Mainly Health Plans SL
6. Making a claim ( Guide )
At times of ill health, you want to concentrate on getting well. We will do everything we can to make your claim as simple and straightforward as possible.
6.1 How to make a claim
Claim forms
Your claim form is important as it gives us the information that we need to process your claim. If it is not fully completed we may have to ask for more information. This can delay payment of your claim.
You must complete a new claim form:
* for each member
* for each condition
* for each in-patient or day-case stay, and
* for each currency of claim.
If a condition continues over six months we will ask for a further claim form to be completed.
What to send us
You need to return the completed form to us by post, with the original invoices, as soon as possible. This must be within six months of receiving the treatment for which you are claiming. Invoices sent to us after six months will not normally be paid.
Requests for further information
We may need to ask you for further information to support your claim. If we do, you must provide this. Examples of things we might ask for include:
* medical reports and other information about the treatment for which you are claiming.
* the results of any medical examination performed at our expense by an independent medical practitioner appointed by us
* written confirmation from you as to whether you think you can recover the costs you are claiming from another person or insurance company.
If you do not provide the information that we ask for, we may not pay your claim in full.
Important
When making a claim please note:
* you must have received the treatment while covered under your membership
* payment of your claim will be under the terms of your membership and up to the benefit levels shown, that apply to you at the time you receive the treatment
* we will only pay for treatment costs actually incurred by you, not deposits or advance notices
* we will only pay for treatment costs that are reasonable and customary
* we do not return original documents such as invoices or letters. However, we will be pleased to return certified copies if you ask us when you submit your claim.
Confirmation of your claim
We will always send confirmation of how we have dealt with a claim. For child dependants (those aged under 18 years) we will write to the principal member. If the claim is for treatment received by the principal member, or an adult dependant (those aged over 18 years), we will write directly to the individual concerned.
6.2 How your claim will be paid
Whenever possible, we will follow the instructions given to us in the "Payment details" section of the claim form.
Who we will pay
We will only make payments to the member who received the treatment, the provider of the treatment, the principal member of the membership or the executor or administrator of the member's estate. We will not make payment to anyone else.
Payment method and bank charges April 2009 updates
We will make payment where possible by electronic transfer or by cheque. Payments made by electronic transfer are quick, secure and convenient. To receive payment by electronic transfer, we need the full bank account, SWIFT code, bank address details and (in Europe only) IBAN number to be provided on the claim form.
We will instruct our bank to recharge the administration fee relating to the cost of making the electronic transfer to us but we cannot guarantee that these charges will always be passed back to us to pay. In the event that your local bank makes a charge for a wire transfer Bupa International will aim to refund this as well. Any other bank charges or fees, such as for currency exchange, are your responsibility.
Cheques will no longer be valid if they have not been cashed within 12 months. If you have an out-of-date cheque please contact customer service services, who will be happy to arrange a replacement for you.
Payment currency and conversions
We can pay in the currency in which you pay your subscriptions, the currency of the invoices you send us or the currency of your bank account.
We cannot pay you in any other currency.
Sometimes, the international banking regulations do not allow us to make a payment in the currency you have asked for. If so, we will send a payment in the currency of your subscriptions.
If we have to make a conversion from one curency to another we will use the exchange rate that applies on either the date on which the invoices were issued or the last date of the treatment, whichever is later.
The exchange rate used will be the average of the buying and selling rates across a wide range of quoted rates by the banks in London on the date in question. If the date is not a working day we will use the exchange rate that applies on the last working day before that date.
6.3 Other claim information
Discretionary payments
We may, in certain situations, make discretionary or 'ex-gratia' payments towards your treatment. If we make any payment on this basis, this will still count towards the overall maximum amount we will pay under your membership. Making these payments does not oblige us to pay them in the future.
We do not have to pay for treatment that is not covered by your plan, even if we have paid an earlier claim for a similar or identical treatment .
Claiming for treatment when others are responsible.
You must complete the appropriate section of the claim form if you are claiming for treatment that is needed when someone else is at fault, for example in a road accident in which you are a victim. If so, you will need to take any reasonable steps we ask of you to:
* recover from the person at fault (such as through their insurance company) the cost of the treatment paid for by BUPA International, and
* claim interest if you are entitled to do so.
Note: Subrogation
In the event of any payment of any claim under your membership, BUPA International or any person or company that it nominates may be subrogated to all rights of recovery of the member and any person entitled to the benefits of this coverage. The member shall sign and deliver all documents and papers and do whatever else is necessary to secure such subrogated rights to BUPA International or its nominated party. The member shall do nothing after the claim to prejudice such rights.
Claiming with joint or double insurance
You must complete the appropriate section on the claim form, if you have any other insurance cover for the cost of the treatment or benefits you have claimed from us. If you do have other insurance cover, we will only pay our share of the cost of the treatment.