Brief Summary on the LT Singapore Plan

Dear Members,

The below is just a summary of the main policy document. Please refer to our
membership guide for more details on the benefits, exclusions and processes.

 Outpatient: 10% co-pay applicable capped to a max of SGD 50 per claim.

 Inpatient & Maternity: No co-payment is applicable
 In case of hospitalisation, semi private room (twin bedded) is covered under the
plan
 Overseas cover: Full cover up to the plan benefits. You will need to pay for the
treatment first and initiate the claim on your return.
 Cover in India is subject to a maximum per trip of 42 consecutive days. Extending
the period of cover in India for maternity cases above 42 days is on a case by case
basis. Pre-approval is required by Mayfair.
 There is no cashless service for any specialist consultation and specialists in Raffles
Hospital, Raffles Women Centre, and Raffles Children Centre are considered as
specialist consultations, thus cashless service would not be available. It will be on
reimbursement only.

 Cashless service is only available for inpatient hospitalisations (guarantee of

payment process) and at Raffles Medical Group of clinics (outpatient GP level
treatment)

 Please produce the Mayfair ID card (E-card) at Raffles Medical Group of clinics to
avail the cashless service for outpatient GP level of treatment. New Joiners details
will be updated in Raffles system in 2-3 weeks time. Please proceed to submit your
claim to Mayfair claims during this period.

 Please note that all claims would need to be submitted for reimbursement within
90 days of the invoice date or the treatment date, whichever is earlier.

 Claims Process:

(1) Request you to kindly provide us with the completely filled claim form
along with the original bills for the claim to be processed. You may
forward the scanned copies of all original documents including the claim
form to mayfair.claims@ihmsworldwide.com.
(2) Please clearly mention the illness type, date of illness etc. (if the claims
are for more than one illness/sickness please use a separate claim forms)
in the respective spaces in the second page of the form.

Mayfair Worldwide
 (3) You are requested to send us a diagnosis report/medical
report/treatment details where applicable.
(4) On page 2(claim form) request you to clearly mention the amount you
are claiming in relation to each treatment.
(5) Please clearly mention your bank details including SWIFT (BIC) code,
bank address & IBAN (only for EU countries) and the account currency.

 It will take a maximum of 10 working days to process the claim upon receiving it.
If the mode of payment is via telegraphic transfer, it will take another 3-5 working
days for the amount to reach your bank account. You will receive an
acknowledgement mail within 48 hours after submitting the claim and once the
claim and the payment has been processed an email on the payment update would
be sent to you.

 For all claim related queries please email Mayfair claims department at
Mayfair.claims@ihmsworldwide.com, toll free number: 8004481532 (press 1)

 For GOP related queries, please email Mayfair assist at

mayfair.assist@ihmsworldwide.com, toll free number: 8004481532 (press 2)

 Please refer to the membership guide for further details on the policy benefits,
limits, exclusions and processes.

 You can access all relevant information pertaining to your coverage (membership
guide, coverage document, claims forms etc) by logging into the Mayfair website
via the below steps.

1. http://www.mayfairworldwide.com/asp/insuredslogin.asp (Copy & Paste the

URL in your browser)
2. Choose the link New user? Please click here.
3. Put in your Mayfair ID & Employee Id.
4. The system will ask you to reset your password. (Your choice)
5. Put in your address & date of birth (If you have logged in for the first time)
6. Click "update"
7. Now click on "home" to access your homepage and relevant documents.

 If you do not have your Mayfair ID please write to

medicalinsurance@mayfairworldwide.com with your employee id and company
name.

 Claim Form – Please refer to the next page.

Mayfair Worldwide
 ACCIDENT AND ILLNESS CLAIM FORM

HOW TO SUBMIT CLAIM FORM

Please e-mail Scan copies of the completed claim form along with all supporting documents / reports/ bills/ invoices to mayfair.claims@ihmsworldwide.com
PLEASE READ THIS CAREFULY
1. Please send the claim form only by the official company email ID.
2. This form is to be used when filing a claim for reimbursement of Medical Expenses and MUST be completed by the Insured in full.
3. Fully itemized bills including Claimant’s Name, Nature of Illness/Injury, and diagnosis must be included with this claim form.
4. This form must be signed and dated in all applicable sections.
5. This form and all attached bills must be submitted as Email Scan copies.(preferably in PDF)
6. Complete Bank details needed (Incorrect details may lead to short transfer, bank transaction charges may be applicable.)
INCOMPLETE CLAIM FORM MAY DELAY REIMBURSEMENT PROCESS
HELPFUL HINTS
1. When you are submitting expenses for more than one family member, please use a separate claim form for each person and each medical condition.
2. It is suggested that you make copies for your own use before you submit the original bills if so requested for the Claims Team.

3. Prescription Drugs-Bills must show the patient’s name, date of service, prescription number amount paid, name, strength & quantity of drug, the name
and address of the pharmacy.
4. If the provider needs to be paid please mention provider’s bank details
******************************************************************************************************************************
Name of Client Company: _________________________ Name of Employee: ____________________________________

Employee Number: ______________________________ Mayfair ID Number: ____________________________________

Email ID: _________________________________________ Date of Birth ___/___/____ Sex: Male Female

Current Residence Address: ____________________________________________________________________________

Daytime Phone Number: __________________________Mobile Phone Number: ___________________________________

Permanent Address (In Home Country):
______________________________________________________________________________________________________
SETTLEMENT DETAILS:

Bank details (For Wire Transfers):

A) Beneficiary Name: _________________________________________________
B) Bank Name: ______________________________________________________
C) Bank Address: ____________________________________________________
___________________________________________________________________
___________________________________________________________________

D) IBAN number (Europe/Bahrain/UAE) ___________________________________

BSB Code (Australia) ________________________________________________
Transit/Sort Code (Canada, South Africa) ________________________________
IFSC Code (India) __________________________________
Clabe number (Mexico) _____________________________
Bank Routing code/sort code/branch code (Indonesia/Malaysia/ Singapore) ___
___________________________________________________________________

E) Account number: ____________________________________

F) Swift code (mandatory) ________________________________

G) Your account currency ________________________________

Address details (if requesting cheque payment only):

A) Beneficiary Name: _________________________________________________
B) Address with Post code: ____________________________________________
__________________________________________________________________
___________________________________________________________________

C) Your account currency __________________________________

CHEQUES ARE SENT OUT BY POST AND POSTAL DELAYS ARE OUT OF OUR CONTROL

Note: If the bank details are other than the primary member, please send a mail from your official email ID authorising the alternative bank details.
This page of the claim form can be saved and used for all claims submitted as long as the above details remain the same, only the second page can be
altered accordingly.
ORIGINALS ORIGNALS WOULD BE REQUESTED ON A CASE TO CASE BASIS
Postal Address: INTERNATIONAL HEALTHCARE MANAGEMENT SERVICES PVT LTD.
Mayfair Claims Department, 6th Floor, Tower 2, 'E City', Phase 1, Electronic City, Survey no. 94/2, Bangalore - 560 100 INDIA.
TOLL FREE: + 800 MAYFAIR0 (+ 800 6293 2470) CALL COLLECT TEL NO. : + 1 317 818 2800 Direct No: - +91 8030147200 (Mon to Fri – 8.00 am to 7.00 pm IST)
Name of Patient: ____________________________________Mayfair ID Patient: __________________________________

Date of Birth ___/___/____ Sex: Male Female Relationship Self Spouse Son Daughter

If Accident, provide details, i.e., how when and where accident occurred
_______________________________________________________________________________________________________

If Illness, advise when and where symptoms first occurred and nature of illness___________________________________

Exact diagnosis: _______________________________________________________________________________________

If Maternity Related (Date of confirmation of pregnancy/ Estimated date of delivery/ Any complications foreseen)
_______________________________________________________________________________________________________

Consulting Physicians – Name: ___________________________________________________________________________

Address: _________________________________________________________Phone Number: _________________

Has Mayfair assistance / Sevencorners been contacted with regards to this illness. Yes No Any GOP issued for the same Yes No

Have you ever been treated for this Illness before? Yes No If Yes, when? _______________________________________

Have you been completely cured of the above diagnosis Yes No

Please advise names of any prescription medications you are presently taking: _________________________________________

Indicate other Health Insurance coverage, include name, address, policy number and certificate number of Insurer: __________
_____________________________________________________________________________________________________________
Any Other Information that you would like to provide: _______________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________

Details of Expenses Claimed

Dates of Treatment Service provided Currency Amount Paid RECEIPTS No.

The furnishing of this form, or its acceptance by the Company, must not be construed as an admission of any liability on the Company, nor a waiver of any of the conditions of the
insurance contract. Any person who knowingly and/or with intent to injure, defraud, or deceive an insurance company or other person files a statement of claim containing false,
incomplete or misleading information, may be guilty of insurance fraud and subject to criminal and substantial civil penalties.

I, the undersigned authorize any hospital or other medical-care institution, physician or other medical professional, pharmacy, insurance support organization, governmental agency, group
policyholder, insurance company, association, employer or benefit plan administrator furnish to the Claims Administrator named above or its representatives, any and all information with respect
to any injury or illness suffered by, the medical history of, or any consultation, prescription or treatment provided to, the pe rson whose death, injury, illness or loss is the basis of claim and copies
of all of that person’s hospital or medical records, including information relating to mental illness and use of drugs and alcohol, to determine eligibility for benefit payments under the Policy
Number identified above. I authorize the group policyholder, employer or benefit plan administrators to provide the Claims Administrator named above with financial and employment-related
information. I understand that this authorization is valid for the term of coverage of the Policy identified above and that a copy of this authorization shall be considered as valid as the original.

I understand that I, or my authorized representative, may request a copy of this authorization.

In addition, I hereby certify that the above information is true and correct to the best of my knowledge and belief.

_____________________________________________ ______________________
Signature of Claimant or Parent, If Claimant is a Minor Date