

Planned In-Patient & Day-Patient Treatment

为了使您获得更及时有效的理赔服务，如拟接受医院住院或日间治疗，建议您遵循以下步骤进行：

In the event of a planned admission on an In-Patient or Day-Patient basis to a Hospital, the following steps must be taken. Payment of all expenses incurred by You will not be recoverable unless You follow these procedures.

1. 在医院住院或日间治疗之前，尽快拨打本公司医疗热线电话，通知我公司您的症状、将要进行的治疗方案、治疗

项目和时间，以及就诊的医院和医生等详情。（本公司的医疗服务热线电话号码印制在您的会员卡背面）

Contact Our Medical Helpline as soon as reasonably possible prior to admission giving full details of the condition, proposed Treatment including dates and name of procedure (if known) together with the name of the Specialist and Hospital details. (The telephone number is provided on the back of Your membership card).

2. 本公司的医疗热线服务人员将确认您提供的信息是否完整或是否需提供进一步的信息。

The Medical Helpline will advise You if they have sufficient information to confirm Your cover. If not, they will advise You what further information is required.

3. 当您已提供了足够的信息后，本公司医疗热线服务人员将先口头确认我公司承担的基本保险责任,随后提交给您书

面的证明。

When sufficient information has been made available to appraise Your claim, the Medical Helpline will verbally confirm the basis of Your cover and will dispatch written confirmation to You.

4. 本公司医疗热线服务人员将尽可能地为您安排，直接由本公司将属于保险责任范围内的医疗费用支付给您就诊的

医院。此时您将无需支付医疗费用给医院。但该情况下请您在递交理赔申请表时，附上您从医院收到的未付的医疗费用的#5@p原件。

The Medical Helpline will attempt at all times to make arrangements with the Hospital for all eligible bills to be settled directly. Where this has been arranged You should send the original Claim Form and any unpaid invoices (if given to You by the Hospital) to Your China Life Claims Service.

5. 每人每次新的病症和不同的住院或留院观察请分别填写单独的理赔申请表。

Please ensure a new/separate Claim Form for each member, each new Medical Condition and each admission to Hospital is submitted.

门诊治疗

Outpatient Treatment

如果您在本公司指定的医疗网络范围以外进行门诊治疗，您须先支付全部医疗费用，然后再向本公司提交索赔申请。网络医院名单见：。

If you receive medical Treatment as an Outpatient, outside of Our Provider Network Treatment must be paid for in full by you at the time of the appointment and re-claimed from us.

如发生上述情形，请确保您和您的医生完整无误地填写了理赔申请表。并请将理赔申请表和索赔所需的支付凭证、处方、诊断书等资料（包括并不仅限于：医疗费#5@p原件、支付凭证、药品处方及医师的书面证明）提供给本公司。

In such circumstances please ensure that a Claim Form is completed by you and the Medical Practitioner or Specialist. Please remit this to your China Life Claims Service with all substantiating proof of your claim, including, but not limited to, the original invoice(s) and proof of payment, prescription and a written diagnosis from the Medical Practitioner.

请将您的理赔申请表递交给本公司康优理赔中心：

Please return your Claim Form to the following office:

Goodhealth Claim Service 康优全球医疗保险理赔中心

Unit 1306B, Harbour Ring Plaza, 上海黄浦区西藏中路18号 18 Middle Xi Zang Rd, 港陆广场1306B单元 Huang Pu District, Shanghai 邮编：200001 Zip code: 200001 传真：8621 6326 8525 Fax: 8621 6326 8525 理赔客服电话： Claim Service Hotline:

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10 800 110 0868 (中国电信 免费) 或 10 800 711 0942 (中国网通 免费)

+1 559 490 4958 (中国以外地区，对方付费) 电邮：chinaservices@goodhealthchina.cn

10 800 110 0868 (China Telecom toll-free) or 10 800 711 0942 (China Netcom toll-free) +1 559 490 4958 (collect, available worldwide)

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Pre-certification Medical Form

全球医疗保险索偿预先批核表格 International Healthcare Plan Pre-certification Medical Form

致: To:

传真: Fax No.:

电话: Tel No.:

日期:

Date:

出生日期:

DOB:

地址

Location:

联系电话

Contact No.

保单号:Policy No.: 日Day 日Day 月 Month 月 Month 由: 中国人寿股份有限公司From: China Life Insurance Company 传真: Fax No.: 电话: Tel No.: 年 页: Pages: Year 1 of 被保险人Insured: 年 Year 身份证号/护照号码：如索赔为人民币付款且大于1万元或外币付款且大于等值美元 1千元，请提供相关护照或身份证件复印件. ID No. / Passport No. : Please attach with your ID card/Passport copy if the claim amount is above RMB10,000 for RMB payment or above USD1,000 for Non-RMB payment 理赔号:Claim No.:

请经治医生填写下表To be completed by treating physician

经治医生: 咨询医生:

Treating Physician: Referring Doctor:

电话 Tel No.:

传真Fax No.:

电子邮件E-mail: 电话 Tel No.: 传真Fax No.: 电子邮件E-mail:

年Year

年Year 医院: 住院日期: 日Day 月Month Admitting Hospital: Admission Date: 医疗机构: 出院日期: 日Day 月Month Medical Facility: Discharge Date:

联系人: 电话: 传真: Contact Person: Tel No.: Fax No.: 请经治医生填写下表

To be completed by treating physician

需要治疗的疾病(如果是慢性病，请如实告知):

Condition requiring treatment (Please advise if a chronic condition):

根本病因 Underlying Cause

首诊日期: 日 月 初次发现症状时间: 年Year 日Day 月Month First consultation Date: Day Month Symptoms apparent from: 既往是否有这种疾病或出现过相似的症状? □否 □是 (如回答“是”请提供详细资料) Has this or any similar condition existed □No □Yes (if Yes please attach details) previously?

治疗方案/计划:

Proposed Treatment/Procedure:

目前的药物治疗:

Medication currently taken:

病人以何种方式在医院治疗:

Admit as: 住院病人 In-patient □ 日间病人

Day patient □ 门诊病人

Out-patient □ 年Year

建议住院日期: 日月 年 预计住院时间: Proposed admission Day Month Year Estimated Length of stay: date:

费用概算(请各相关部门填写)

Cost Estimate (to be completed by all relevant parties)

手术费（近似） 麻醉费（近似）

Surgeons fee (approx) Anaesthetist Fee (approx)

床位费 住院费（近似）

Room Rate Hospital Charges (approx)

同意支付的费用 按时付款的折扣

Agreed Fee Prompt Payment Discount

费用总计Package Cost

医生签名/医院签章 日期:

Signature Doctor / Hospital Authority Date:

日Day 月Month 年Year

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请将病人所有的检查报告和实验室检查结果的资料发送电子邮件chinaservices@goodhealthchina.cn或传真至以下号码: +8621 6326 8525。

Please return by e-mail to chinaservices@goodhealthchina.cn or fax to +8621 6326 8525 along with full medical reports held in respect of the patient and any laboratory test results.

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