Administered by

CLAIM FORM

IMPORTANT INFORMATION
Return this form with original invoices to: Bupa Global, Victory House, Trafalgar Place, Brighton, BN1 4FY, UK.
If you have any questions when completing this form, please call us on +44 (0) 1273 323 563
Raffles Health Insurance Pte Ltd (“RHI”) (Company Registration Number: 200413569G) is the insurer and Bupa Global, the trading name of Bupa Insurance
Services Limited, is the administrator of RHI international health insurance plans in Singapore.
Please ensure that all sections of the claim form are fully completed. Note that claims payment may be delayed if all sections of the claim form are not
completed in full. The form should be returned to us within six months of the initial treatment date. Always enclose the original invoices - photocopies,
receipts and credit card vouchers are not acceptable. Please write clearly in black ink and BLOCK CAPITALS.
Please complete a new / separate claim form for: {{ each patient {{ each in-patient / day-case stay {{ each medical condition {{ each currency
If you have more invoices, you do not need to send a further claim form. Just send the invoices with a covering letter stating the condition and payment
instructions. If the condition continues for more than six months, we may request a new claim form to be completed.
We are unable to return original documents, but we will be happy to provide certified copies on request.

This policy is protected under the Policy Owners’ Protection Scheme which is administered by the Singapore Deposit Insurance Corporation (SDIC). Coverage for your policy is
automatic and no further action is required from you. For more information on the types of benefits that are covered under the scheme as well as the limits of coverage, where
applicable, please contact your insurer or visit the GIA/LIA or SDIC web-sites (www.gia.org.sg or www.lia.org.sg or www.sdic.org.sg.)

1 PATIENT’S DETAILS (to be completed by the person undergoing treatment)

Patient membership number: Group name (if applicable):

BI - - -

Title:

First name:

Family name:

Other names:

Date of birth: D D M M Y Y Age last birthday:

Current correspondence address:

Building:

Street:

Town / city:

Area code: PO Box:

Region:

Country:

Email:

Telephone (Please include country code, area code and number):

Do you want all future correspondence sent to this address? Yes   No 

If posting your claim to us, would you like an email acknowledgement to confirm receipt of your claim? Yes   No 

If yes to email, please write your email address clearly here

Insured by
 (all sections must be completed by the Medical Practitioner /
2 CLAIM/MEDICAL DETAILS Dental Surgeon in overall charge of the patient’s treatment)

In which country did the treatment take place?

What is the currency of the invoice?

What is the total amount of the claim?

Medical Practitioner’s details:

Name:

Address:

Telephone (Please include country code, area code and number):

Qualifications:

Reason for treatment / visit to medical practitioner

Onset date when symptoms first noticed by patient: D D M M Y Y

When did the patient first see a doctor? D D M M Y Y

Details of treatment:

Details of operation:

Details of medication:

Dental treatment

Annual check Preventive

Major restorative Orthodontics

Accident / emergency treatment

Details of treatment:

Hospital dates: Admission date: D D M M Y Y Discharge date: D D M M Y Y

Name and address of admitting hospital: Reference number:

Name:

Address:

Telephone (Please include country code, area code and number):

Fax:

Email:
 2 CLAIM / MEDICAL DETAILS
Medical practitioner’s / dental surgeon’s signature

Print Name: Date D D M M Y Y

3 CASH BENEFIT

The hospital should complete this section if there were no charges for your overnight admission, and your plan includes a cash benefit

I confirm that
was in hospital  from           to
And this admission was free of charge

The hospital needs to stamp this claim form here:

4 PAYMENT DETAILS

IMPORTANT INFORMATION

We can settle claims in over 80 currencies. This must be in one of the following; (i) the currency in which you pay your premium (ii) the currency of the
invoices you send us or (iii) the currency of your bank account.

Who would you like us to pay? (tick one only)

Doctor/hospital Principal member Patient Group (if on a company plan)

Please complete either Section A or Section B

Section A – Payment by Electronic Funds Transfer to a bank account

Bank name:

SWIFT / BIC code:*

Sort code (UK only): - -

Account number:

FULL IBAN NUMBER:*

Account name / payee:

Currency for the transfer:

Bank address:

Post / Zip code:

Country:

*To process your payment as quickly and securely as possible, we strongly recommend this option as a preferred payment method. Please provide both
your IBAN and the SWIFT code of your bank branch. Your bank will be able to provide you with this information if necessary.
We recommend that bank transfers are made in the currency of your bank account. If you submit a claim and have asked us to pay you, your benefit will be paid less the amount
of deductible or co-insurance applicable to your plan. If you have asked us to pay the provider, and an annual deductible or co-insurance applies to your cover, the shortfall will
be collected using your direct debit or credit card. If you are part of a company plan, we will send payment to the medical provider for the eligible claim. We will deduct from this
payment the remaining annual deductible or co-insurance on your membership. You are responsible for paying any shortfall to the provider after your claim has been assessed and
paid. To find out if you have a co-insurance or deductible on your plan, please refer to your membership certificate. To find out more about how co-insurances and deductibles work
please refer to your membership guide
 4 PAYMENT DETAILS CONTINUED
Section B - Payment by cheque
In which currency would you like us to pay the cheque (please tick one only)

Currency of your invoices Currency of your premiums

Currency of your bank account

Please specify this:

Cheques payable to members will be sent by post to the correspondance address provided on the front page

5 YOUR CONSENT TO OBTAIN A MEDICAL REPORT

IMPORTANT INFORMATION
Please read this section carefully, as it sets out your rights under the Singapore Personal Data Protection Act 2012 / Do Not Call Regime and the
Access to Medical Reports Act 1988 and the Access to Personal Files and Medical Reports (NI) Order 1991.
I understand, acknowledge, agree and consent that:
(a) Raffles Health Insurance Pte. Ltd., Bupa Global, the trading name of Bupa Insurance Services Limited, who is the administrator of international health insurance policies in
Singapore and the General Insurance Association of Singapore (“GIA”) may/are permitted to collect, use, disclose and/or process my personal data/personal information set out
in this form and any other personal information provided by me or possessed by Raffles Health Insurance Pte. Ltd. and Bupa Global (collectively the “Personal Information”) and
disclose and transfer such Personal Information to reinsurers, lawyers /law firms of Raffles Health Insurance Pte. Ltd. or Bupa Global and the Monetary Authority of Singapore
and any relevant government agency/authority (such as the police), for the purpose(s) of:
(i) processing, handling and/or dealing with my claims including the settlement of the claims and any necessary investigations relating to the claims;
(ii) investigating the accident and/or my claims;
(iii) carrying out and/or dealing with my instructions or responding to any enquiries by me;
(iv) administering my claims (including the mailing of correspondence, statements, invoices, reports or notices to me, which could involve disclosure of certain personal data
about me to bring about delivery of the same as well as on the external cover of envelopes/mail packages); and/or
(v) complying with applicable law in administering, processing, handling and/or dealing with my claims. (collectively the “Purposes”)

(b) Reinsurers, lawyers /law firms of Raffles Health Insurance Pte. Ltd. and lawyers /law firms of Bupa Global may/are permitted to collect, use, disclose and/or process my
Personal Information for one or more of the above Purposes; and
(c) my Personal Information may/can be disclosed by any of the Insurers and/or GIA to their third party service providers or agents (including their lawyers/law firms), which may
be sited outside of Singapore, for one or more of the above Purposes.

Member Name:

NRIC No / Passport No:

Member’s signature: Date

Contact address: If you do not wish to receive information about products and services, or have any other Data Protection queries please write to your administrator’s Head of
Information Governance, at Bupa, 1 Angel Court, London EC2R 7HJ or at [email protected].

6 THIRD PARTY INSURERS

Are some of the costs recoverable from someone else (for example, state insurer or a person / organisation involved in an accident?): Yes  No 

Name:

Address:

Email:

Telephone (Please include country code, area code and number):

P7 P
I VA C YRNIOVA
TICC
E Y N OT I C E
We are committed to protecting your privacy when dealing with your 6 Sharing your information
personal information. This privacy notice provides an overview of the We share your information within the Bupa Group, with relevant
information we collect about you and how we use and protect it. It also policyholders (including your employer if you are covered under a group
provides information about your rights. Fuller details can be found in our scheme), with funders commissioning services on your behalf, those acting
Full Privacy Notice available at: www.ihi.com/privacy. If you do not have on your behalf (e.g. brokers and other intermediaries) and with others
access to the internet and would like a paper copy of the Full Privacy who help us provide services to you (e.g. healthcare providers) or from
Notice, please contact the Bupa Global service team on +45 70 23 00 42. whom we need information to handle or verify claims or entitlements (e.g.
Alternatively you can email or write to the team via [email protected] or Bupa professional associations). We also share your information in accordance
Global, Palægade 8, DK-1261 Copenhagen K, Denmark. If you have any with the law.
questions about how we handle your information, please contact us at
[email protected] All correspondence concerning your policy, including documents
containing sensitive information such as medical details, will be sent to the
Information about Bupa Global policyholder and may be sent via your intermediary. All insured persons
In this privacy notice, references to ”we” or ”us” or “our” are to Bupa Global. on the policy may have access to correspondence and other information,
For company contact details, visit www.ihi.com/legal-information including documents containing sensitive information such as medical
details, sent by Bupa Global or accessed at www.ihi.com via the myPage
1 Scope of our privacy notice login.
This privacy notice applies to anyone who interacts with us in relation
to our products and services (“you”, “your”), via any channel (e.g. email, 7 Transfers outside of the European Economic Area (EEA)
website, telephone, app). Bupa Global deals with many international organisations and uses global
information systems. As a result, Bupa Global transfers your personal
2 Ways in which we obtain personal information information to countries outside of the European Economic Area (”EEA”),
We obtain personal information from you and from certain third parties that is the EU member states and Norway, Liechtenstein and Iceland, for the
(e.g. those acting on your behalf, like brokers, healthcare providers). Where purposes set out in this privacy notice.
you provide us with information about other individuals, you must ensure
that they have seen a copy of this privacy notice and are comfortable with 8 How long we retain your personal information
you doing this. Bupa Global retains your personal information in accordance with retention
periods calculated in accordance with the criteria detailed in the Full
3 Categories of personal information Privacy Notice available on our website.
We process two categories of personal information about you and/or, where applicable,
your dependants, namely standard personal information (e.g. information we use to 9 Your rights
contact you, identify you or manage our relationship with you); and special categories of You have rights to have access to your information and to ask us to rectify,
information (e.g. health information, information about race, ethnic origin and religion that erase and restrict use of your information. You also have rights to object to
allows us to tailor your care, and information about crime in connection with screening). your information being used, to ask for the transfer of information you have
made available to us, to withdraw consent to the use of your information
4 Purposes and lawful grounds of our processing personal information and not to be subject to automated decision-making which produces legal
We process your personal information for the purposes set out in our Full effects concerning you or similarly significantly affects you.
Privacy Notice, including to administer our relationship with you (including
for claims and complaints handling), for research and analysis, to monitor 10 Data Protection Contacts
our expectations of performance (including of health providers relevant to If you have any questions, comments, complaints or suggestions in relation
you) and in order to protect the rights, property, or safety of Bupa Global, to this notice, or any other concerns about the way in which we process
our customers, or others. The legal ground upon which we process personal information about you, please contact us at [email protected].
information depends on what category of personal information we process.
Standard personal information is normally processed by us on the basis You also have a right to make a complaint to your local privacy supervisory
that it is necessary for the performance of a contract, our or a third party’s authority. Bupa Global’s main establishment is in the UK, where the local
legitimate interests or it is required or permitted by applicable law. supervisory authority is the Information Commissioner, who can be
contacted at: Information Commissioner’s Office, Wycliffe House, Water
5 Processing for Profiling and Automated Decision Making Lane, Wilmslow, Cheshire SK9 5AF, United Kingdom. Tel: 0303 123 1113 (local
Like many businesses, we sometimes use automation to provide you with rate) or 01625 545 745 (national rate)
a quicker, better, more consistent and fair service, as well as with marketing
information we think will be of interest (including discounts on our products
and services). This may involve evaluating information about you and, in some
cases, using technology to provide you with automatic responses or decisions.
You can read more about this in our Full Privacy Notice. You have the right to
object to direct marketing and profiling relating to direct marketing. You may
also have rights to object to other types of profiling and automated decision-
making. Further details are available in our Full Privacy Notice.

8 DECLARATION
IMPORTANT INFORMATION - TO BE COMPLETED BY THE PATIENT

I confirm that the information I have given on this form is accurate, correct and complete, to the best of my knowledge. I confirm
that I give explicit consent, within the provisions of all applicable data processing law and regulation, to the processing of my
personal information with respect to this claim, as set out under this form. I give explicit consent on behalf of myself or the
patient (if acting on the patient’s behalf) for the doctors and any other medical providers responsible for my treatment, care or
other services provided to me, to provide Bupa Global or its service partners with any information requested in connection with
this claim or any past claim, for the purpose of considering, processing, auditing or otherwise handling this claim.

Patient’s signature (Parent or guardian if patient is under 16)

SGP-GENE-CLAF-EN-1904-V1.01-XXXX-0012888

Print Name: Date D D M M Y Y

If you have any queries regarding your claim, log onto our website www.bupaglobal.com/membersworld or contact our customer services team on:
{{ Telephone: +44 (0) 1273 323 563 {{ Fax: +44 (0) 1273 820 517  {{ Email: [email protected]
Email is used for your convenience and speed, but we cannot always guarantee the security of this method of communication. You need to be aware that
some companies and countries do monitor email traffic. You need to take this into account when choosing to use this method of communication.
Please refer to your membership certificate for details of your insurer.

Raffles Health Insurance Pte Ltd | Company Registration No. 200413569G |Corporate Office: 585 North Bridge Road Raffles Hospital #11-00 Singapore 18870