Fill - Free fillable Medical Insurance Hospitalization Surgical Claim Form PDF form

1 of 3

MEDICAL INSURANCE –

HOSPITALIZATION & SURGICAL CLAIM FORM

醫療保險 – 住院及手術賠償表

This form is applicable to both inpatient

and outpatient surgical claim

本表格適用於住院或門診手術賠償

Manulife (International) Limited (Incorporated in Bermuda with limited liability)

宏利人壽保險（國際）有限公司（於百慕達註冊成立之有限責任公司）

C13 (03/2019)

PART I – TO BE COMPLETED BY THE INSURED / POLICYOWNER

第一部份 – 由受保人 / 保單持有人填寫

For document requirements of this claim, please refer to the Hospital Claims Instructions. 有關此索償的所需文件，請參考「住院索償指引」。

Branch code Location

分行編號 地點

Advisor code

保險顧問編號

Advisor’s name

保險顧問姓名

Contact no.

聯絡電話

Please indicate your Policy no./ Cert no. in sequence of claim.請依索償次序填寫閣下之保單編號/受保證書編號：

Policy No./ Cert No.保單編號/受保證書編號： Type of produts 產品類別：  Name of Policyowner / Employee / Member 保單持有人/僱員/成員姓名︰

1. Individual 個人 Group 團體

2. Individual 個人 Group 團體

Under ManuEnrich Medical Top-up Plan (“ManuEnrich”), all eligible medical expenses must rst be claimed under any other available insurance coverage of the insured before

claiming under ManuEnrich. If the insured is entitled to any benets payable for such eligible medical expenses under another insurance policy issued by Manulife (either a group medical

scheme or an individual medical scheme), this claim will automatically be processed & settled under such other insurance policy rst and the balance will then be claimed under ManuEnrich.

根據倍康醫療加保計劃（「倍康」），所有合資格醫療費用必須先向受保人其他可用的保險保障索償，然後才可於倍康提出索償。若受保人有權於宏利發出的其他保單下，就合資格醫療

費用獲得支付賠償（不論團體醫療計劃或個人醫療計劃），此索償個案將先自動於該其他保單進行處理及索償，餘額再於倍康進行索償。

Name of Insured 受保人姓名︰ HKID / Passport No.

香港身份證/護照號碼︰

(please attach copy 請附上副本)

Occupation 職業︰ Date of Birth 出生日期︰

(DD / MM / YYYY 日/月/年)

Sex 性別︰

 M 男 F 女

(1) If the medical expenses are incurred outside Hong Kong or Macau, please

provide the reason.

若醫療費用於香港或澳門以外地區產生，請提供原因。

(2) Please provide the reference no. of Preliminary Assessment (if applicable)

請提供初步評估之參考編號（如適用）：

IFP - PA

(3) Have you had any prior treatment for this or related condition(s)? 閣下是否曾經因同一病況而接受治療？

 No 否  Yes 是 Doctor’s Name 醫生姓名︰

Address 地址︰ 

Treatment Date 診治日期︰ 

(4) Are you making any other insurance claim as a result of this hospitalization / surgery? 有關是次住院/手術，閣下有否申請其他保險賠償？

 No 否  Yes 有  Medical reimbursement 醫療費用  Hospital income 住院現金  Others 其他

Name of Insurance Company 保險公司名稱︰

Policy No. 保單編號︰ 

 Original receipt will not be returned. Please “✓” this box for obtaining certied true copy of receipt. 正本收據將不獲發還。如需取得收據的核實副本，請於方格內加上“✓”。

(5) Was the hospitalization / surgery a result of an accident? 是次住院/手術是否由於一宗意外引致？

 No 否  Yes 是 Date 日期︰ Time 時間︰ Place 地點︰

Brief Description 經過︰ 

 Claim the outstanding balance under the accident coverage provided by Manulife, if applicable. (Please provide the relevant policy no. above)

索償餘額於宏利提供之意外保障索償，如適用。（請於上方提供相關保單編號）

Payment Instructions (Only applicable to Individual Products) 付款指示（只適用於個人產品）:

Remarks (For Direct Credit Instruction) 備註（適用於直接存入指示）:

- Only applicable to payment with daily transaction limit of HKD100,000 per policy. If payment exceeds HKD100,000 or the instruction cannot be executed, it will be issued by cheque.

每份保單每日存款交易上限為港元

100,000

。如交易超逾港元

100,000

或無法執行有關付款指示，總額將以支票形式支付。

- The instruction will replace any existing bank account record/setup for receiving payment including regular withdrawals (if any).

此帳戶資料將取代現時紀錄內/設立收取款項的帳戶包括用作定期提取的帳戶（如有）。

□ By Direct Credit to one of my following bank accounts (only applicable to policyowner’s bank account in HKD currency)

直接存入本人下列其中一個銀行帳戶（只適用於保單持有人之港元戶口）：

□ Current autopay bank account for premium payment 現時繳付保費之自動轉帳銀行帳戶

□ Last bank account for receiving claims payment or policy payment (including dividend, loan payment, regular withdrawal, etc.)

上一次收取理賠金額或保單款項（包括紅利、貸款金額、定期提取金額等）之銀行帳戶

□ Bank account speciﬁed below 以下指定的銀行帳戶：

Name of account holder 帳户持有人姓名：

Bank Name Bank No. Branch No. Bank Account No.

 銀行名稱 銀行編號 分行編號 銀行帳户號碼

Please provide account proof (e.g. bank statement or bank book copy showing the name of account holder and account number)

請提供帳戶資料證明（如列有帳戶持有人之姓名及帳戶號碼之銀行帳單或銀行存摺影印本）

□ By Cheque 以支票形式

Cheque Collection Method 支票交付方法

□ Through the Insurance Advisor 由保險顧問轉交

□ By Mail to Policyowner's latest correspondence address with Manulife

寄往保單持有人於宏利紀錄的最新通訊地址

Cheque Currency

(a)

(for USD policy only) 支票幣值

(a)

（只適用於美元保單）

□ USD Cheque (drawn in Hong Kong) 美元支票（由香港的銀行付款）

□ USD Cheque (drawn in United States) 美元支票（由美國的銀行付款）

□ HKD Cheque

(b)

港元支票

(b)

Notes 註:

(a) Unless request to the contrary is speciﬁcally made, the claim reimbursement cheque will be drawn in HKD for Hong Kong policies and MOP for Macau policies. The cheque will be

forwarded to the Policyowner with the Payment Advice after approval of the claim.

除特別要求外，於香港簽發的保單的賠償支票將以港元支付，而於澳門簽發的保單的賠償支票則以澳門幣支付。當索償獲批准後，支票將連同通知書一併送交保單持有人。

(b) In general, it takes a long settlement period to clear a foreign cheque in Hong Kong. Bank charges may be incurred by client for clearing the cheque.

銀行通常需要較長的結算時間於香港兌現外幣支票；另銀行或會向客戶徵收兌現支票的相關手續費。

(c) The HKD equivalent will be based on the currency exchange rate provided by the Company at the time of issue of the cheque and it can be changed from time to time.

相等之港元將會以支票發出時的貨幣兌換率計算，而宏利將不時提供有關的貨幣兌換率。

Manulife (International) Limited (Incorporated in Bermuda with limited liability)

宏利人壽保險（國際）有限公司（於百慕達註冊成立之有限責任公司）

C13 (03/2019)

The Chinese version of this claim form is for reference only. In the event of conicts between the Chinese and English versions, the English version shall prevail. 此索償表格之中文譯本只供參考之用，若與英文有異，一概以英文為準。

2 of 3

Other Information 其他資料

Declaration and Authorization 聲明及授權

I/We hereby declare that the answers to the above questions are full and true to the best of my/our knowledge. I/We further authorize any physician,

hospital, insurance company, claims investigation company, government authority or organization that has any record or knowledge of me/us, my/our

health or my/our activities (including records relating to Social Welfare, Workers’ Compensation, credit, financial, earnings and employment history)

to furnish to Manulife (International) Limited (“Manulife”) or its authorized representative such information including without limitation all information

with respect to any illness or injury, medical history, consultation, prescription or treatment and copies of all hospital or medical records. A photostatic

copy of this authorization shall be as effective and valid as the original.

本人／我們特此聲明填報於本表格內之資料已是本人／我們所知之全部並為真實無訛。本人／我們茲授權任何醫生、醫院、保險公司、賠償調查公司、政府有

關部門或其他持有本人／我們個人資料、健康狀況或記錄（包括有關本人／我們所獲之社會福利及勞工賠償、本人／我們之存款、財政狀況、入息及就業記

錄）之組織可以將該等資料，包括但不限於所有有關本人／我們之疾病或受傷，傷患之病歷、診斷報告、藥方或治療及所有醫院或醫療記錄副本等資料予宏

利人壽保險（國際）有限公司（”宏利”）或其代理人。此授權書之複製本與正本具同等效力。

Personal Information Collection Statement 個人資料收集聲明

I/we acknowledge that the personal data (including but not limited to credit information and claims history) provided in this Form will be used by

Manulife for the purposes of processing, adjudicating, investigating and settling claims application(s) and request(s) for credit service, approving and

underwriting insurance applications, administering and reinsuring policies, detecting and preventing fraud (whether or not relating to the policy issued

in respect of this application), complying with applicable laws and other related purposes and for such purposes, may be transferred to such persons

or entities (whether within or outside Hong Kong) as: (a) any person in connection with any claims made by or against or otherwise involving customers

in respect of any products and/or services; (b) any agent, contractor or third party service provider who provides administrative, telecommunications,

computer, information technology, payment, data processing or storage, marketing, mailing, printing, telemarketing, customer satisfaction analysis,

or other services to Manulife or any member of Manulife's group of companies in connection with the operation of business, including any custodian,

administrator, investment manager, investment advisor or distributor; (c) any credit reference agencies or, in the event of default, any debt collection

agencies; (d) any advisor (including his or her employees) or other intermediary (including their employees); (e) reinsurers, insurance adjusters, health

care professionals, hospitals, medical service providers, accountants, financial advisors, and legal advisors; (f) employers of the customers; (g) any

person which has undertaken to Manulife or any member of Manulife's group of companies to keep such data confidential; (h) any actual or proposed

assignee, transferee, participant or sub-participant of the rights or business of Manulife or any member of Manulife's group of companies ; (i) any

member of Manulife's group of companies; (j) any person to whom Manulife or any member of Manulife's group of companies is under an obligation

or otherwise required to make disclosure under the requirements of any law, rules, regulations, codes of practice, guidelines or guidances binding on

or applicable to Manulife or any member of Manulife's group of companies including but not limited to any local or foreign regulators, governmental

bodies, or industry recognised bodies; (k) any person to whom Manulife or any member of Manulife's group of companies is under an obligation or

otherwise required to make disclosure pursuant to any contractual or other commitment or arrangement with local or foreign regulators, governmental

bodies, or industry recognised bodies (whether within or outside Hong Kong) that is assumed by or imposed on Manulife or any member of Manulife's

group of companies by reason of its financial, commercial, business or other interests or activities in or related to the jurisdiction of the relevant

local or foreign regulators, governmental bodies, industry recognised bodies; (l) organisations that consolidate claims and underwriting information

for the insurance industry, fraud prevention organisations, other insurance companies (whether directly or through fraud prevention organization

or other persons named in this paragraph), the police and databases or registers (and their operators) used by the insurance industry to analyse

and check information provided against existing information. All information may be treated by Manulife in the same manner as mentioned in the

"Notice to Customers relating to the Personal Data (Privacy) Ordinance" ("Notice") (for Hong Kong policy) / Manulife Personal Information Collection

Statement (“Statement”) (for Macau policy) (where applicable). In case I/we have not read the Notice / Statement (where applicable) before, I/we

can obtain such Notice / Statement (where applicable) from my/our Manulife's intermediary or through Manulife’s website at www.manulife.com.hk. I/

we understand that I/we am/are not obliged to provide such personal data as requested but if I/we refuse to provide such data, Manulife may not be

able to proceed further on my/our application(s) and/or request(s) in this Form. I/we may request access to and correction of my/our personal data

held by Manulife, by writing to Privacy Officer at Manulife (International) Limited, 22/F., Tower A, Manulife Financial Centre, 223-231 Wai Yip Street,

Kwun Tong, Kowloon, Hong Kong.

本人／我們確認載於本表格內之個人資料（包括但不限於信用資料和以往申索紀錄）將被宏利用以處理、判定、調查及結清有關之索償及代繳費用服務申

請，批核及承保保險申請，管理保單並安排分保，偵測和防止欺詐行為（無論是否與就此申請而發出的保單有關），遵守適用法律及其他相關用途並就此等

用途，該等個人資料可被轉送到下列人士或機構（無論在香港境內還是境外）(a) 與客戶、針對客戶或涉及客戶就任何產品及／或服務提起的任何索賠相關的

任何人士；(b) 向宏利或宏利的公司集團任何成員提供與業務經營相關的行政管理、電信通訊、電腦、資訊技術、付款、資料處理或儲存、市場推廣、郵寄、列

印、電話行銷、客戶滿意度分析或其他服務的任何代理、承辦商或第三方服務供應商，包括任何託管人，執行人，投資管理人，投資顧問或分銷商；(c) 任何信

貸資料服務機構或（如出現付款違約）任何債務托收機構；(d) 任何顧問（包括其僱員）或其他中介人士／機構（包括其僱員）；(e) 再保險商、保險理算人、醫

護專業人士、醫院、醫療服務供應商、會計師、財務顧問和法律顧問；(f) 客戶的僱主；(g) 已向宏利或宏利的公司集團任何成員承諾將對該等資料保密的任

何人士；(h) 宏利或宏利的公司集團任何成員的權利或業務的任何實際或擬議受讓人、承讓人、參與人或次級參與人；(i) 宏利的公司集團任何成員；(j) 宏利

或宏利的公司集團任何成員根據對其有約束力或適用的任何法律、法規、規章、守則、指引或指南的規定有義務或必須向其披露的任何人士，其中包括但不

限於任何當地或外國的監管機構、政府機構或公認行業組織；(k) 根據由於宏利或宏利的公司集團任何成員在相關當地或外國監管機構、政府機構、或公認

行業組織（無論在香港境內還是境外）所在司法管轄區的或涉及該等司法管轄區的財務、商業、業務或其他利益或活動而由宏利或宏利的公司集團任何成員

承擔或施加給其的、與該等當地或外國監管機構、政府機構、公認行業組織之間的任何合同、其他承諾或安排，有義務或必須向其披露的任何人士；(l) 整合

保險業申索和承保資料的組織、防欺詐組織、其他保險公司（無論是直接地，或是通過防欺詐組織或本段中指名的其他人士）、警察、和保險業就現有資料

而對所提供的資料作出分析和檢查的數據庫或登記冊（及其運營者）。宏利可按於《有關〈個人資料（私隱）條例〉的客戶通知》（「通知」）（適用於香港保

單）/《宏利個人資料收集聲明（「聲明」）（適用於澳門保單）（如適用）所述，處理有關資料。假如本人／我們未有細閱該通知/聲明（如適用），本人／我們可

從本人／我們的宏利中介人或透過宏利網址 www.manulife.com.hk 取得該通知/聲明（如適用）。本人／我們明白本人／我們並無責任提供該等個人資料。但

如果本人／我們拒絕提供該等資料，宏利可未能繼續處理本人／我們的申請及／或本表格內之申請。本人／我們可去信個人資料主任於宏利人壽保險 ( 國際 ) 有

限公司，香港九龍觀塘偉業街223-231號宏利金融中心A座22樓要求查閱及更改本人／我們在宏利之個人資料。

Signature of Insured (if Aged 18 or Above)* Name (In BLOCK LETTERS) & I.D. No. of Insured Date (DD/MM/YYYY)

受保人簽署（如十八歲或以上） 受保人姓名（請以正楷書寫）及身份証號碼 日期（日／月／年）

Signature of Policyowner Name (In BLOCK LETTERS) & I.D. No. of Policyowner Date (DD/MM/YYYY)

保單持有人簽署 保單持有人姓名（請以正楷書寫）及身份証號碼 日期（日／月／年）

* For insured aged below 18, signature of the policyowner must be provided for the application for the claim

十八歲以下受保人之索償申請必須由保單持有人簽署。

Manulife (International) Limited (Incorporated in Bermuda with limited liability)

宏利人壽保險（國際）有限公司（於百慕達註冊成立之有限責任公司）

C13 (03/2019)

PART II – TO BE COMPLETED BY THE ATTENDING PHYSICIAN / SURGEON AT THE CLAIMANT’S OWN EXPENSES

第二部份 – 由主診醫生 / 外科醫生填寫，所需費用由索償人自行承擔

3 of 3

Patient Name (in full) 病人姓名（全名）：

Date of Admission 入院日期(DD日/MM月/YY年) Date of Discharge 出院日期(DD日/MM月/YY年)

Name of Hospital 醫院名稱：

Level of hospital ward 病房級別：   Private 頭等房 Semi-private 二等房 Ward 三等房 Isolation room 隔離病房 ICU 深切治療病房 Clinical Surgery 門診小手術

1. Clinical History 求診記錄：

a) Date on which the patient rst consulted you related to this illness / injury 病人就此疾病 / 受傷後，首次向閣下求診的日期  (DD日/MM月/YY年)



b) Symptom(s) / complaint(s) of the patient relating to this hospitalization / treatment / investigation 病人就此次住院/治療/檢驗所出現的相關症狀/主訴

 

c) How long had the patient been experiencing these symptoms / complaints before the rst consultation? 病人在首次求診前已患有此症狀/主訴多久？

 

2. Hospitalization Details 住院詳情：

a) Final Diagnosis 最後的診斷 Date of Operation 手術日期(DD日/MM月/YY年)

b) Operation procedure(s) performed 手術的名稱

c) If the patient has been referred to consult other physician during this hospitalisation, please provide the following

如病人於住院期間曾被轉介向其他醫生求診，請提供以下資料：

Name of physician consulted 求診醫生姓名 Reason 原因

  What treatment had the physician performed 治療詳情

d) Please give a brief discharge summary (including etiology, types and results of major examinations, treatments, complications and follow up dates & plan)

請提供出院撮要（包括病因、主要檢查的種類及結果、治療、併發症及覆診日期和詳情）

 

 e) Can the medical test(s) and the operation procedure be done on an outpatient basis / at day surgery centre? 該檢查及手術可否在門診/日間手術中心進行？

Yes 可以



No, please provide reason(s) 不可以，請提供原因 

 

3. Professional Comment 專業意見：

a) In your opinion, was the patient hospitalized as a result of recurrent episode or a chronic illness or related to a previous complaint / diagnosis.

If "yes", please provide date of the rst episode and details.

就閣下意見，病人是次住院治療是否因繼發性或慢性疾病所引致或與以往的主訴/診斷有關?若答案為“是”，請提供首次發病日期及詳情。

 

b) Was the condition due to or associated with the following?(Please tick the appropriate boxes) 上述情況是否出於或與以下問題關連（請在適當空格填上號）

 

Accidental bodily injury意外身體受傷 Pregnancy懷孕  Congenital condition 先天性疾病/異常

   Self-inicted injury 自我傷害 Infertility or sterilization 不育或絕育 Developmental condition 發育問題

 

 Abuse of drugs or alcohol 濫用藥物或酒精 Contraception 避孕  Hereditary condition 遺傳性問題

 

Mental disorder 精神紊亂  Treatment for cosmetic purpose 美容性質的治療 General check-up 一般身體檢查

 

Refractive error 屈光不正  Vaccination 疫苗接種  N/A 不適用

 

Venereal disease, sexually transmitted disease or AID / HIV related illness 性病，性傳播疾病或愛滋病/愛滋病毒有關的疾病

4. Others 其它：

a) If the patient was referred by another doctor, please provide the referring doctor's name and address. 如病人由其他醫生轉介，請提供轉介醫生的姓名和地址。

 

b) (ONLY APPLICABLE TO Preliminary Assessment of VHIS Product) Compared with Preliminary Assessment, are there any variations on the medical services

actually received (e.g. cost and treatment)? If yes, please provide reason(s).

（僅適用於自願醫保產品初步評估）與初步評估相比，實際接受之醫療服務有否任何改變（例如費用及治療）？如有，請提供原因。

 

c) Are you the patient's usual physician? 閣下是否該病人的慣常醫生？ No 否/ Yes 是Since 自(DD日/MM月/YY年)

I hereby certify that all information given above is accurate and true to the best of my knowledge. 本人特此聲明，就本人所知，上述所有資料均準確無誤。

Signature and chop of attending physician / surgeon

主診醫生

/外科醫生簽名及蓋章

Address and Telephone No.

地址及電話號碼

Name of attending physician / surgeon & qualications

主診醫生姓名/外科醫生姓名及資歷



Date

日期

(DD

日

/MM

月

/YY

年

)

HOSPITAL CLAIMS INSTRUCTIONS 住院索償指引

This guideline is for reference only 本指引只供參考

Please ensure all questions on Part I and Part II of the Medical Insurance - Hospitalization & Surgical Claim Form are answered and check that all

required claim documents are submitted. Otherwise, the claim may not be processed due to incomplete information. The policyowner may be requested

to provide additional information relating to this claim.

請確保已回答「醫療保險─住院及手術賠償表」第一及第二部份所有問題及提交所需索償文件，否則此索償申請可能因資料不足而未能被處理。保單持有人可

能被要求就此項索償提供額外資料。



Please submit aforesaid required documents to Individual Financial Products, Manulife (International) Limited, 22/F., Manulife Financial Centre, 223-231 Wai

Yip Street, Kwun Tong, Kowloon, Hong Kong.

請將上述所需文件寄回香港九龍觀塘偉業街223-231號宏利金融中心22樓宏利人壽保險（國際）有限公司個人理財產品業務部。

: For receipt charged HKD3,000 or below, it can be submitted to http://www.claimsimple.hk or by scanning the QR code.

任何收據金額不多於3,000港元，可以通過 http://www.claimsimple.hk或掃描QR code提交索償。

Below required documents must be received by Manulife within 90 days from the date on which medical expenses were incurred.

以下所需索償文件須在有關醫療費用支付後九十日內提交宏利。

Manulife (International) Limited (Incorporated in Bermuda with limited liability)

宏利人壽保險（國際）有限公司（於百慕達註冊成立之有限責任公司）

C13 Guide (02/2020)

Claims Document Checklist - Basic Requirements 索償文件清單︰基本要求

 Fully completed Medical Insurance – Hospitalization & Surgical Claim Form (C13); and 完整填妥之「醫療保險 - 住院及手術賠償表」(C13)；及

 Original hospital receipts; and 醫院收據正本；及

 Original statement of charges / accounts; and 收費單正本；及

 HKID card / passport copy of both Policyowner and Insured (if you have not provided the relevant document(s) to us before or the document(s)

in our records is / are no longer valid or do(es) not comply with the current regulatory requirements) 保單持有人及受保人的香港身份證／護照副本

（如閣下從未提供予我們有關文件，或我們記錄內之有關文件已不再有效或未能遵守現行的監管要求）

(Additional basic requirements applicable for ManuMaster / ManuShine Healthcare/ Manulife Supreme VHIS 適用於晉領／活亮人生醫療保障／

宏利晉悅自願醫保的附加基本文件)



Full set copy of medical documents from hospital, including copy of laboratory, diagnostic, imaging & histopathology report and discharge

summary 醫院提供之全套醫療文件副本，包括:化驗、診斷、影像和病理報告之副本及出院紙副本

 Breakdown of charges of laboratory, investigation tests, medication and meal 化驗、檢驗、藥物和膳食費用細分

Applicable For / When 適用於 Additional Documents

Note (1)

附加文件

註(1)

Pre- / post- hospitalization / day case surgery outpatient benet

住院/出院/日間手術前後門診

 Original receipts with diagnosis proof 附有診斷證明之收據正本

Claims paid by other insurers

已獲其他保險公司支付賠償

 Copy of payment advice and original / certiﬁed true copy of receipts

from other insurers 其他保險公司賠償明細表副本；及收據正本／該保

險公司發出的收據核實副本

Laboratory examinations / investigations done

已接受檢查／化驗

 Diagnostic / Laboratory reports診斷／化驗報告

Hospitalized in Mainland China hospital

入住中國內地醫院

 Copy of daily hospitalization record 每日住院記錄副本

 Copy of Home Visit Permit 回鄉卡副本

Claims for dependent of the insured who is a student & aged 18 to 25

如為受保人之家屬索償而其為學生及年齡介乎十八至二十五歲



Copy of student identity card

 學生證副本

Trac accident involved

涉及交通意外



Copy of police report / trac accident report / police statement

 警察報告／交通意外報告／警察口供紙副本

Hospitalized in Government Hospital

Note (2)

入住政府醫院

註(2)

 Copy of discharge summary / slip; or 出院紙副本;或

 Copy of sick leave certicate with diagnosis 列明診斷的病假證明書副本

Note

 註︰

(1) Manulife reserves the right to request for original documents or other supplementary documents / information if deemed necessary 如有需要，宏利保留

要求提供正本文件或其他補充文件/資料的權利

(2) For payment incurred in Public Ward Unit of hospitals governed by the Hospital Authority of Hong Kong only, completion of Part II of the Form will be

waived if ALL of the following conditions are met: 若於香港醫院管理局轄下的公眾病房內留醫，且索償符合以下所有項目，則可獲豁免填寫表格第二部份：

a) Daily hospital fee was charged at at rate 每天固定醫療收費

b) The claims amount is less than USD500.00 or HKD4,000.00 索償金額少於500美元或4,000港元

c) The claim must be accompanied by the original / certied true copy of Sick Leave Certicate or other ocial documents (e.g. Discharge Summary / Slip)

with Diagnosis 必須遞交列有診斷結果的病假證書或其他正式證明文件（例如出院紙）之正本或核實副本

d) Qualifying Duration 合資格期限

- The policy / benet has been eective for more than 2 years – all diagnosis (except exclusions) 計劃／保障生效兩年以上︰任何診斷結果（不受保項目除外）

- The policy / benet has been eective for less than or equal to 2 years – diagnosis specied on below annexed list only 計劃／保障生效少於或相等於

兩年︰只限下列診斷結果

Annexed List of Diagnosis 診斷結果列表

Accident Cause 意外造成 Duodenitis 十二指腸炎 Laryngitis 喉炎 Roseola 玫瑰疹

Allergic Rhinitis 過敏性鼻炎 Enteritis 腸炎 Lymphadenitis 淋巴結炎 Rubella 德國麻疹

Appendicitis 闌尾炎（肓腸炎） Fascitis 筋膜炎 Measles 痲疹 Tonsilitis 扁桃腺炎

Balanitis 龜頭炎 Gastritis 胃炎 Mole /Subcutaneous Cyst 痣／皮下囊腫 Tracheitis 氣管炎

Bronchitis 支氣管炎 Gastroentercolitis 胃腸結腸炎 Muscularskeletal Pain 肌（與）骨骼痛 Upper Respiratory Tract Infection 上呼吸道感染

Cellulitis 蜂窩織炎 Gastroenteritis 胃腸炎 Otitis Externa 外耳炎 Urinary Tract Infection 尿道炎

Chalazion 瞼板腺囊腫 Hemorrhoids 痔瘡 Parotitis 腮腺炎 Viral Infection 病毒感染

Chest Infection 胸部感染 Hepatitis A 甲型肝炎 Peritonitis 腹膜炎 Vocal Polyps 聲帶息肉

Cholecystitis 膽囊炎 Hernia 疝氣（小腸氣） Pharyngitis 咽炎 Wart 疣

Chondritis 軟骨炎 Herpes Zoster 單純庖疹 Pneumonia 肺炎

Cystitis 膀胱炎 Inuenza 流行性感冒 Renal Stones 腎石

單一收據金額唔多過港幣3,000元嘅索償，可以填好呢張索償表格，上載嚟呢度!

For single receipt not exceeding HK$3,000, you can ll in this claim form and upload here!

Fill Online, Printable, Fillable, Blank Medical Insurance Hospitalization Surgical Claim Form Form

Related forms

Fillable Medical Insurance Hospitalization Surgical Claim Form

Fill Online, Printable, Fillable, Blank Medical Insurance Hospitalization Surgical Claim Form Form

Related forms

First 20 documents completely FREE!