Get Combined Insurance Claim Form

Get Combined Insurance Claim Form

The Combined Insurance Claim Form is a document used to file claims with Combined Insurance, a division of Chubb Insurance New Zealand Limited. This form is essential for ensuring that your claim is processed efficiently and accurately. To get started on your claim, fill out the form by clicking the button below.

Structure

The Combined Insurance Claim Form is an essential document for individuals seeking to file a claim with Combined Insurance, a division of Chubb Insurance New Zealand Limited. This form is designed to gather all necessary information to process your claim efficiently. To ensure a smooth experience, it is crucial to follow the provided instructions carefully. The form includes various sections, each requiring specific details. Section 1 focuses on the claimant's personal information, including contact details, employment information, and the nature of the claim. Section 2 must be completed by your medical practitioner, who will provide insights into your condition and treatment. Timeliness is key; claims should be submitted within 30 days of the event giving rise to the claim. Supporting documents, such as medical reports or invoices, should be attached to substantiate your claim. The form outlines the claims process, detailing how Combined Insurance will acknowledge receipt, assess the claim, and communicate updates. Understanding these requirements can significantly speed up the claims process and ensure you receive the benefits you are entitled to.

Combined Insurance Claim Preview

Combined Insurance

Claim Form A division of Chubb Insurance New Zealand Limited

Important Instructions

Important Instructions on how to complete the attached Claim Form and how we assess claims. Please read these important instructions on how to complete the attached Claim Form. This may help us to assess your claim faster.

In this ‘Important Instructions’ section we refer to the Insured or Covered Person as “you” or “your”; and Combined Insurance a division of Chubb Insurance New Zealand Limited (Chubb) as “Combined Insurance”, “we”, “our” or “us”, in the following instructions.

We refer to Chubb Insurance New Zealand Limited (Company No. 104656 Financial Services Provider No 35924) as “Chubb”.

1.It is important that you contact us as soon as possible once you are aware of any circumstance or event giving rise to a claim and provide honest, complete, up-to-date and relevant information when completing this claim form.

2.You should complete Section 1 in full to the extent relevant and attach any relevant invoices and other documents to support your claim. If you do not fully complete the Claim Form this may result in delays processing your claim while we seek missing information. Please see the Important Notes for Particular Benefits.

3.Your Medical Practitioner, and only your Medical Practitioner should complete Section 2 in full to the extent relevant. Your Medical Practitioner must also sign and date the Claim Form in the appropriate place.

4.We normally pay benefits up to the date that your Medical Practitioner has signed the Claim Form. If your disability is ongoing after that date, we will send you a Continuing Claim Form or Progress Form which your Medical Practitioner should sign and complete on your next visit.

Once we have received this completed form, we can make a further payment up to the date your Medical Practitioner has signed the form. The reason we do not pay benefits in advance of when your Medical Practitioner signs a Claim Form, is that the future disability has not yet occurred, and insurance only pays for losses that have already occurred. We follow this procedure even if your Medical Practitioner states an ‘approximate date’ for your disability to end. Of course, all payments depend on your claim falling within the terms and conditions of your Policy.

5.We may ask you or your Medical Practitioner for more information concerning your claim, or we may arrange a further independent assessment by a Specialist of our choosing.

6.Please send this Claim Form together with all supporting documents within 30 days of the commencement of your disability via post to Combined Insurance, Private Bag COMBINED, Remuera, Auckland 1541, via fax to 09-520-9009, or email the form to claims@combined.com. If you do not report your claim within 30 days and we consider the delay has prejudiced our ability to assess your claim, this may affect and/ or delay payment of your claim.

7.Our Claims Process

On receipt of this completed claim form we will take the following steps:

Acknowledge receipt of your claim within 5 business days.

Identify your insurance policy, register your matter against it and assign a claim number for reference. Determine whether or not to accept your claim within 10 business days of the date we have all the information we need to determine your claim.

If we are unable to determine whether or not to accept your claim within 10 business days, such as when we request that you provide further information from your doctor or employer, we will advise you of the additional information we require. You must cooperate with us by providing the information we seek to settle your claim.

If we require information from an independent specialist, or a doctor or other third party which we request directly, then we will advise you of the information required and will provide you with an estimate of how long we expect it will take to determine your claim, once we have this information.

We will update you once every 20 business days, or another such interval as we may agree with you, until your claim is resolved.

8.With the exception of some circumstances, you have a right to access the information we have relied on in evaluating your claim and you can ask us to correct any mistakes or inaccuracies in that information.

9.If we decline your claim in whole or in part, we will clearly explain the reason or reasons. You have a right to access our Complaints and Disputes Resolution process which is summarised on the back page of this claim form.

10.Should you require any assistance in completing this Claim Form, or have any queries about claiming, or how we assess a claim, please contact us on 0800 COMBINED (266 246) and we will be happy to assist you.

Important Notes for Particular Benefits

11.If your Policy covers you for benefits while you

are hospitalised, please attach a copy of your hospital statement showing the dates of admission and discharge. If you were in intensive care during your period of hospitalisation, the Statement should indicate this.

12.If you are claiming for a Fracture Benefit, please attach a copy of the medical report verifying a fracture.

13.If you are claiming for Covered Cancer please attach a copy of a Pathology, Histology, or Histopathology Report, that medically verifies the diagnosis and a copy of your hospital statement showing any out-patient treatments if you are claiming an Out-patient Treatment benefit.

14.If you are claiming a benefit for Skin Cancer, please attach a medical statement verifying this.

15.If you are claiming a Transportation benefit please attach a receipt for your travel expenses.

16.If you are claiming a Family Lodging benefit please attach a copy of your hotel/motel bill.

17.If you are claiming a Facial Disfigurement benefit, please send a photograph of the relevant scar with your claim form. Please note that we may require you to submit a further photograph of your scar if your injury had not fully healed at the time you first lodged your claim.

18.If you are claiming an Emergency Ambulance benefit, please attach a copy of your ambulance statement or account.

Page 1 of 7

Fair Insurance Code

Chubb is a member of the Insurance Council of New Zealand (ICNZ) and a signatory to ICNZ’s Fair Insurance Code (the Code). The Code and information about the Code is available at http://www.icnz.org.nz/ and on request.

Privacy Statement

Combined Insurance is a division of Chubb Insurance New Zealand Limited. Chubb collects, uses and retains your personal information in accordance with Chubb’s Privacy Policy, which also applies to Combined Insurance.

This statement is a summary of Our privacy policy and provides an overview of how We collect, disclose and handle Your personal information. Our privacy policy may change from time to time and where this occurs, the updated privacy policy will be posted on Our website.

Chubb is committed to protecting Your privacy. Chubb collects, uses and retains Your personal information in accordance with the requirements of New Zealand’s Privacy Act, as amended or replaced from time to time.

Personal Information Handling Practices

When do We collect Your personal information?

Chubb collects Your personal information (which may include health information) from You when You interact with Us, including when You are applying for, changing or renewing an insurance policy with Us or when We are processing a claim, complaint or dispute. Chubb may also (and You authorise Chubb to) collect Your personal information from other parties such as brokers or service providers, as detailed in Our privacy policy.

Purpose of Collection

We collect and hold the information to offer products and services to You, including to assess applications for insurance, to provide and administer insurance products and services, and to handle any claim, complaint or dispute that may be made under a policy.

If You do not provide Us with this information, We may not be able to provide You or Your organisation with insurance or to respond to any claim, complaint or dispute, or offer other products and services to You or Your organisation.

Sometimes, We may also use Your personal information for Our marketing campaigns and research, to improve Our services or in relation to new products, services or information that may be of interest to You.

Recipients of the Information and Disclosure

We may disclose the information We collect to third parties, including:

contractors and contracted service providers engaged by Us to deliver Our services or carry out certain business activities on Our behalf (such as actuaries, loss adjusters, claims investigators, claims handlers, professional advisers including lawyers, doctors and other medical service providers, credit reference bureaus and call centres);

intermediaries and service providers engaged by You (such as current or previous brokers, travel agencies and airlines);

other companies in the Chubb group;

the policyholder (where the insured person is not the policyholder);

insurance and reinsurance intermediaries, other insurers, Our reinsurers, marketing agencies; and

government agencies or organisations (where We are required to by law or otherwise).

These third parties may be located outside New Zealand. In such circumstances We also take steps to ensure Your personal information remains adequately protected.

From time to time, We may use Your personal information to send You offers or information regarding Our products that may be of interest to You. If You do not wish to receive such information, please contact Our Privacy Officer using the contact details provided below.

Rights of Access to, and Correction of, Information

If You would like to access a copy of Your personal information, or to correct or update Your personal information, want to withdraw Your consent to receiving offers of products or services from Us or persons We have an association with, please contact the Privacy Officer by posting correspondence to Chubb Insurance New Zealand Limited, PO Box 734, Auckland; telephoning:

+64 (9) 3771459; or emailing Privacy.NZ@chubb.com.

How to Make a Complaint

If You have a complaint or would like more information about how We manage Your Personal Information, please review Our Privacy Policy for more details, or contact Our Privacy Officer at the details above.

You also have a right to address Your complaint directly to the Privacy Commissioner by telephoning 0800 803 909, emailing enquiries@privacy.org.nz or using the online form available on the Privacy Commissioner’s website at www.privacy.org.nz.

Complaints and Dispute Resolution

We take the concerns of its customers very seriously and has detailed complaint handling and dispute resolution procedures that you may access, at no cost to you. To assist us with your enquiries, please provide us with your claim or policy number (if applicable) and as much information as you can about the reason for your complaint or dispute.

Our complaints and dispute procedures are as follows:

Stage 1 – Complaint Handling Procedure

If you are dissatisfied with any of our products or services and you wish to lodge a complaint, please contact us via:

Email: Complaints.NZ@chubb.com

Phone: COMBINED (266 246) (call free within NZ)

+64 9 520 9000 (if calling from overseas) Fax: +64 9 520 9009

Post: The Complaints Officer Combined Insurance Private Bag COMBINED Remuera Auckland 1541

Stage 2 –Dispute Resolution Procedure

If you are dissatisfied with our response to your complaint, you can advise that you wish to take your complaint to Stage 2 and referred to our dispute resolution team. Our internal dispute resolution team can be contacted via:

Email: DisputeResolution.NZ@chubb.com

Phone: +64 9 377 1459

Fax +64 9 303 1909

Post: Internal Dispute Resolution Service

Chubb Insurance New Zealand Limited

PO Box 734

Shortland Street

Auckland 1140

Stage 3 – External Dispute Resolution

We are a member of an independent external dispute resolution scheme operated by Financial Services Complaints Limited (FSCL) and approved by the Ministry of Commerce & Consumer Affairs. Subject to FSCL’s Terms of Reference, if you are dissatisfied

with our dispute determination or we are unable to resolve your complaint or dispute to your satisfaction within two months you may contact FSCL via:

Post: PO Box 5967, Lambton Quay, Wellington 6145

Phone: 0800 347 257 (call free for consumers) or +64 4 472 FSCL (472 3725)

Fax: +64 4 472 3728

Email: info@fscl.org.nz

Website: www.fscl.org.nz

Please note if you would like to refer your complaint or dispute to FSCL you must do so within 2 months of the date of our dispute determination.

Further details regarding our complaint handling and dispute resolution procedures are available from our website and on request.

Page 2 of 7

 

 

 

 

 

 

 

 

 

 

Claimant to complete this page

SECTION 1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Please print using BLOCK LETTERS)

IMPORTANT. Write your Account Number here

 

 

 

Office Use Only

Claimant’s Details

 

 

 

 

 

 

 

 

 

 

Mr

Mrs

Ms

Miss

Other:

 

Claimant's Full Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Birth:

/

/

 

 

 

Height:

Weight:

 

 

 

 

 

 

 

 

 

 

 

 

Residential Address:

 

 

 

 

 

 

Postcode:

 

 

 

 

 

 

 

 

 

 

 

Postal Address (If different from above):

 

 

 

 

 

Postcode:

 

 

 

 

 

 

 

 

 

 

Claimant’s Telephone Number: Daytime: (

)

 

 

Mobile: (

)

 

 

 

 

 

 

 

 

 

 

 

 

Claimant’s Email Address :

 

 

 

 

 

Occupation:

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer’s Name:

 

 

 

 

 

 

Employer’s Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer’s Contact Person:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer’s Contact Telephone Number: (

)

 

 

 

 

 

 

 

 

 

 

 

 

 

Are you claiming under a Family Policy?

Yes

No

If Yes, please provide Family Policy Account Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

It is our preference to make claims payments by Electronic Funds Transfer (EFT).

ADo you want us to make payments on this claim by EFT into your account?

Yes No

BIf Yes to ‘A’, is the account that you pay your premium from the Account you want us to pay your claim payments to?

Yes No

CIf No to ‘A’ and/or ‘B’, please provide name of preferred Financial Institution:

Account Name:

Bank

Branch Number

Account Number

Suffix

Complete for Accident only

1.

When did the accident occur?

Date:

/

/

at

am / pm

 

 

 

 

 

 

2.

Where did the accident occur?

Street Number:

 

Street Name:

 

 

 

 

 

 

 

 

 

Suburb:

 

 

City/Town:

 

 

3.Nature of Injuries: (Please be specific)

4.How did the accident occur? (Please be specific)

5.If it was a motor vehicle accident, please provide a description of the vehicle(s) involved.

(Note: if more than 2 vehicles involved attached details of other vehicles separately)

 

Your vehicle

Registration No.:

 

Make:

 

 

Model:

 

 

 

 

 

 

 

 

 

The other person’s vehicle

Registration No.:

 

Make:

 

 

Model:

 

 

 

 

 

 

 

 

 

6.

Was the accident reported to the Police?

Yes

No

Date:

/

/

 

Police Station:

 

 

 

 

 

 

 

 

Was anyone charged by the Police?

Yes

 

No

If Yes, who was charged?

 

 

 

 

 

 

 

 

 

 

What was the charge?

 

 

 

 

 

(Note: You must provide us with a copy of the Police Report if we request you to)

 

 

 

 

7.

During the 24 hours before the accident, did you drink any alcohol or take any drugs?

Yes

No

 

(If Yes, please provide details - state types and quantities)

 

 

 

 

 

 

 

 

 

 

 

 

 

Did you have a Blood Alcohol Test or Drug Test by the Police?

Yes

No

 

If Yes, what was the result?

 

 

 

 

 

 

8.

Were you transported to Hospital by Ambulance after the accident?

Yes

No

 

 

 

Name of Hospital you attended:

 

 

 

(Note: You must provide us with a copy of the Ambulance Report if we request you to)

 

 

 

 

 

 

 

9.

Eye witness details. Please provide details of any eye witness.

 

 

 

 

 

 

Witness 1 - Full Name:

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

Email Address:

 

 

 

 

Telephone Number: (

)

Daytime

 

 

 

 

 

 

 

 

 

 

 

Witness 2 - Full Name:

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

Email Address:

 

 

 

 

Telephone Number: (

)

Daytime

 

 

 

 

 

 

 

 

 

 

 

Witness 3 - Full Name:

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

Email Address:

 

 

 

 

Telephone Number: (

)

Daytime

 

 

 

 

 

 

 

 

 

 

 

Page 3 of 7

Complete for Sickness only

10.Nature of sickness: (Please be specific)

11. When were the symptoms first noticed?

Date:

/

/

12.Who was the first Medical Practitioner you consulted for this condition? Medical Practitioner’s Name:

Medical Practitioner’s Address:

Medical Practitioner’s Telephone Number: (

)

 

 

 

 

 

 

 

 

 

When did you first see the Medical Practitioner for this condition?

Date:

/

/

 

 

 

 

13. Have you consulted any other Medical Practitioner for this condition?

Yes

No

(If Yes, please provide details)

Medical Practitioner’s Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medical Practitioner’s Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medical Practitioner’s Telephone Number: (

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dates of Consultations:

 

 

 

 

 

 

 

 

 

 

 

 

14. Did you go to Hospital in respect of this sickness?

Yes

No

(If Yes, please provide details)

Hospital Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Admission:

/

/

Date of Discharge:

 

/

/

Number of Days in Hospital:

 

 

 

 

 

15. Have you previously had the same sickness?

Yes

No

(If Yes, please provide details)

 

Date(s):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Treatment Received:

 

 

 

 

 

 

 

 

Name of treating Medical Practitioner/Specialist:

Address of Medical Practitioner/Specialist who treated you:

Complete for Accident and Sickness

16.

Which Medical Practitioner is currently treating you for your injury/illness? (If the same as ‘Q12’ write ‘As above’)

 

Medical Practitioner’s Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medical Practitioner’s Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

Medical Practitioner’s Telephone Number: (

)

 

 

 

 

 

 

 

 

 

When did you first see the Medical Practitioner for this condition?

Date:

/

/

 

 

 

 

 

 

 

 

 

Other Dates of Treatment?

Yes

No

(If Yes, please provide details)

 

 

 

 

 

 

 

17.

Who is your usual family Medical Practitioner? (If the same as ‘Q16’ write ‘As above’)

 

 

 

Medical Practitioner’s Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medical Practitioner’s Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

Medical Practitioner’s Telephone Number: (

)

 

 

 

 

 

 

18.

What other significant medical

or surgical treatments have you received in the past 5 years? (Please provide details)

 

Date(s):

 

 

 

 

 

 

Nature of the condition(s) treated:

Name of treating Medical Practitioner/Specialist:

Address of Medical Practitioner/Specialist who treated you:

19.

Are you affected by any other long term or chronic disability?

Yes

No

(If Yes, please provide details)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

20.Were you hospitalised?

Yes

No

(If Yes, please state date of hospitalisation) From:

/

/

To:

/

/

 

(Please also attach a copy of any hospital statements if you are hospitalised and claiming a confinement benefit)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

21. Are you claiming for Transportation and Family Lodging Benefits?

 

 

 

 

 

 

 

 

 

Yes

No (Please attach receipts supporting your claim if you are claiming for these)

 

 

 

 

 

 

 

 

 

22. If you are claiming a benefit as the result of the diagnosis of any covered Skin Cancer, please attach proof of diagnosis.

Yes

No

 

 

 

23.

‘Total Disability’. Between what dates were you unable to perform any duties? (Refer to the ‘Definitions’ at the top of ‘Section 2’)

 

 

From:

/

/

 

To:

/

/

 

 

 

 

 

 

 

 

 

 

 

24.

‘Partial Disability’. Between what dates were you able to perform only partial duties? (Refer to the ‘Definitions’ at the top of ‘Section 2’)

 

 

From:

/

/

 

To:

/

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

25. Date you returned to your normal duties.

Date:

/

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Page 4 of 7

Authority and Declaration

Chubb Insurance New Zealand Limited Claim Privacy Consent, Medical Authority and Declaration

Claim Privacy Consent

I/ we:

i.understand that Chubb Insurance New Zealand Limited CU1-3, Shed 24, Princes Wharf, Auckland (Chubb) requires personal information (which may include Health information) so that Chubb can evaluate this claim and administer the insurance policy and that failure to consent to the collection, use and disclosure of personal information may result in the claim being refused in part or in full;

ii.authorise Chubb to obtain from other parties personal information (which may include Health information) about me/us that Chubb views as relevant to the claim;

iii.agree to Chubb disclosing to other parties, including but not limited to, service providers engaged by Chubb, the insurance broker, the policy holder (if this differs from the claimant) or reinsurers personal information (including Health information) collected in relation to this claim or the insurance policy;

iv.I authorise any person or entity, including but not limited to Medical Practitioners and the Parties referred to in the Privacy Consent, to provide to Chubb such personal information (including health information) as Chubb in its absolute discretion considers relevant for its assessment of my claim or my entitlement to benefit;

v.understand that I/we have rights of access to, and correction of, personal information held by Chubb; and

vi.understand that further information about how Chubb collects, uses, discloses and processes my/our information is set out in Chubb’s Privacy Policy, available at www.chubb.com/nz-en/footer/privacy.html.

If you would like to access a copy of your personal information, or to correct or update your personal information, please contact Chubb’s Privacy Officer on +64 (9) 377 1459 or email Privacy.NZ@chubb.com.

Authority and Declaration

I/ we:

understand that in evaluating my/our claim or by accepting documents in support of my/our claim, Chubb has made no acceptance of liability, nor waived any of its rights;

confirm that any information that I/we supply will be true, correct and complete and that I/we will not withhold any information likely to affect the acceptance or handling of my/our claim and understand that if I/we provide untrue information or do not disclose relevant information that it might result in my/our claim being declined in part or in full;

will give all reasonable assistance to Chubb and co-operate in the assessment of my/our claim; and

appoint Chubb to do everything necessary to give effect to the consents and authorisations in this document and to execute, on my/our behalf, any documents or to do such acts required to give effect to this Privacy Consent and Authority.

Name of claimant:

Signature of

X

 

Date:

/

/

claimant:

 

 

 

 

 

 

 

 

 

Name of

Witness:

Signature of

X

Date:

/

/

Witness:

Page 5 of 7

 

Medical Practitioner only to complete this section

SECTION 2

This section must be fully completed by a Legally Qualified Medical Practitioner, at the Claimant’s expense.

 

Please read carefully before completing this section.

Total Disability

The inability to perform each of the substantial duties of your business or occupation (usual activities if not employed).

Definitions

Partial Disability

The inability to perform one or more, but not all of the substantial duties of your business or occupation (usual activities if not employed).

Medical Practitioner

Means a licenced medical practitioner operating within the scope of his or her New Zealand licence and who is not a member of your immediate family.

Patient’s Full Name:

 

Date of Birth:

/

/

 

 

 

1. Please tick whether claim is for:

Sickness

Injury

 

 

Diagnosis:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cause:

2. If the patient is suffering from an injury, how did the patient advise you that the injury occurred?

3.

Please Complete for Fractures only. Was the Fracture confirmed by an X-Ray?

Yes

No (Please attach a copy of the X-Ray report)

 

Describe the type of Fracture:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

When did the symptoms first appear, or the accident happen?

Date:

/

 

/

 

 

 

 

 

 

 

 

 

 

 

 

5.

When did the patient first consult you for this condition?

Date:

/

/

 

 

 

 

 

Did Total Disability begin this day?

Yes

No

If No, please state date total disability began

Date:

/

/

6.

Has the patient ever had this condition before?

Yes

 

No

 

 

 

 

 

 

If Yes, please state if the present condition is an aggravation or recurrence of a previous injury or sickness.

 

 

 

 

 

 

 

 

Recovery Date:

/

/

 

 

 

 

 

7.

Has the patient ever had any other disease or infirmity that may be affecting the present condition?

Yes

No

 

 

If Yes, what was the disease or infirmity?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

To what degree did this contribute to current disability?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8.

Is the patient still under your care for this condition?

Yes

No

 

 

 

 

 

 

If Yes, and the patient has not recovered, what is the expected recovery date?

/

/

 

 

 

Please provide details of the Treatment Plan to assist the patient’s recovery:

 

If No, and the patient has recovered, please write the recovery date.

Recovery Date:

/

/

 

 

 

 

 

 

 

 

 

 

 

 

9.

Has the patient had surgery or is surgery anticipated?

Yes

No

Date:

/

/

 

 

 

 

Details of surgery:

 

 

 

 

 

 

 

 

 

 

 

 

 

10. Has the patient been referred to any other Medical Practitioner or Specialist?

Yes

No

(If Yes, please provide details)

 

Medical Practitioner’s Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medical Practitioner’s Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medical Practitioner’s Telephone Number: (

)

 

 

 

 

Date Referred:

/

/

 

 

 

 

 

 

 

 

11.

Are you the patient’s usual Treating Medical Practitioner?

 

Yes

No

If Yes, for how many years?

 

 

 

 

 

 

 

If No, please advise the details of the patient’s usual Treating Medical Practitioner/Medical Practice.

 

 

 

Medical Practitioner/Medical Practice’s Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medical Practitioner/Medical Practice’s Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medical Practitioner/Medical Practice’s Telephone Number: (

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Page 6 of 7

12.Disability Periods. (Refer to ‘Definitions’ at top of the opposite page)

a) Totally Disabled:

 

 

 

 

 

 

 

From:

/

/

To:

/

/

 

(Inclusive)

 

 

 

 

 

 

 

 

b) Partially Disabled

 

 

 

 

 

 

 

From:

/

/

To:

/

/

 

(Inclusive)

 

 

 

 

 

 

c) Hospitalised as an overnight In-patient

 

 

 

 

 

From:

/

/

To:

/

/

 

(Inclusive)

 

 

 

 

 

 

 

 

At: (Hospital Name)

 

 

 

 

 

 

 

 

 

 

 

 

d) Hospitalised as an overnight In-patient in Intensive Care

 

 

 

 

From:

/

/

To:

/

/

 

(Inclusive)

 

 

 

 

 

 

 

 

At: (Hospital Name)

 

 

 

 

 

 

 

 

 

 

e) Do you expect the patient to remain totally disabled for the next 12 months?

Yes

No

13. Is there any further medical information relevant to this claim?

Medical Attendant Authority and Declaration

Chubb Insurance New Zealand Limited Privacy Consent and Declaration

Privacy Consent

I/ we:

i.understand that Chubb Insurance New Zealand Limited CU1-3, Shed 24 Princes Wharf, Auckland requires personal information (which may include my/our personal information and the patient’s health information) so that Chubb can evaluate the patient’s claim and administer their insurance policy;

ii.agree to Chubb disclosing to other parties, including but not limited to, service providers engaged by Chubb, the insurance broker, the policy holder or reinsurers personal information collected in relation to this claim or the insurance policy;

iii.understand that I/we have rights of access to, and correction of, personal information held by Chubb; and

iv.understand that further information about how Chubb collects, uses, discloses and processes my/our information is set out in Chubb’s Privacy Policy, available at www.chubb.com/nz-en/footer/privacy.html.

If you would like to access a copy of your personal information, or to correct or update your personal information, please contact Chubb’s Privacy Officer on +64 (9) 377 1459 or email Privacy.NZ@chubb.com.

Declaration

I/we confirm that to the extent I/we am/are aware, the information supplied in this form is true and correct.

Medical Practitioner’s Declaration

 

 

 

WE RECOMMEND THAT A COPY OF THIS FORM IS TAKEN FOR YOUR FILES.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date:

/

/

Provider Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Qualifications:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address: (If not on stamp)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone Number: (If not on stamp) (

)

 

 

 

 

 

 

 

 

 

 

MEDICAL PRACTITIONER’S

 

Email Address: (If not on stamp)

 

 

 

 

STAMP REQUIRED

 

 

 

 

 

 

Full Name of the

Medical Practitioner’s:

Signature of the

Medical Practitioner’s: X

A division of Chubb Insurance New Zealand Limited

Combined Insurance is a division of Chubb Insurance New Zealand Limited Chubb Insurance New Zealand Limited | Company No. 104656 | FSP No. 35924

Customer Service Phone 0800 COMBINED (266 246) Email claims@combined.com

Website www.combinedinsurance.co.nz Postal Address Private Bag COMBINED Remuera Auckland 1541

Form Number: NZ00010 / ChubbNZ11-22-0721

Page 7 of 7

Document Data

Fact Name Description
Claim Submission Deadline You must submit the Combined Insurance Claim Form along with all supporting documents within 30 days of the start of your disability.
Medical Practitioner Requirement Section 2 of the form must be completed by your Medical Practitioner, who must also sign and date the form.
Honesty in Information Providing honest and complete information is crucial. Inaccuracies can delay the processing of your claim.
Claims Processing Timeline The company will acknowledge receipt of your claim within 5 business days and aims to determine acceptance within 10 business days once all information is received.
Access to Information You have the right to access the information used to evaluate your claim and request corrections if needed.
Independent Assessment Combined Insurance may request additional information or arrange for an independent assessment by a specialist to evaluate your claim.
Communication Frequency Once your claim is under review, you will receive updates every 20 business days or as agreed until the claim is resolved.
Governing Laws This claim form is governed by the laws of New Zealand, including the Privacy Act and the Fair Insurance Code.

How to Use Combined Insurance Claim

Filling out the Combined Insurance Claim form requires careful attention to detail. Make sure to provide accurate and complete information to help expedite the processing of your claim. Follow the steps below to complete the form properly.

  1. Contact Combined Insurance as soon as you become aware of a claimable event.
  2. Complete Section 1 of the form with your personal details, including:
    • Your full name, date of birth, height, and weight.
    • Your residential and postal addresses.
    • Your contact numbers and email address.
    • Your occupation and employer’s information.
    • Indicate if you are claiming under a Family Policy.
    • Choose your preferred method for claim payments.
  3. If applicable, provide specific details regarding the accident or sickness.
  4. Have your Medical Practitioner complete Section 2, ensuring they sign and date the form.
  5. Attach any relevant supporting documents, such as invoices, medical reports, or hospital statements.
  6. Send the completed form and documents to Combined Insurance within 30 days of the event. You can do this via post, fax, or email.

After submitting your claim, Combined Insurance will acknowledge receipt within five business days. They will review your claim and communicate any additional information they may need. Regular updates will be provided throughout the claims process until a resolution is reached.

Key Facts about Combined Insurance Claim

What should I do if I need to file a claim?

As soon as you become aware of a situation that may lead to a claim, contact Combined Insurance. It’s crucial to provide honest and complete information when filling out the claim form. Be sure to complete Section 1 fully and attach any relevant invoices or documents that support your claim. Incomplete forms can delay processing, so take your time to ensure everything is filled out correctly.

How do I ensure my claim is processed quickly?

To speed up the process, complete all sections of the claim form accurately. Your Medical Practitioner must fill out Section 2 and sign it. Submit the form along with any necessary supporting documents within 30 days of your disability. If we need more information, we will reach out to you or your Medical Practitioner, so be prepared to cooperate promptly.

What happens after I submit my claim?

Once we receive your completed claim form, we will acknowledge receipt within 5 business days. Our team will review your information and determine whether to accept your claim within 10 business days. If we require additional information, we will let you know what is needed and provide an estimate of how long it will take to resolve your claim.

What if my claim is denied?

If your claim is denied, we will explain the reasons clearly. You have the right to access the information we used to evaluate your claim and can request corrections if necessary. Additionally, we have a complaints and disputes resolution process available to you if you are dissatisfied with our decision.

How do I contact Combined Insurance for help?

If you have questions about the claim form or need assistance, you can reach out to us at 0800 COMBINED (266 246). Our team is ready to help you navigate the claims process and answer any questions you may have.

Common mistakes

Filling out the Combined Insurance Claim form can be a straightforward process, but many individuals inadvertently make mistakes that can delay their claims. Understanding these common pitfalls can help ensure a smoother experience. One frequent error is failing to provide complete information in Section 1. Each field is designed to gather essential details about the claimant and the circumstances of the claim. Omitting even a small piece of information can lead to significant delays as the insurance company seeks the missing data.

Another common mistake involves the medical practitioner’s section. Claimants often overlook the requirement for their medical practitioner to fill out Section 2 completely. This section is crucial, as it verifies the medical basis of the claim. If this part is incomplete or lacks a signature, it can result in further complications and delays in processing the claim.

Timeliness is also a key factor in successful claims. Many individuals fail to submit their claims within the 30-day window stipulated in the instructions. This oversight can jeopardize the claim’s acceptance, especially if the delay is deemed to have affected the insurer's ability to assess it. It’s vital to keep track of deadlines and ensure that all necessary documents are sent promptly.

Supporting documentation is another area where claimants often falter. Each specific benefit claimed requires different types of evidence. For instance, those seeking a Fracture Benefit must include a medical report verifying the fracture. Failing to attach the required documents can lead to outright denial of the claim or requests for additional information, which can prolong the process.

Claimants sometimes neglect to provide specific details about their injuries or illnesses. General descriptions can create ambiguity, leaving the claims adjuster unsure about the nature of the claim. The more precise the information, the easier it is for the insurer to make a determination. This applies not only to the nature of the injuries but also to the circumstances surrounding the event that led to the claim.

Moreover, some individuals mistakenly assume that their claims will be paid in advance based on verbal assurances from their medical practitioners. The insurance process requires formal documentation, and benefits are typically paid only up to the date signed by the medical professional. Understanding this policy can help avoid confusion and frustration down the line.

In addition, not following up on the claim can be detrimental. After submitting the claim form, it’s essential to keep communication lines open with the insurance company. Many claimants do not inquire about the status of their claims, which can lead to unnecessary delays. Regular updates from the insurer can provide peace of mind and keep the process moving forward.

Finally, some claimants overlook the importance of understanding their policy terms. Familiarizing oneself with the specifics of what is covered can prevent misunderstandings about what benefits are available. This knowledge not only aids in completing the claim form accurately but also sets realistic expectations about the outcome of the claim.

By being aware of these common mistakes, claimants can navigate the Combined Insurance Claim form with greater ease and confidence, ultimately leading to a more efficient claims process.

Documents used along the form

The Combined Insurance Claim form is an essential document for initiating a claim with Combined Insurance, a division of Chubb Insurance New Zealand Limited. Along with this form, several other documents may be required to support your claim. Each of these documents serves a specific purpose in ensuring that the claim process is thorough and efficient. Below is a list of additional forms and documents commonly used in conjunction with the Combined Insurance Claim form.

  • Medical Report: A detailed report from your medical practitioner outlining your diagnosis, treatment, and prognosis. This document is crucial for verifying the medical basis of your claim.
  • Hospital Statement: This statement should include dates of admission and discharge if you were hospitalized. It provides proof of your treatment and the duration of your stay.
  • Invoice Receipts: Any invoices related to medical treatments or services received should be attached. These receipts help substantiate the financial aspect of your claim.
  • Police Report: If your claim involves an accident, a police report detailing the incident may be required. This report offers an official account of the event.
  • Continuing Claim Form: If your disability persists beyond the initial claim period, this form allows your medical practitioner to confirm ongoing treatment and the need for continued benefits.
  • Transportation Receipts: If you are claiming for transportation costs related to medical visits, receipts for travel expenses should be included to support your claim.
  • Photographs of Injuries: For claims related to visible injuries, such as facial disfigurement, photographs may be required to provide visual evidence of the condition.
  • Pathology Reports: If you are claiming for a cancer diagnosis, attaching pathology, histology, or histopathology reports is necessary to confirm the diagnosis medically.

Submitting these additional documents alongside the Combined Insurance Claim form can significantly expedite the claims process. It is advisable to ensure all documents are complete and accurate to avoid delays. For any further questions regarding specific requirements, contacting Combined Insurance directly can provide clarity and assistance.

Similar forms

  • Health Insurance Claim Form: Similar to the Combined Insurance Claim form, this document requires detailed information about the claimant's medical condition and treatment history. Both forms ask for supporting documentation from medical practitioners to validate the claim.
  • Disability Insurance Claim Form: This form focuses on claims related to disability benefits. Like the Combined Insurance Claim form, it emphasizes the need for a medical professional’s input and documentation to substantiate the claim.
  • Life Insurance Claim Form: In the event of a policyholder's death, this form collects necessary information to process the claim. Both forms require the submission of supporting documents, such as death certificates and medical records.
  • Accident Claim Form: This document is specifically for claims arising from accidents. Similar to the Combined Insurance Claim form, it requires detailed descriptions of the accident and supporting medical documentation to process the claim.
  • Travel Insurance Claim Form: This form is used for claims related to travel-related incidents. Like the Combined Insurance Claim form, it requires evidence of the incident and any relevant medical documentation to support the claim.
  • Homeowners Insurance Claim Form: This document is used to claim damages to property. Similar to the Combined Insurance Claim form, it requires detailed descriptions of the damages and supporting evidence, such as photographs or repair estimates.
  • Auto Insurance Claim Form: Used for vehicle-related claims, this form collects information about the incident and damages. Both forms require detailed descriptions and supporting documents to facilitate the claims process.
  • Workers' Compensation Claim Form: This form is for employees seeking compensation for work-related injuries. It shares similarities with the Combined Insurance Claim form in that it requires medical documentation and detailed descriptions of the injury.
  • Long-Term Care Insurance Claim Form: This document is used to claim benefits for long-term care services. Like the Combined Insurance Claim form, it requires medical documentation and detailed information about the services provided to support the claim.

Dos and Don'ts

When filling out the Combined Insurance Claim form, there are several important guidelines to follow. Here’s a list of five things you should and shouldn't do:

  • Do provide honest and complete information. Ensure all details are accurate to avoid delays.
  • Don't leave any sections incomplete. Each part of the form is essential for processing your claim.
  • Do have your Medical Practitioner fill out and sign the relevant section. Their input is crucial for your claim.
  • Don't wait too long to submit your claim. Aim to send the form within 30 days of your disability.
  • Do attach any necessary supporting documents. This includes medical reports and receipts, which help validate your claim.

Following these guidelines can help streamline the claims process and ensure that you receive the benefits you are entitled to in a timely manner.

Misconceptions

  • Misconception 1: The Combined Insurance Claim Form can be submitted without all necessary documents.
  • This is not true. Submitting incomplete forms or missing documents can delay the processing of your claim. It’s essential to attach all relevant invoices and medical reports to support your claim.

  • Misconception 2: Anyone can fill out Section 2 of the Claim Form.
  • This is incorrect. Only your Medical Practitioner should complete Section 2. Their signature and date are crucial for the claim’s validity.

  • Misconception 3: Claims can be reported anytime after the event.
  • Actually, claims should be reported within 30 days of the event. Delays may affect the assessment and payment of your claim.

  • Misconception 4: The insurance company pays benefits in advance of the Medical Practitioner’s signature.
  • This is a misunderstanding. Benefits are paid only up to the date the Medical Practitioner signs the Claim Form. Future benefits depend on ongoing evaluations.

  • Misconception 5: You do not have the right to access information used in evaluating your claim.
  • This is false. You have the right to access the information used to evaluate your claim and can request corrections for any inaccuracies.

Key takeaways

  • Contact Combined Insurance as soon as you become aware of a claim situation. Timely communication can help speed up the process.

  • Complete Section 1 of the claim form thoroughly. Missing information may lead to delays in processing your claim.

  • Your Medical Practitioner is responsible for filling out Section 2. Ensure they sign and date the form.

  • Submit the completed claim form and all supporting documents within 30 days of your disability starting. Delays may affect your claim's outcome.

  • Keep track of your claim's progress. Combined Insurance will update you every 20 business days or as agreed until your claim is resolved.