Metlife Reimbursement Claim Form

Submit your claim via myMetLife website or mobile app in 4 simple steps. Just login, navigate to cash claim, and enter the details and click submit.
Remember to update your bank details to receive your reimbursement directly into your bank account.

If you are unable to access myMetLife, please provide the below information. To avoid any delays in the processing of your claim, please ensure that:

1) All claim documents are submitted in English or Arabic. Documents in other languages must be translated by an official public translator prior to submission.
2) All necessary claim documents are to be submitted within 30 days of the incurred date. Subject to your policy terms and conditions, claims submitted more than 90 days after the incurred date may be denied.
3) All the required information is provided (marked with *). Without all the required info we will be unable to approve your claim.

For support please call Customer Services on 800-METLIFE (800-6385433).

Employees’s full name*

Date of birth*

Patient’s full name*

Date of birth*

Employee’s nationality*

Patient’s nationality*

Policy number* (Mentioned on your Medical Card)

Certificate number* (Mentioned on your Medical Card)

Reimbursement Method

Wire Transfer Cheque Total Amount Claimed Currency : AED
Bank detail must be updated on myMetLife

Authorization Statement

I hereby certify that all answers and all original documents submitted with the claim form are complete and true. I hereby authorize any doctor, hospital, or medical provider, any insurance company or any other company, institution or any other person who has any record or information about me and/or any of my family members to provide MetLife (American Life Insurance Company) with the complete information's, including copies of their records with reference to my sickness or accident, any treatment, examination, advice, or hospitalization. Any photocopy of this authorization shall be taken as the original copy.

Disclaimer

MetLife will bear charges on account of claims reimbursement levied by the remitting bank. All charges that may be levied by the beneficiary’s bank / other third-party provider will be borne by the beneficiary. We suggest confirming these charges, if any, with your banking provider”.

I verify that the documentation submitted electronically is true and unaltered and I have all the original documents that can be presented upon request of the Insurance Company. I also accept and recognize that at the sole discretion of the MetLife, these documents may be requested at any time during a period of one year counted from the submission of the claim, which I will provide within a period not exceeding of 30 days from the request. Failing to comply could imply the claim to be declined. If the case is confirmed to be declined, I will reimburse any amount paid by MetLife to me or to any party as related to this claim.

MetLife will not provide coverage in, reimburse for treatment obtained in, reimburse for services received in, or make wire transfers or any payments to the countries identified on OFAC’s sanctions list, including but not limited to payments to any financial institutions or medical providers located in a sanctioned country. Also, MetLife will not pay a claim to individuals who: i) are residing in a sanctioned country; ii) are listed on the OFAC Specially Designated Nationals (SDN) list or any other international or local sanctions list; or iii) have traveled to a sanctioned country for purposes of receiving medical, or other treatment or services, subject to the Policy and / or Supplementary contract terms and conditions.

hereby provide MetLife unambiguous consent, to process, share, and transfer my personal data to any recipient whether inside or outside the country, including but not limited to the Company Headquarters in the USA, its branches, affiliates, Reinsurers, business partners, professional advisers, Insurance Brokers and/or service providers where the transfer or share, of such personal data is necessary for: (i) the performance of this Policy; (ii) assisting the Company in the development of its business and products; (iii) improving the Company’s customers experience; (iv) for the compliance with the applicable laws and regulations; or (v) for the compliance with other law enforcement agencies for international sanctions and other regulations applicable to the Company.

*Personal Data means all information relating to me (whether marked “personal” or not) disclosed to MetLife by whatever means either directly or indirectly which concerns, including but not limited to, my medical conditions, treatments, prescriptions, business, operations, contact details, account balances/activities or any transactions undertaken with MetLife

Employee’s signature

Date

Attending Physician Section (*Mandatory fields)

To be filled by attending physician

Patient’s full name*

Patient Date of birth*

Chief Complaints:

Diagnosis :

ICD Code:

How long has the patient been suffering from this sickness?*

Please specify the date when then symptoms first appeared:

If treated by other medical provider please specify the name and treatment details:

If the claim is resulting from pregnancy/childbirth, please provide the LMP*:

Details of the treatment (other than prescription):

If further treatment or operative procedure anticipated, please provide the details:

Physician’s name, address and tel. no. :

Physician’s Signature and Stamp :

Checklist for Insured member

Required

CheckBox

Documents

Notes

Yes

Claim Form (including Attending Physician Section)

Fully completed and signed by you and your physician/surgeon

Yes

Detailed medical report

Detailing ailment/diagnosis or accident with dates it started/happened, signed by your treating physician

Yes

Original hospital/clinic bill

Original

If applicable

Copy of all relevant X-rays/Echography /MRIs and reports

Should reflect your name and date they were taken

If applicable

Copy of all lab tests and reports

Only related to this incident

If applicable

Copy of police report

Required if claim relates to an accident

Please remember:

To help us process your insurance claim as quickly as possible, we ask you to provide the above documents. Otherwise your claim could be delayed or potentially rejected.

How to submit the claim: