RPA MAPFRE Health Insurance Claim Form

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Health Insurance Claim Form
Important Notes

All Treatment must be undertaken and given by and under the control of a Specialist or your General Practitioner. A referral by a Specialist is required for CT/MRI Scans, Hospital Admissions, Alternative and Psychiatric Treatment.

For approval of cover for planned In-patient/ Day Case Treatment you must always contact MAPFRE Middlesea at healthclaims@middlesea.com to confirm eligibility and extent of cover.

All Claims documentation must be submitted within 3 months of initial date of treatment.
1. Policy Holder/Patient Details
Policy Number
Please refer to your membership certificate
Policy fill counter
Start with counter
Invalid Policy number - Your Policy number should be 13 digits long and starts with 151,152,153 or 281
Group / Company Name*
if applicable
ID Type*

ID Card (Malta)Passport
ID. Card Number*
Expected format: 7 Numbers 1 Character
Passport Number*
Patient's Name*

First NameLast Name
Date of birth*

DayMonthYear
Current Date

DayMonthYear
Age
Legal Guardian's Name*

First NameLast Name
ID Type*

ID Card (Malta)Passport
ID. Card Number*
Expected format: 7 Numbers 1 Character
Passport Number*
Date of birth*

DayMonthYear
Email*
Landline/Mobile No. Country Code*
Landline/Mobile Number*
Landline/Mobile Number*

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2. Reason for Seeking Medical Advice
Consultations*

One VisitMultiple Visits
Number of Visits*
Date of First Consultation*

DayMonthYear
Date of Last Consultation*

DayMonthYear
Date of first consultation must be before date of last consultation
Medical Professional*
Reason for seeking medical advice*
Reason for seeking medical advice*
Symptoms/Diagnosis*
Symptoms/Diagnosis*
Symptoms/Diagnosis*
Symptoms/Diagnosis*
Symptoms/Diagnosis*
Reason for seeking medical advice*
Symptoms/Diagnosis*
Other Medical Professional*
Other reason*
Amount of Expense being claimed in Euro*
Over €30
Under €30
Please confirm treatment given*
Please advise treatment given*
'Cause' Tron Mapping

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3. Documentation Upload
Upload file checklist*

Claim Form - Signed by ClaimantReceipts*Itemised Invoice*Results/Reports if any
Upload files*

Cancelof
* Invoices that are not supported by receipts will not be eligible for reinbursement
You may utilise the existing paper based claim form to obtain details of your medical condition and the signature/stamp of your medical practitioner. Alternatively please ask for your medical practitioner to sign and stamp a detailed medical report and subsequently taking a picture and uploading.

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4. Bank account details

to facilitate any claim payments
We cannot process claims without this information. Please complete all fields and provide correct details.
Payment Instructions

Use Direct Credit details already on fileUse the details below for this and all future claimsCheque against a bank & administration charge
Beneficiary Bank Compliance*
Beneficiary Account Name and Surname*

First NameLast Name
Sort Code
IBAN number (Local)*
Ex: MT-14-AAAA-12345-XXXXXXXXXXXXXXXXXX
IBAN number*

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Declaration
I understand that in the event of an incomplete and/or non-disclosure of material information, MAPFRE Middlesea p.l.c reserves the right to repudiate the claim. I authorise MAPFRE Middlesea p.l.c. to share information with others (including insurers and Insurance Associations) in order to prevent fraudulent claims. I declare that all the answers given and the statements made are true and correct. Furthermore I declare that I have not withheld any information relevant to the claim. I give explicit and unequivocal consent to MAPFRE Middlesea p.l.c. to seek any information from any doctor, surgeon, hospital, clinic, laboratory or persons that have records or knowledge of my health in order for the validity of the claims to be established.

I hereby authorise any doctor, surgeon, hospital, clinic, laboratory or persons that have records to provide full medical information concerning myself and my dependants.

I give consent to MAPFRE Middlesea p.l.c. to process my personal data supplied by myself or any person, body or entity in order to process, handle and settle the claim.
Signature Date

DayMonthYear
DATA PROTECTION

MAPFRE Middlesea p.l.c. is legally bound to follow the provisions of the Data Protection Act, 2018. If you require any further information about how MAPFRE Middlesea Plc processes your personal data, please follow this link https://www.mapfre.com.mt/privacy-policy .
MAPFRE Middlesea p.l.c. (C-5553) is authorised by the Malta Financial Services Authority (MFSA) to carry on both Long Term and General Business under the Insurance Business Act. MAPFRE Middlesea p.l.c. is regulated by the MFSA.
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Health Insurance Claim Form

1. Policy Holder/Patient Details

2. Reason for Seeking Medical Advice

3. Documentation Upload

4. Bank account details

Declaration