Claims Reimbursement Procedure Sample Clauses

Claims Reimbursement Procedure. As an exceptional procedure, in case the Insured did not obtain the Authorization Form, he may be reimbursed for the total or partial incurred fees and Expenses of covered Healthcare Services under this Contract, subject to complying with a special Reimbursement Procedure provided for hereinafter: 1. The Insured must complete and submit directly to the Company a signed Claim Reimbursement Request within 15 (fifteen) days from the date of discharge if the Healthcare Services were delivered on the Territorial Limits defined in the (T.B. & P.) and 30 (thirty days) if elsewhere, with all the following supporting documents: 1.1. The medical report filled and signed by the Treating Physician; 1.2. The discharge report; 1.3. The original and official bills and receipts duly signed and stamped; 1.4. A photocopy of the medical and exams reports, diagnoses and results related to the Healthcare. 2. The Claim Reimbursement Procedure may be applicable exclusively in the following cases: 2.1. As an appeal by the Insured to a previously declined approval of coverage at an approved Healthcare Provider; 2.2. In instances of emergency treatments at a non-approved Healthcare Provider on condition that the Company or the T.P.A. is informed in writing of the hospitalization within 24 (twenty four) hours from admission; 2.3. When the Insured has secured the prior approval of coverage from the T.P. A. Claims Center, for Healthcare to be delivered at a non-approved Healthcare Provider; 2.4. In case of medical necessity where the treatment is not available within the approved Healthcare Provider Network, provided that the Insured has secured a prior approval of coverage from the T.P. A. Claims Center for In-Patient Healthcare Services to be delivered at a non-approved Healthcare Provider. In the above instances provided for in sub-sections 2.1. and 2.2., the reimbursement of Expenses incurred, after applying the deductible if any, will be affected based on the preferential tariffs applicable to the Company at an equivalent approved Healthcare Provider for the same classification and the same case at the time of incurred expenses.

Claims Reimbursement Procedure. The Insured has to inform the Company about all the incurred expenses, approved by the Assistance Company and for which he wishes to be reimbursed. The Insured should submit to the Company all the evidence to establish the validity of his request as well as any element deemed necessary for the treatment of his request. The Company will reimburse, upon acceptance of the submitted evidence and within the Maximum Limit set in the (T.B. & P.) of the Contract the expenses incurred by the Insured. C- ADDITIONAL COVER - Ambulatory Healthcare Plan (optional) Terms, Provisions and Conditions related exclusively to part C The Company grants, on condition that the In-Hospital Healthcare Plan is in force and subject to the payment of premium, an additional Out-Patient Healthcare Benefits that are governed by the General Terms and Conditions of the Contract and the Provisions of this Plan.