Section V - Claims Process and Procedures

Making Claims: Please also refer to the member guide for details of how to make a claim.

1) Claims Reimbursement Process

a) Before AXA Insurance can consider a claim, the member must ensure that:
(i) the member sends AXA Insurance a completed claim form as soon as they can and
no later than 90 days from the date the treatment starts; and
(ii) we receive original invoices for treatment costs; and
(iii) the member promptly gives AXA Insurance all the information we request.
(iv) the claim is for the level of benefits, as shown in the benefits table

b) What documentation is required to submit a reimbursement claim?

(i) Before submitting any claim on a reimbursement basis to AXA Insurance, it is very
important to ensure that all of the sections of the claim form have been completed
and you have attached all the supporting documentation.

(ii) For reimbursement you need to ensure that:

 all fields on the claim form are complete including symptoms and treatments are
complete. If the Medical Practitioner has missed anything you will need to go
back and ask him/her to properly complete his/her sections of the form.
 the claim form is stamped and signed by the treating medical practitioner
 the claim form is signed and dated by you.
 original invoices with itemized breakdown of services and proof of payment
(receipts) are attached.
 physician prescriptions & referral (if any) are attached.
 investigation results (if any) are attached
 medical reports (if any) are attached*
 discharge summary (if any) is attached
 documentation relating to any medical service that you have paid for.

*Please note that AXA Insurance will only pay for eligible treatment costs, and not for
deposits or advance invoices or registration or administration fees charged by the
provider of treatment

c) How to submit my reimbursement claim?

(i) The member can submit a reimbursement claim online from the comfort of a home
or office. All you have to do is visit our website at www.axa-gulf.com

 enter the personal details

 enter treatment details
 upload the claim documents
 the member will then receive a reference number by email or SMS
 using the reference number you can track the journey of the claim
(ii) Alternatively the member may send the claim by post or visit one of the AXA
Insurance branches with all of the completed required documentation (as listed
within the reimbursement claims process).

(iii) Please be aware that all documentation and claims must be submitted within 90
days of receiving the treatment for which you are claiming. Invoices sent to AXA
Insurance after 90 days of treatment will not be eligible for settlement. Please be
aware when submitting any documentation online, the member must retain all of
the originals as AXA Insurance retains the right to request these on a periodic basis
for further assessment.

(iv) If for any reason the claim form and supporting documentation is incomplete, this
could result in the claim being returned to you for completion and may delay the
processing of the claim

(v) Please note that the date of receipt of all complete documents required to
substantiate, assess and validate the claim will be treated as the first date of receipt
of the claim for administration purpose. It is therefore in the member’s interest to
ensure that all requirements are fully met to minimize any delay. Where AXA
Insurance is required to obtain further medical reports to clarify aspects of
treatment it reserves the right to withhold payment of any claim until all such
reports are received and properly evaluated.

(vi) Please be aware it is important that you provide all of the relevant information as
listed in the reimbursement claims process to ensure there is no delay in the claims
settlement. AXA Insurance will use its best endeavours to settle all eligible
reimbursement claims within 15 working days following receipt of completed
documents as detailed above, and as per terms and conditions of this Agreement.

(vii) Please be aware that whilst AXA Insurance ensures that the reasonable and
customary payment is fair and reflective of the level of cover you have, choosing a
provider outside of our network can result in you contributing towards the cost of
the treatment. AXA Insurance therefore encourages you to use the designated
provider network to avoid any potential shortfalls in treatment costs.

(viii) Unless agreed otherwise with AXA Insurance in writing, claim costs incurred in any
currency other than what the plan has been set-up in, will be converted using the
HSBC daily published exchange rate for all currencies except US Dollar. For US
Dollar the fixed rate of 3.67 will be used when we assess the claim.

If we agree, in writing, in advance to reimburse benefits to a member in a currency

other than what is outlined in the benefits table, the exchange rate used will be as
above. Any exchange costs incurred will be payable by the member and will be
subtracted from any payment made to the member in respect of such a claim.
2) Prior-approval claims process
Prior-approval is a process whereby AXA Insurance and/or our appointed TPA reviews and
gives its decision on treatment proposed by the treating Physician for which an approval is
required. We or our appointed TPA will approve, reject or require further information.
AXA Insurance will authorize the prior approval in conjunction with the member, the
attending medical practitioner and the provider, to ensure that appropriate solutions are
being utilized.

a) Written prior-approval is required for treatments such as (but not limited to) the
following:
(i) In-patient and Daycare treatment
 All In-patient and daycare admissions, including laboratory tests, diagnostic
tests, surgery and all other medical services
 In-patient maternity services
 In-patient dental services
 Psychiatric treatment

(ii) Out-patient treatment

 For all treatment exceeding or which are likely to exceed AED 1,000, QAR 1,000,
OMR 100, BD 100 or equivalent (these amounts may change depending on the
country of treatment)
 MRI, CT, PET and Gait Scans and internal diagnostics such as but not limited to
endoscopy, colonoscopy, gastroscopy, etc
 Physiotherapy services
 Alternative/Complementary therapy services
 Prescriptions or other medication required for more than 30 days.
 Dental/Optical/Health screen services
 Maternity treatment
 Psychiatric treatment

b) Members must ensure that designated providers network contact AXA Insurance for
pre-authorization. Pre-authorization will not normally be given to the member.

c) Please note that if the member does not obtain prior approval as required, it may
prevent AXA Insurance from settling all or part of any claim. AXA Insurance pays only
for treatment charges which are, in our experience, reasonable and customary
depending on the level of cover.

d) Prior approvals are cost, time and benefit specific. If any details on the original prior
approval change, such as (but not limited to) cost, time, benefit, etc; a further written
prior approval should be obtained from AXA Insurance.

e) If the illness or injury is not covered by the policy or if the member has reached the
policy limits for the benefit the member will be required to pay any shortfall to the
provider. We reserve the right to recover any such sum not thus paid, being due for
ineligible treatment, from the member or the company.
 f) AXA Insurance will not authorize any treatment nor make any direct settlement
arrangement if any premium due is outstanding.

g) Please note: Failure by the member or member’s representative to follow pre-

authorization procedures, (for non-emergency cases) which allow AXA Insurance to
manage claims costs, where such failure results in costs which are over and above
those negotiated as available to AXA Insurance members will render the member liable
to bear the difference between the negotiated or negotiable cost and the price actually
charged.

3) Network and Non-network claims

a) As an AXA Insurance member you have the option to access designated providers
networks within the region and across the globe, as applicable to the plan. You will
benefit from this extensive designated provider network that works with AXA Insurance
to provide direct settlement facilities.

AXA Insurance reserves the right not to entertain claims of any kind including
reimbursement claims from the list of providers included in the member’s welcome
pack at the latest renewal. Please note that this list is not exhaustive and is subject to
amendment by AXA Insurance at any time.

This list is subject to change and you would find the latest updated list in our website.
You can search for different types of medical providers including hospitals, clinics,
pharmacies, medical centres, radiology centres, dentists, optical centres and many
more across the globe.

Direct settlement is normally only available for in-patient, day-care or out-patient

treatment within designated network of medical providers unless AXA Insurance have
agreed otherwise in writing. It is in the interests of members to use the designated
network of medical providers.

This means that when you receive treatment at these providers, all bills will be settled
directly between the provider of the treatment and AXA Insurance, allowing you to
continue the treatment with complete peace of mind without having to worry about
the settlement of bills.

Please refer to the Benefits Table for the designated provider network and area of
cover shown for the plan.

b) Treatment within the designated provider network

(i) When a member visits a hospital or clinic within the designated provider network
shown for the plan, the hospital or clinic representative will request for the AXA
Insurance medical card, along with some form of identification, to validate
member eligibility.
 (ii) The member can then see the Medical Practitioner, who will give the treatment
you need, along with any prescription you might need and/or refer you for further
investigation.
(iii) At the end of this consultation the member and the Medical Practitioner should
complete and sign the claim form (the hospital or clinic will provide this).
(iv) Should there be any treatment that will require Prior-approval from AXA Insurance,
the designated medical provider will contact AXA Insurance directly in order to
obtain a prior approval for the medical treatment (including in an emergency).
(v) If the plan requires you to pay a deductible/coinsurance you must pay it before
leaving the clinic or hospital. Details of this are given on the AXA Insurance medical
card.
(vi) If you have been prescribed any medications, please obtain these from a
designated provider network pharmacy (this may be inside the clinic or hospital
itself). If not please refer to the Pharmacy Network shown for the plan.

If you wish to use a pharmacy outside the designated provider network take the
prescription with you to the pharmacy, collect the medication and a receipt.
You will need to submit the receipt as shown in the claims reimbursement process.

NB. Members are requested to not sign an empty, incomplete or incorrect claim forms.

c) Treatment Outside the designated provider network

(i) If you are visiting a hospital or clinic outside the designated provider network
shown for the plan, then there is no need for prior approval with AXA Insurance,
unless it is a treatment that is specifically listed as requiring a prior approval.

For planned treatment, you are requested to contact AXA Insurance at least 5 days
prior to the treatment taking place. Please contact AXA Insurance before the
treatment if you have any concerns.
(ii) You will be required to submit the claim for reimbursement as per the claims
reimbursement process.

4) Treatment outside of the area-of-cover

In case the plan provides coverage outside the area of cover and the same is mentioned in
the benefit table, this will be to cover emergency treatment, or treatment of a medical
condition which arises suddenly whilst outside the member’s area of cover. This benefit
does not provide cover for treatment for any condition if you have travelled outside the
area of cover to get treatment (whether or not that was the only reason) or for any
treatment which was, or may have reasonably been known about, before travel
commenced. Under no circumstance will benefit be payable for any aspect of pregnancy or
childbirth.

Wherever possible AXA Insurance will use its best endeavours to provide direct settlement
facilities for emergency in-patient admissions in even non-network providers. The member
or member’s representative should contact AXA Insurance as soon as possible after
 admission to allow AXA Insurance to co-ordinate events. Where direct settlement cannot
be arranged the member should refer to the Prior approval and claims reimbursement
process.

5) Emergency Treatment within the area-of-cover or outside of the area-of-cover

AXA Insurance knows that in a real emergency the member may not be able to contact us
for prior approval before the treatment. In such circumstances AXA Insurance takes a
pragmatic approach, so, we ask the member or their representative to contact AXA
Insurance beforehand if they can and it is safe to do so. If it is not, and the member needs
immediate treatment please make that the priority.

Do, however, ask somebody to contact AXA Insurance as soon as possible and make sure
that, at the earliest opportunity, whoever is providing treatment is given the members AXA
Insurance Medical card and form of identification so that they can contact AXA Insurance
immediately.

In any event, under these circumstances, AXA Insurance’s prior approval must be sought
and given before the member is discharged from the medical provider; otherwise the
member may be required to pay the entire cost of the treatment and submit the
reimbursement claim to AXA Insurance, as per the claims reimbursement process.

Please refer to the Benefits Table for details on the coverage for an emergency arising
outside the area of cover.

Please note: Failure by the member or member’s representative to follow pre-

authorization procedures, (for non-emergency cases) which allow AXA Insurance to
manage claims costs, where such failure results in costs which are over and above those
negotiated as available to AXA Insurance members will render the member liable to bear
the difference between the negotiated or negotiable cost and the price actually charged.

6) Shortfall
If the illness or injury is not covered by the policy or if the member has reached the policy
limits for the benefit the member will be required to pay any shortfall to the provider.

AXA Insurance reserve the right to recover any such sum not thus paid, being due for
ineligible treatment, from the company. The member will still be eligible for the
discounted rates applicable to AXA Insurance members even when required to make a self-
payment provided the membership is current at the time of treatment.
This benefit of membership is not transferable to non-members.

AXA Insurance pays only for treatment charges which are, in our experience, reasonable
and customary depending on the member’s level of cover.

7) Third-party Claims
The member must advise AXA Insurance on the claim form if they think any of the cost can
be claimed from anyone else or under another insurance policy or source (such as but not
limited to Workman’s Compensation or G.O.S.I etc.). If so, then:
 a) if another insurance policy is involved AXA Insurance will only pay our proper share; or

b) if benefits are claimed for treatment of a member whose injury or medical condition
was caused by some other person (the “third party”), we will pay only those benefits
the member can claim under the policy (unless these are covered by another insurance
policy, when we will only pay our proper share of the benefits). However, in paying
those benefits we obtain both through the terms of the policy and by law a right to
recover the amount of those benefits from the third party. In this case the following
shall apply:

(i) you must tell AXA Insurance as quickly as possible that the injury or medical
condition was caused by, or was the fault of a third party. We will then send you a
form on which the member can give AXA Insurance full written details.

(ii) if you or the member is making a claim, or has not made (or refuses to make) a
claim against the third party, you or the member must act in good faith and do all
the things we shall require to ensure that monies are recovered from the third party
and are repaid to AXA Insurance up to the amount of the benefits we have paid (and
any interest). You will be asked to sign a written undertaking to this effect; and

(iii) if you or the member do not repay to AXA Insurance, monies recovered from the
third party up to the amount of benefits (and any interest), we shall be entitled to
recover the same from you or the member.

8) Our right to require another Medical Opinion

AXA Insurance can appoint and pay for an independent medical practitioner to advise AXA
Insurance on the medical facts and/or issues relating to any claim. If required by AXA
Insurance, the independent medical practitioner will also medically examine the member
making the claim and provide AXA Insurance with a report. The member must co-operate
with the independent medical practitioner otherwise we will not pay the claim. This is only
needed very rarely and we use this right only where there is uncertainty as to the nature or
extent of the medical condition or our liability under the policy.

9) Confirmity with Statutes

Any provision of the Policy which on its Effective Date, is in conflict with the requirements
of Governmental statutes or regulations (of the jurisdiction in which issued and/or
delivered) shall be amended to conform to the requirements of such statutes and
regulations.

10) Payment of Stamps and Taxes required by Government entities

The Policyholder/Eligible Dependants shall be liable for payment of any stamps or taxes
required by Government entities on the provision of health care Benefits.

11) If any member breaks any of the terms of the policy or makes, or attempts to make, any
dishonest claim, AXA Insurance reserves the right to take any one and/or all of the below
actions:
a) refuse to make any payment for that claim;
 b) refuse to renew the policy;
c) impose different terms to any cover we are prepared to provide;
d) If, in our opinion, any such breach represents a significant threat to the safe
performance of the policy we can end the policy and all cover under it immediately.
e) if we have already paid benefits for that claim before we discovered the dishonesty we
can recover those benefits from the company
f) act in accordance with Clause 10 of section III.

12) AXA Insurance do not pay for medical reports.