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MEDICAL INSURANCE –
HOSPITALIZATION & SURGICAL CLAIM FORM
療保險 – 住院及術賠償表
This form is applicable to both inpatient
and outpatient surgical claim
表格適於住院或門手術賠償
Manulife (International) Limited (Incorporated in Bermuda with limited liability)
人壽(國際)有限公司於百之有公司)
C13 (03/2019)
PART I TO BE COMPLETED BY THE INSURED / POLICYOWNER
第一 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參考住院索償指引
Branch code Location
分行編號 地點
Advisor code
險顧問編號
Advisor’s name
險顧問姓名
Contact no.
聯絡電
Please indicate your Policy no./ Cert no. in sequence of claim.請依索償次序填寫閣下保單編號/受保證書編號
Policy No./ Cert No.保單編號/受保證書編號: Type of produts 別: Name of Policyowner / Employee / Member 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.
倍康醫療加保計劃倍康」合資格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受保人有權於宏利發出的其他保單下就合資格醫
用獲得支(不計劃或個人醫計劃)此索償個案將先自動於該其他保單進行處理及索償額再於倍康進行索償
Name of Insured 名︰ HKID / Passport No.
香港身份證/護照號碼
(please attach copy 附上副本)
Occupation 業︰ Date of Birth 期︰
(DD / MM / YYYY 日/月/)
Sex 別︰
M 男 F
(1) If the medical expenses are incurred outside Hong Kong or Macau, please
provide the reason.
醫療費用於香港或澳門以外地區產生請提原因
(2) Please provide the reference no. of Preliminary Assessment (if applicable)
請提步評估之參考編號(如適用)
IFP - PA
(3) Have you had any prior treatment for this or related condition(s)? 下是否曾經因同一病況而接受治
No 否 Yes 是 Doctor’s Name 醫生姓名︰
Address 址︰
Treatment Date 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
No 否 Yes 有 Medical reimbursement 醫療費用 Hospital income 住院金 Others 其他
Name of Insurance Company 險公司名稱
Policy No. 號︰
Original receipt will not be returned. Please “this box for obtaining certied true copy of receipt. 正本收將不獲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/手術是否由一宗意外引致
No 否 Yes 是 Date 期︰ Time 間︰ Place 點︰
Brief Description 過︰
Claim the outstanding balance under the accident coverage provided by Manulife, if applicable. (Please provide the relevant policy no. above)
索償餘額宏利之意外保障索償適用(請上方提相關編號)
Payment Instructions (Only applicable to Individual Products) 付款指示只適用於個人產品:
Remarks (For Direct Credit Instruction) (適用於直接存示):
- 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.
每日為港
100,000
如交易超逾
100,000
或無法執行有關付款指總額將以支票形支付
- The instruction will replace any existing bank account record/setup for receiving payment including regular withdrawals (if any).
此帳戶資將取代現時錄內/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(只適用於保單持有人之港元戶
Current autopay bank account for premium payment 現時之自動
Last bank account for receiving claims payment or policy payment (including dividend, loan payment, regular withdrawal, etc.)
上一次收取理金額或保單款項括紅利金額定期提取金額等)之銀行帳
Bank account specified below 戶:
Name of account holder 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
Cheque Collection Method 支票交付方
Through the Insurance Advisor 由保險顧問轉
By Mail to Policyowner's latest correspondence address with Manulife
寄往保單持於宏利紀錄的新通訊地
Cheque Currency
(a)
(for USD policy only) 支票幣值
(a)
只適用於美元保
USD Cheque (drawn in Hong Kong) 元支由香港的銀行付款)
USD Cheque (drawn in United States) 元支票由美國的銀行付款)
HKD Cheque
(b)
港元支
(b)
Notes :
(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另銀行或會向客戶徵收兌現票的相關手續費
(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.
相等會以票發出貨幣兌而宏關的幣兌
Manulife (International) Limited (Incorporated in Bermuda with limited liability)
人壽(國際)公司 (於百註冊之有公司)
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. 此索償表格之中文本只供參考之若與文有異概以英為準
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Other Information 他資
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.
/我 /我 /我 調
或其他持有本我們個人資料健康狀況或記錄包括有關人/們所獲之社會福利及工賠償人/們之存款政狀入息及就業記
錄)之組織可以將該等資包括但不限於所有有關本人我們之疾病受傷傷患之病歷斷報方或治療及所有醫院或醫療錄副本等資料予宏
利人壽保險(國際有限公司利”其代書之複製本與正本具同等
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.
我們於本表格內之人資(包括但不限用資料和以往申索紀錄)利用以處判定調有關之索償及代繳費用服務申
批核及承保保險管理保單並安排分保測和止欺詐行無論是否與就此請而的保單有關守適法律及其他相並就此
用途個人資料可被轉送到下列人士或機在香港境內還是境(a) 客戶針對客戶或涉及客戶就任何產品及服務起的任何索賠相關的
何人士(b) 向宏利或利的公司集團任何成員提務經營相關的行政管電信通訊電腦訊技付款料處理或儲市場推廣郵寄
電話行銷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執行投資管理人資顧問或分銷商(c) 任何
貸資料服務機構(如出現付款何債務托收機構(d) 任何顧問包括其僱員其他中介人士/機構括其僱員(e) 再保險商保險理算
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) 的僱(g) 向宏利或宏利的公司集團任何成員承諾將對該等料保密的任
何人士(h) 宏利或宏利的公司集團任何成員的權利或的任何實際擬議承讓與人或次級參與人(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有約束力或適用的任何法律法規守則指引或指南的規定有義務或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(無論在香境內還是境所在司法轄區的或涉該等司法管區的財商業務或利益或活動而由宏利或利的公司集團任何成
承擔或施加其的與該等當地或外國監管機構府機構認行業組織之間的任何合同其他承諾或安排有義務或必向其披露的任何人士(l) 整合
保險業申和承保資料的組防欺詐組其他保險公(無論是直接地是通過防欺詐組或本段中指的其他人士警察和保險業就現有資
而對所提的資作出分析和查的或登記冊及其運營者)宏利可按《有關〈個人資(私隱例〉的客戶通知》「通知」(適用於香
單)/個人資料收聲明明」(適用於澳門保單)(如適理有關資我們未有細閱該通知/聲明(如我們
從本我們的宏利中介或透宏利網址 www.manulife.com.hk 取得該通知/聲明(如適用我們明我們並無責任提供該等個人資
/我 ,宏 /我 /或 。本 /我 ( )
限公香港九龍觀塘偉業街223-231宏利金融A座22樓要求查閱及更改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(如八歲或以) 受保人姓請以正楷書及身份証號碼 /月
Signature of Policyowner Name (In BLOCK LETTERS) & I.D. No. of Policyowner Date (DD/MM/YYYY)
保單持有人簽署 保單持有請以正楷書寫)及身份証號碼 /月
* For insured aged below 18, signature of the policyowner must be provided for the application for the claim
十八 署。
Manulife (International) Limited (Incorporated in Bermuda with limited liability)
人壽(國際)公司 (於百註冊之有公司)
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 / 外科醫生填所需費由索償人承擔
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Patient Name (in full) 病人姓名(全名
Date of Admission 入院期(DD/MM/YY) Date of Discharge 出院日(DD/MM/YY)
Name of Hospital 稱:
Level of hospital ward 別: Private 頭等房 Semi-private 等房 Ward 三等 Isolation room 隔離病房 ICU 深切治療病房 Clinical Surgery 門診小
1. Clinical History 錄:
a) Date on which the patient rst consulted you related to this illness / injury / ,首 (DD/MM/YY)
b) Symptom(s) / complaint(s) of the patient relating to this hospitalization / treatment / investigation 病人此次住院/治療/檢驗出現的相關症狀/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 情:
a) Final Diagnosis 最後的診斷 Date of Operation 術日期(DD/MM/YY)
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
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
Yes 可以

No, please provide reason(s) 以,

3. Professional Comment 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或與以往的主訴/診斷有關?若答案為請提供首次發病期及詳情

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(請適當空格填號)

Accidental bodily injury意外身體受傷 Pregnancy懷孕 Congenital condition 先天性疾病/異
 Self-inicted injury 自我傷 Infertility or sterilization 育或絕育 Developmental condition 發育問題

Abuse of drugs or alcohol 用藥物或酒精 Contraception 避孕 Hereditary condition 傳性問題

Mental disorder 精神紊亂 Treatment for cosmetic purpose 美容性質的治療 General check-up 身體檢

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 性傳播疾病或愛滋病/愛滋病毒有關的疾病
4. Others 它:
a) If the patient was referred by another doctor, please provide the referring doctor's name and address. 人由其他醫生轉轉介生的名和地

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).
適用於自願醫保產品初步評估與初步評估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 No 否/ Yes Since 自(DD/MM/YY)
I hereby certify that all information given above is accurate and true to the best of my knowledge. 本人特本人所有
Signature and chop of attending physician / surgeon
主診醫生
/外科醫生名及蓋章
Address and Telephone No.
及電
Name of attending physician / surgeon & qualications
主診醫生姓名/外科醫生姓名及資
Date
日期
(DD
/MM
/YY
)
HOSPITAL CLAIMS INSTRUCTIONS 索償指引
This guideline is for reference only 指引只供
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.
保已回答險─住院手術償表」第一第二部份有問題需索償否則此索償申請可能因資料不足而未能被單持
能被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.
上述所需文件寄回香港九龍觀塘偉業街223-231宏利金融中22樓宏利人壽保險(國際有限公司個人財產品業
: For receipt charged HKD3,000 or below, it can be submitted to http://www.claimsimple.hk or by scanning the QR code.
任何金額不多3,000 ,可 http://www.claimsimple.hk掃描QR code 償。
Below required documents must be received by Manulife within 90 days from the date on which medical expenses were incurred.
以下所索償文件用支付十日
Manulife (International) Limited (Incorporated in Bermuda with limited liability)
人壽(國際)公司 (於百註冊之有公司)
C13 Guide (02/2020)
Claims Document Checklist - Basic Requirements 索償文件清單本要求
Fully completed Medical Insurance – Hospitalization & Surgical Claim Form (C13); and 完整填妥療保險 - 手術賠償表(C13);及
Original hospital receipts; and 醫院收據正;及
Original statement of charges / accounts; and ;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) 保單持有及受保人的香港身份證照副本
下從文件或我們記錄內之有關文件已不再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/亮人生醫療保障
宏利晉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 醫院提全套醫療文件副括:化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 驗、檢驗、藥 費用細
Applicable For / When 適用於 Additional Documents
Note (1)
文件
(1)
Pre- / post- hospitalization / day case surgery outpatient benet
住院/出院/間手術前後門
Original receipts with diagnosis proof 附有診斷證明收據正本
Claims paid by other insurers
公司支付
Copy of payment advice and original / certified true copy of receipts
from other insurers 他保險公司賠償明細表副及收據 該保
公司發出
Laboratory examinations / investigations done
已接受查/化驗
Diagnostic / Laboratory reports診斷/化驗報告
Hospitalized in Mainland China hospital
入住中國內地
Copy of daily hospitalization record 每日住
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至二十五歲
Copy of student identity card
學生證副本
Trac accident involved
涉及
Copy of police report / trac accident report / police statement
警察報告/交通意外報告/口供紙副本
Hospitalized in Government Hospital
Note (2)
入住政
(2)
Copy of discharge summary / slip; or 院紙副本;或
Copy of sick leave certicate with diagnosis 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 ,宏
要求正本文件文件/資
(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: 若於香港醫院管局轄下的公眾病房內留索償符合以下所有項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
b) The claims amount is less than USD500.00 or HKD4,000.00 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 必須遞列有診斷結果的病假證書或其他式證明文例如出院紙)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) /保 果(
- The policy / benet has been eective for less than or equal to 2 years – diagnosis specied on below annexed list only /保
兩年只限下列診斷結果
Annexed List of Diagnosis 結果列
Accident Cause 意外造成 Duodenitis 十二 Laryngitis 喉炎 Roseola 玫瑰疹
Allergic Rhinitis 鼻炎 Enteritis 腸炎 Lymphadenitis 淋巴結炎 Rubella 德國麻疹
Appendicitis 尾炎(肓腸 Fascitis 筋膜 Measles 痲疹 Tonsilitis 扁桃腺炎
Balanitis 龜頭炎 Gastritis 胃炎 Mole /Subcutaneous Cyst /皮 Tracheitis 氣管炎
Bronchitis 氣管 Gastroentercolitis 胃腸 Muscularskeletal Pain 肌( )骨 Upper Respiratory Tract Infection 上呼
Cellulitis 窩織 Gastroenteritis 胃腸 Otitis Externa 外耳 Urinary Tract Infection 尿道
Chalazion 板腺囊 Hemorrhoids 痔瘡 Parotitis 腮腺炎 Viral Infection 病毒感染
Chest Infection 胸部感 Hepatitis A 甲型 Peritonitis 腹膜炎 Vocal Polyps 帶息
Cholecystitis 膽囊炎 Hernia 氣( Pharyngitis 咽炎 Wart
Chondritis 軟骨炎 Herpes Zoster 單純庖疹 Pneumonia 肺炎
Cystitis 膀胱炎 Inuenza 流行感冒 Renal Stones 腎石
單一3,000元嘅索償可以填好呢索償表格上載嚟呢!
For single receipt not exceeding HK$3,000, you can ll in this claim form and upload here!
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