Reimbursement Claim Form PDF

Reimbursement Claim Form
Healthcare Insurance
One Claim Form per person, family members must apply individually. Please refer to page 2 for instructions on how to fill the form.
For the required supporting documentation, use the attached Summary Table as cover sheet.
Before you submit, check your Table of Benefits in your policy document for exclusions to avoid rejections.
Please submit the form within 30 days of treatment to ensure timely processing. Only original claim forms will be accepted as each form
carries a unique form number. To download a form, please visit our website www.tameen.ae
1. Claimant Details Form Number 58657029
Claimant Name
Card Number Mobile No. 0 5
Email Address
2. Principal Member Bank Details (in case not provided already or needs to be updated)
Account Name Bank A/C #
Bank Name Branch
IBAN (23 digits)
3. Claim Details
Is the claim in UAE? Yes No If No, precise Country
Name of Hospital/Dr.
Date of Treatment / / 1 Number of Invoices
Total Amount Claimed Currency
For breakdown of Total Amount Claimed, use attached summary table cover sheet to tabulate entries in chronological order.
4. Medical Details – to be completed by the treating Doctor

Is it work related? Yes No If Yes, specify
Treatment Type In-Patient Out-Patient Day Care
Chief Complaint
Diagnosis
Treatment Details
l, the undersigned treating doctor, hereby declare I have attended to this patient and the particulars provided are
correct and accurate to the best of my knowledge.
Doctor Name
Signature Date
& Stamp
5. Claimant’s Declaration & Authorization

I confirm that all particulars filled are true, accurate and complete. I hereby authorize (i) the medical provider/other entities
to provide & discuss health/treatment details with Oman Insurance Company (‘Insurer’) and/or its third party administrator
(ii) the Insurer to (a) disclose my personal/claim information for claim processing or as may be required (b) to use alternate
claim payout option if required (iii) contact me for claim/other products information. I understand that (i) any person, who
intentionally conceals, makes false or misleading statement to obtain claim reimbursement, is subject to penalization and
legal action (ii) acceptance of claim form does not constitute acceptance of liability by the Insurer (iii) my claim is subject
to terms and conditions of my policy. This authorization shall remain valid notwithstanding death or incapacity. A
photocopy or facsimile copy of this authorization shall be as valid as the original.
Claimant
Signature Date
Name
Oman Insurance Company (P.S.C.), Paid up Capital 461,872,125, C.R. No. 41952, Insurance Authority No. 9 dated 24/12/1984
Head Office: P.O. Box 5209, Dubai, United Arab Emirates. Tel.: 800 4746 Fax: +971 4 233 7775, www.tameen.ae
How to Complete the Form
Healthcare Insurance
Both you and the attending doctor must fill in the claim form for each
individual visit or course of treatment. Please look at the below definitions
to understand who is Principal member, Dependant and Claimant.
Principal Member is the insured employee under the policy.

Dependant refers to Principal Member’s spouse or children.
Claimant is the person undertaking the treatment.
1
Principal Member: Please fill section 2
• Enter the bank details including the IBAN of the account where 2
we can transfer the settled claim amount for you or your
dependant. 3
Claimant: Please fill section 1, 3 & 5
• Fill in your name and card number. Give us your contact details
so we can keep you informed on the progress of your claim by 4
SMS or e-mail.
• Include the breakdown of expenses that need reimbursement.
Complete the summary table on the next page giving the full
required details. Each invoice detail should be on a separate 5
line.
• Read the Declaration section carefully and remember to sign
and date the form.
Doctor: Please fill section 4

• Please ensure that the doctor completes each question of the Medical section in full and then signs
and stamps it.
Medical Claims Department

Oman Insurance Company
Level 3, Al Rigga Business Centre,
Send your claim to:
Al Rigga Street, Deira
PO 5209, Dubai, UAE
Tel: +971 4 230 2700
Claim Processing
Your claim will be assessed in full confidentiality by one of our personal advisers. If OIC has received all
required documents and information, you will receive within 15 working days the reimbursement in UAE Dirham
along with a claim report and explanations in the case of declined amounts.
It is preferable and recommended for the reimbursement claim form to be submitted within thirty (30) days of
the original claim knowing that claims submitted after ninety (90) days of treatment shall not be accepted.
800 4746
If you have any enquiries, UAE Toll Free 8am till 8pm Sunday to Thursday, 8am till 4pm on Saturday
contact us on: Fax: +971 (0) 4 238 4769
service@tameen.ae
Summary Table of Invoices
Reimbursement Claim Form Attachment
Mark the sequence number of the corresponding invoice.

Sequence Service Invoice ref. Claimed
Provider Name Service Description Currency
Number Date Number Amount
In case you have more invoices to send, please photocopy this sheet.
Checklist - Before you submit, please check that you have included all of the following as applicable: 
1. Completed, stamped and signed Reimbursement Claim Form
2. Original invoices/bills showing payments confirmation
3. Medical and/or Lab test reports
4. All claims submitted must be in original & translated to either English or Arabic for the settlement
5. Healthcare Insurance card copy of the claimant
6. Summary Table of Invoices (above) completed
7. You have retained a copy of the Form, Summary Table and original invoices and report for your reference
Claimant Name & Signature
Member Name Signature Date

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Reimbursement Claim Form

4. Medical Details – to be completed by the treating Doctor

5. Claimant’s Declaration & Authorization

Principal Member is the insured employee under the policy.

Doctor: Please fill section 4

Medical Claims Department

Mark the sequence number of the corresponding invoice.

Claimant Name & Signature

Member Name Signature Date

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