CLAIM FORM Maternity MEAF RSA 69041 3
CLAIM FORM Maternity MEAF RSA 69041 3
CLAIM FORM Maternity MEAF RSA 69041 3
Treatment Reimbursements
E-mail:
Daytime phone: Evening phone:
Does the patient have another insurance plan or policy that covers maternity costs? Yes No
If ‘Yes’, provide the other insurer’s details including the name of the insurer, the insurer’s address and the patient’s plan or policy
number with that insurer:
Failure to complete all information for the chosen reimbursement method may result in you, the named person or entity:
• experiencing delays in receiving the claim settlement; and
• incurring additional bank charges.
1. Bank transfer – this is the quickest and safest method of payment
Name of account holder:
If the claimant’s name (as given in Section 1) is different to the account holder name, please provide the following details
Address of account holder:
E-mail address of account holder:
Telephone number of account holder:
Relationship to the claimant:
Bank account details
Bank name:
Bank address (including town/city and country):
BIC/SWIFT code:
Payment currency:
Currency of bank account:
Account number:
To help us direct your payments efficiently, supply the following as relevant
IBAN number (mandatory for all payments to bank accounts in countries that have adopted IBAN):
E-mail:
Date the patient first registered with you/the clinic/the hospital (mm/dd/yyyy):
2. Details of pregnancy
a) Date of the patient’s LMP (mm/dd/yyyy):
b) How many weeks pregnant is the patient?
c) Is the pregnancy a result of any infertility treatment including infertility medication or conception by artificial means? Yes No
d) Expected type of delivery: Normal Vaginal Delivery C-Section
If ‘C-Section’, advise the reason:
e) Provide relevant details of any previous complicated pregnancies or complicated childbirth:
f) Does the patient suffer from any medical conditions that might put the current pregnancy at risk? Yes No
If ‘Yes’, provide details:
g) Is the reason for this visit Routine antenatal checkup? Antenatal complications?
If this visit is for ‘Antenatal complications’ provide details:
3. Declaration
I declare that to the best of my knowledge and belief the information I have given in the Medical section of this Claim form is full, true
and complete.
Medical practitioner’s/specialist’s signature: Date (mm/dd/yyyy):
Practice stamp
Sections 1 to 5 must be completed by the patient, or the main member on behalf of the patient if the patient is a dependant under the age
of 18.
Section 6 must be completed by the patient’s medical practitioner or specialist unless the claim is for:
• a routine follow up
For any other type of claim, we understand that it may not always be possible to have Section 6 completed by the medical practitioner or
specialist. In such circumstances, we will process the claim if the invoices and receipts for the treatment costs incurred contain all of the
following:
• diagnosis of the medical condition treated;
• treatment date;
• type of treatment; and
• the medical provider’s official stamp.
We may need to contact the patient’s medical practitioner or specialist for more medical information in order for us to process the claim under
the terms and conditions of the policy. We will tell you if we need to do this.
A quick guide on how to submit your claim. For detailed information, please refer to the “Your guide to making a claim” section in
your Member Handbook.
Send us the claim within 180 days of the first treatment date. You must send the following items to make sure that we can process your claim:
Important information
Please remember these important points when completing your Claim form.
Section 4 – Declaration
If the declaration has not been read and signed, we will not be able to process the claim.
(continued)
• If you are not personally seeking reimbursement we will pay the treatment provider directly, as long as the payment instructions are
shown clearly on the invoice.
• If you are personally seeking reimbursement, we will only issue payment to:
• the patient if they are 18 or over;
• the plan holder if the patient is under 18 and is a dependant under the plan; or
• the parent or legal guardian named as the primary member, if the patient is under 18.
• Ensure that you are able to receive payment in the method and currency you have requested.
• We reserve the right to pass on any payment charges incurred by us for cancelling the original payment due to inaccurate information
submitted to us.
• We will not be responsible for any payment shortfall due to exchange rate fluctuations and/or recipient bank service charges. Please
contact your bank for further details.
• If you do not give us the sort code/routing code, BIC/ SWIFT code and/or IBAN number, you may incur additional bank charges and it
will result in a delay in us paying your claim. You can find the payment information on your bank statement.
• Payment by foreign draft / cheque in certain currencies can result in long delays. These delays are beyond our control. We will not
pay any bank charges incurred in encashing a foreign draft / cheque. We strongly recommend that, wherever possible, you choose to
be reimbursed by bank transfer as this is the quickest and safest method of payment.
• We can make payment in most readily traded currencies and to most countries. In the event that we are unable to make payment in
the currency or to the country you have specified, we will contact you to confirm an alternative currency. If you do not specify a
payment currency, we will pay your claim in the base currency of your plan. For the current list of applicable currencies and countries
please refer to our website.
• Your bank may ask you to complete additional paperwork before they can release our payment to you. This may delay your receipt of
the payment and is outside our control.
• Whenever coverage provided by any insurance policy is in violation of any U.S, U.N or EU economic or trade sanctions, such
coverage shall be null and void. For example, RSA & Aetna companies cannot pay for health care services provided in a country
under sanction by the United States unless permitted under a written Office of Foreign Asset Control (OFAC) license. Learn more on
the US Treasury’s website at: www.treasury.gov/resource-center/sanctions.
We know you may have questions and we're always here to help. You can call us any time on the phone number listed on the back of your
RSA - Aetna ID Card.
You can also send us a secure e-mail by logging in to www.aetnainternational.com and clicking 'Contact us'
You can scan your claims to us, rather than post them. It is important that any claim you send to us is done either by scan or originals, but
not both.
Health insurance plans and programs are offered, underwritten, reinsured or administered by Royal & Sun Alliance (Middle East) BSC ©, Aetna Life &
Casualty (Bermuda) Ltd, Aetna Global Benefits (Middle East) LLC and its subsidiary companies and various global partners. Information is believed to
be accurate as of the production date; however, it is subject to change.
Aetna® is a trademark of Aetna Inc. and is protected throughout the world by trademark registrations and treaties.
RSA & Aetna do not provide care or guarantee access to health services. Not all health services are covered. Health information programs provide
general health information and are not a substitute for diagnosis or treatment by a health care professional. See plan documents for a complete
description of benefits, exclusions, limitations and conditions of coverage. Information is believed to be accurate as of the production date; however, it is
subject to change. For more information, refer to www.AetnaInternational.com.
RSA & Aetna companies cannot pay for health services provided in a country under sanction by the United States unless permitted under a written
Office of Foreign Asset Control (OFAC) license. Learn more at US Treasury’s website at www.treasury.gov/resource-center/sanctions