Smart Baby Shield Claim

Mother & Child SBS Benefit

Mandatory Documents

– CTC Of Life Assured’s NRIC & Policyowner’s
– CTC Of Absolute Assignee’s NRIC (if different from Life Assured)

Fill In By DOCTOR
– Confidential Medical Certificate (Great Lady Rider / Mother or Child Illness)
– must be completed by Specialist in the related field of specialty

Fill And Prepare By CLIENT

1. Great Lady Rider/Mother or Child Illness Claim Form – Claimant’s Statement

2. Original copy of Letter of Authorisation / Consent X 3

3. Blood – Total Serum Bilirubin (TSB) report

4. Itemized hospital bill for phototherapy

Other Documents

· Full Passport Book for non- Malaysian/incident outside Malaysia & Singapore
· ALL Diagnostic reports in addition to specific reports as stated

Death of Foetus（胎儿死亡）

Mandatory Documents

– CTC Of Life Assured’s NRIC & Policyowner’s
– CTC Of Absolute Assignee’s NRIC (if different from Life Assured)

Fill In By DOCTOR
– Confidential Medical Certificate (Great Lady Rider / Mother or Child Illness)

– must be completed by Specialist in the related field of specialty

Fill And Prepare By CLIENT

1. Death Claim Form – Claimant’s Statement

2. Daftar kematian / Permit mengubur

Other Documents

· Full Passport Book for non- Malaysian/incident outside Malaysia & Singapore

· Still-birth Certificate / Sijil Kelahiran Mati (if any)

Maternity Cancer（产妇癌症）

Mandatory Documents

– CTC Of Life Assured’s NRIC & Policyowner’s
– CTC Of Absolute Assignee’s NRIC (if different from Life Assured)

Fill In By DOCTOR
– Confidential Medical Certificate (Cancer)

– must be completed by Specialist in the related field of specialty

Fill And Prepare By CLIENT

1. Living Assurance Claim Form – Claimant’s Statement

2. Original copy of Letter of Authorisation / Consent X 3

Histopathology report
(if Biopsy cannot be done, to submit other Diagnostic reports eg. CT/MRI & Cancer Marker blood test reports)

Other Documents

· Full Passport Book for non- Malaysian/incident outside Malaysia & Singapore
· ALL Diagnostic reports in addition to specific reports as stated

· CT Scan / MRI Reports, if available
· Bone Marrow Aspiration /Trephine Biopsy
· Report (Leukemia only)
· Blood and laboratory test report

Other illnesses（其他疾病）

Mandatory Documents

– CTC Of Life Assured’s NRIC & Policyowner’s
– CTC Of Absolute Assignee’s NRIC (if different from Life Assured)

Fill In By DOCTOR
– Confidential Medical Certificate (Great Lady Rider / Mother or Child Illness)

– must be completed by Specialist in the related field of specialty

Fill And Prepare By CLIENT

1. Great Lady Rider/Mother or Child Illness Claim Form – Claimant’s Statement

2. Original copy of Letter of Authorisation / Consent X 3

3. ALL Diagnostic reports

4. Hospital / Admission Bill

Other Documents

· Surgery report (if surgery was performed)

Hospitalisation Benefit Of SBS / 住院利益

Child's Congenital Conditions Hospitalisation Reimbursement（儿童先天性疾病住院）

Mandatory Documents

– CTC Of Life Assured’s NRIC & Policyowner’s
– CTC Of Absolute Assignee’s NRIC (if different from Life Assured)

Fill In By DOCTOR
– Hospitalisation & Surgical-Attending Physician’s Statement

Fill And Prepare By CLIENT

1. Hospitalisation & Surgical -Claimant’s Statement

– Original bill(s)/tax invoice(s) and Original receipt(s)
(including deposit and refund receipt, if any)

– Itemised Breakdown: if
(a) pharmacy charges >20% of total bill/tax invoice,
(b) laboratory charges >10% of total bil/tax invoice.

– CTC of Laboratory Test Result, X-Ray, MRI/CT scan, Ultrasound, Histopathology report (if any)

– Claim settlement details from third party (other insurer/employer) if claiming balance

Hospitalisation Reimbursement & Daily Benefits（住院报销和每日福利）

Mandatory Documents

– CTC Of Life Assured’s NRIC & Policyowner’s
– CTC Of Absolute Assignee’s NRIC (if different from Life Assured)

Fill In By DOCTOR
– Hospitalisation & Surgical-Attending Physician’s Statement

Fill And Prepare By CLIENT
1. Hospitalisation & Surgical -Claimant’s Statement

– CTC of Claimant’s NRIC
– CTC of Life Assured’s NRIC
– Direct Credit Facility Form
(if not submitted before)

– CTC of hospitalisation bill//tax invoice

– For Reimbursement Claim-Original bill(s)/tax invoice(s) and Original receipt(s)
(including deposit and refund receipt, if any)

Pregnancy Complication / 妊娠并发症

Abruptio Placenta（胎盘早期剥离）

Mandatory Documents

– CTC Of Life Assured’s NRIC & Policyowner’s
– CTC Of Absolute Assignee’s NRIC (if different from Life Assured)

Fill In By DOCTOR
– Confidential Medical Certificate(Great Lady Rider / Mother or Child Illness)

– must be completed by Specialist in the related field of specialty

Fill And Prepare By CLIENT

1. Great Lady Rider/Mother or Child Illness Claim Form – Claimant’s Statement
2. Original copy of Letter of Authorisation / Consent X 3

Other Documents

· Full Passport Book for non- Malaysian/incident outside Malaysia & Singapore
· If with Gestational Diabetes Mellitus – Blood Oral Glucose Tolerance Test report
· ALL Diagnostic reports in addition to specific reports as stated
· Hospital / Admission Bill (if admitted to ICU / HDU)

· Caesarean Surgery Report (if any)
· Daftar kematian / Permit mengubur (if any)
· Still-birth Certificate / Sijil Kelahiran Mati (if any)

Amniotic Fluid Embolism（羊水栓塞症）

Mandatory Documents

– CTC Of Life Assured’s NRIC & Policyowner’s
– CTC Of Absolute Assignee’s NRIC (if different from Life Assured)

Fill In By DOCTOR
– Confidential Medical Certificate (Great Lady Rider / Mother or Child Illness)

– must be completed by Specialist in the related field of specialty

Fill And Prepare By CLIENT

1. Great Lady Rider/Mother or Child Illness Claim Form – Claimant’s Statement

2. Original copy of Letter of Authorisation / Consent X 3

3. Chest X-ray & / CT Thorax report

Other Documents

Eclampsia（子癇）

Mandatory Documents

– CTC Of Life Assured’s NRIC & Policyowner’s
– CTC Of Absolute Assignee’s NRIC (if different from Life Assured)

Fill In By DOCTOR
– Confidential Medical Certificate (Great Lady Rider / Mother or Child Illness)

– must be completed by Specialist in the related field of specialty

Fill And Prepare By CLIENT

1. Great Lady Rider/Mother or Child Illness Claim Form – Claimant’s Statement

2. Original copy of Letter of Authorisation / Consent X 3

3. Urine FEME report

Other Documents

Placenta Increta / Percreta（胎盘增量）

Mandatory Documents

– CTC Of Life Assured’s NRIC & Policyowner’s
– CTC Of Absolute Assignee’s NRIC (if different from Life Assured)

Fill In By DOCTOR
– Confidential Medical Certificate (Great Lady Rider / Mother or Child Illness)

– must be completed by Specialist in the related field of specialty

Fill And Prepare By CLIENT

1. Great Lady Rider/Mother or Child Illness Claim Form – Claimant’s Statement

2. Original copy of Letter of Authorisation / Consent X 3

3. Placenta Histology report

Other Documents

. Ultrasound Uterus report (if any)

Postpartum Haemorrhage requiring Hysterectomy（产后出血需要子宫切除术）

Mandatory Documents

– CTC Of Life Assured’s NRIC & Policyowner’s
– CTC Of Absolute Assignee’s NRIC (if different from Life Assured)

Fill In By DOCTOR
– Confidential Medical Certificate (Great Lady Rider / Mother or Child Illness)

– must be completed by Specialist in the related field of specialty

Fill And Prepare By CLIENT

1. Great Lady Rider/Mother or Child Illness Claim Form – Claimant’s Statement

2. Original copy of Letter of Authorisation / Consent X 3

3. Hysterectomy Histology or Surgery report

Other Documents

. Ultrasound Uterus report (if any)

Acute Fatty Liver in Pregnancy（妊娠急性脂肪肝）

Mandatory Documents

– CTC Of Life Assured’s NRIC & Policyowner’s
– CTC Of Absolute Assignee’s NRIC (if different from Life Assured)

Fill In By DOCTOR
– Confidential Medical Certificate (Great Lady Rider / Mother or Child Illness)

– must be completed by Specialist in the related field of specialty

Fill And Prepare By CLIENT

1. Great Lady Rider/Mother or Child Illness Claim Form – Claimant’s Statement

2. Original copy of Letter of Authorisation / Consent X 3

3. Diagnostic Test reports: Ultrasound Liver &/ CT Abdomen report

4. Blood – Liver Function Test report

Other Documents

Disseminated Intravascular Coagulation (D.I.C.) due to pregnancy（弥散性血管内凝血）

Mandatory Documents

– CTC Of Life Assured’s NRIC & Policyowner’s
– CTC Of Absolute Assignee’s NRIC (if different from Life Assured)

Fill In By DOCTOR
– Confidential Medical Certificate (Great Lady Rider / Mother or Child Illness)
– must be completed by Specialist in the related field of specialty

Fill And Prepare By CLIENT

1. Great Lady Rider/Mother or Child Illness Claim Form – Claimant’s Statement

2. Original copy of Letter of Authorisation / Consent X 3

3. Blood Test reports:
(i) Full Blood Picture
(ii) Prothrombin Time (PT)
(iii) Partial Thromboplastin Time (PTT)

Other Documents

Blood test reports:
(i) D-dimer (if any)
(ii) Fibrinogen (if any)

Infectious Disease (Upon diagnosis) / 疾病感染利益 (确诊）

Measles with complication（严重麻疹）

Mandatory Documents

– CTC Of Life Assured’s NRIC & Policyowner’s
– CTC Of Absolute Assignee’s NRIC (if different from Life Assured)

Fill In By DOCTOR
– Confidential Medical Certificate (Great Lady Rider / Mother or Child Illness)
CLM-CMCGRLMC-V00-102019
– must be completed by Specialist in the related field of specialty

Fill And Prepare By CLIENT

1. Great Lady Rider/Mother or Child Illness Claim Form – Claimant’s Statement

2. Original copy of Letter of Authorisation / Consent X 3

3. Diagnostic Test reports: Chest X-ray report

4. CT / MRI Brain report

5. Ultrasound Abdomen &/ CT Abdomen report

6. Blood – Liver Function Test report

Other Documents

· Full Passport Book for non- Malaysian/incident outside Malaysia & Singapore
· ALL Diagnostic reports in addition to specific reports as stated

· Electroencephalogram (EEG) report (if any)

Hand Foot Mouth Disease with complication（手足口病）

Mandatory Documents

– CTC Of Life Assured’s NRIC & Policyowner’s
– CTC Of Absolute Assignee’s NRIC (if different from Life Assured)

Fill In By DOCTOR
– Confidential Medical Certificate (Great Lady Rider / Mother or Child Illness)
– must be completed by Specialist in the related field of specialty

Fill And Prepare By CLIENT

1. Great Lady Rider/Mother or Child Illness Claim Form – Claimant’s Statement

2. Original copy of Letter of Authorisation / Consent X 3

3. Diagnostic Test reports: Viral test report to confirm Hand Foot Mouth Disease

4. CT / MRI Brain report

Other Documents

· Full Passport Book for non- Malaysian/incident outside Malaysia & Singapore
· ALL Diagnostic reports in addition to specific reports as stated

· Echocardiogram &/ Cardiac MRI report (if any)

Chikungunya Fever with complication（基孔肯雅热）

Mandatory Documents

– CTC Of Life Assured’s NRIC & Policyowner’s
– CTC Of Absolute Assignee’s NRIC (if different from Life Assured)

Fill In By DOCTOR
– Confidential Medical Certificate (Great Lady Rider / Mother or Child Illness)
– must be completed by Specialist in the related field of specialty

Fill And Prepare By CLIENT

1. Great Lady Rider/Mother or Child Illness Claim Form – Claimant’s Statement

2. Original copy of Letter of Authorisation / Consent X 3

3. Blood test report to confirm Chikungunya Virus

Other Documents

· Full Passport Book for non- Malaysian/incident outside Malaysia & Singapore
· ALL Diagnostic reports in addition to specific reports as stated

· Echocardiogram &/ Cardiac MRI report (if any)
· Ultrasound Abdomen &/ CT Abdomen report
· Blood – Liver Function Test report
· CT / MRI Brain report
· MRI Spine report

Typhoid Fever with complication（伤寒并发症）

Mandatory Documents

– CTC Of Life Assured’s NRIC & Policyowner’s
– CTC Of Absolute Assignee’s NRIC (if different from Life Assured)

Fill In By DOCTOR
– Confidential Medical Certificate (Great Lady Rider / Mother or Child Illness)
CLM-CMCGRLMC-V00-102019
– must be completed by Specialist in the related field of specialty

Fill And Prepare By CLIENT

1. Great Lady Rider/Mother or Child Illness Claim Form – Claimant’s Statement

2. Original copy of Letter of Authorisation / Consent X 3

3. Diagnostic Test reports: Blood / Stool culture test report to confirm Typhoid infection

4. Blood – Widal / Tubex report

Other Documents

· Full Passport Book for non- Malaysian/incident outside Malaysia & Singapore
· ALL Diagnostic reports in addition to specific reports as stated

· CT / MRI Abdomen report
· CT / MRI Brain report (if any)

Rabies（狂犬病）

Mandatory Documents

– CTC Of Life Assured’s NRIC & Policyowner’s
– CTC Of Absolute Assignee’s NRIC (if different from Life Assured)

Fill In By DOCTOR
– Confidential Medical Certificate (Great Lady Rider / Mother or Child Illness)
– must be completed by Specialist in the related field of specialty

Fill And Prepare By CLIENT

1. Great Lady Rider/Mother or Child Illness Claim Form – Claimant’s Statement

2. Original copy of Letter of Authorisation / Consent X 3

3. Diagnostic test report to confirm Rabies

Other Documents

· Full Passport Book for non- Malaysian/incident outside Malaysia & Singapore
· ALL Diagnostic reports in addition to specific reports as stated

Infectious Disease (Upon hospitalisation) / 疾病感染利益 (入院）

Zika Virus Infection（兹卡病毒感染）

Mandatory Documents

– CTC Of Life Assured’s NRIC & Policyowner’s
– CTC Of Absolute Assignee’s NRIC (if different from Life Assured)

Fill In By DOCTOR
– Confidential Medical Certificate (Great Lady Rider / Mother or Child Illness)
– must be completed by Specialist in the related field of specialty

Fill And Prepare By CLIENT

1. Great Lady Rider/Mother or Child Illness Claim Form – Claimant’s Statement

2. Original copy of Letter of Authorisation / Consent X 3

3. Diagnostic test report to confirm Zika

4. Discharge Summary / Discharge Note

Other Documents

· Full Passport Book for non- Malaysian/incident outside Malaysia & Singapore
· ALL Diagnostic reports in addition to specific reports as stated

Middle East Respiratory Syndrome coronavirus (MERSCoV)（中东呼吸综合征冠状病毒）

Mandatory Documents

– CTC Of Life Assured’s NRIC & Policyowner’s
– CTC Of Absolute Assignee’s NRIC (if different from Life Assured)

Fill In By DOCTOR
– Confidential Medical Certificate (Great Lady Rider / Mother or Child Illness)
– must be completed by Specialist in the related field of specialty

Fill And Prepare By CLIENT

1. Great Lady Rider/Mother or Child Illness Claim Form – Claimant’s Statement

2. Original copy of Letter of Authorisation / Consent X 3

3. Diagnostic Test reports: Diagnostic test report to confirm MERS

4. MERS CoV RNA test report

5. Discharge Summary / Discharge Note

Other Documents

· Full Passport Book for non- Malaysian/incident outside Malaysia & Singapore
· ALL Diagnostic reports in addition to specific reports as stated

Ebola Virus Infection（伊波拉病毒）

Mandatory Documents

– CTC Of Life Assured’s NRIC & Policyowner’s
– CTC Of Absolute Assignee’s NRIC (if different from Life Assured)

Fill In By DOCTOR
– Confidential Medical Certificate (Great Lady Rider / Mother or Child Illness)
– must be completed by Specialist in the related field of specialty

Fill And Prepare By CLIENT

1. Great Lady Rider/Mother or Child Illness Claim Form – Claimant’s Statement

2. Original copy of Letter of Authorisation / Consent X 3

3. Diagnostic test report to confirm Ebola

4. Discharge Summary / Discharge Note

Other Documents

· Full Passport Book for non- Malaysian/incident outside Malaysia & Singapore
· ALL Diagnostic reports in addition to specific reports as stated

SARS（非典住院）

Mandatory Documents

– CTC Of Life Assured’s NRIC & Policyowner’s
– CTC Of Absolute Assignee’s NRIC (if different from Life Assured)

Fill In By DOCTOR
– Confidential Medical Certificate (Great Lady Rider / Mother or Child Illness)
– must be completed by Specialist in the related field of specialty

Fill And Prepare By CLIENT

1. Great Lady Rider/Mother or Child Illness Claim Form – Claimant’s Statement

2. Original copy of Letter of Authorisation / Consent X 3

3. Diagnostic Test reports: Diagnostic test report to confirm SARS.

4. SARS-CoV RNA test report – 2 positive test results from 2 different sources or 2 different days.

5. Discharge Summary / Discharge Note

Other Documents

· Full Passport Book for non- Malaysian/incident outside Malaysia & Singapore
· ALL Diagnostic reports in addition to specific reports as stated

Influenza A - Avian influenza A (H7N9) & A(H5N1) 甲型流感 - 甲型禽流感（H7N9）和甲型（H5N1）

Mandatory Documents

– CTC Of Life Assured’s NRIC & Policyowner’s
– CTC Of Absolute Assignee’s NRIC (if different from Life Assured)

Fill In By DOCTOR
– Confidential Medical Certificate (Great Lady Rider / Mother or Child Illness)
– must be completed by Specialist in the related field of specialty

Fill And Prepare By CLIENT

1. Great Lady Rider/Mother or Child Illness Claim Form – Claimant’s Statement

2. Original copy of Letter of Authorisation / Consent X 3

3. Diagnostic test report to confirm Influenza A

4. Discharge Summary / Discharge Note

Other Documents

· Full Passport Book for non- Malaysian/incident outside Malaysia & Singapore
· ALL Diagnostic reports in addition to specific reports as stated

Nipah Virus Encephalitis（立百病毒脑炎）

Mandatory Documents

– CTC Of Life Assured’s NRIC & Policyowner’s
– CTC Of Absolute Assignee’s NRIC (if different from Life Assured)

Fill In By DOCTOR
– Confidential Medical Certificate (Great Lady Rider / Mother or Child Illness)
– must be completed by Specialist in the related field of specialty

Fill And Prepare By CLIENT

1. Great Lady Rider/Mother or Child Illness Claim Form – Claimant’s Statement

2. Original copy of Letter of Authorisation / Consent X 3

3. Diagnostic Test reports: Diagnostic test report to confirm Nipah Virus

4. CT / MRI Brain report

5. Discharge Summary / Discharge Note

Other Documents

· Full Passport Book for non- Malaysian/incident outside Malaysia & Singapore
· ALL Diagnostic reports in addition to specific reports as stated

Japanese Encephalitis（日本脑炎）

Mandatory Documents

– CTC Of Life Assured’s NRIC & Policyowner’s
– CTC Of Absolute Assignee’s NRIC (if different from Life Assured)

Fill In By DOCTOR
– Confidential Medical Certificate (Great Lady Rider / Mother or Child Illness)
– must be completed by Specialist in the related field of specialty

Fill And Prepare By CLIENT

1. Great Lady Rider/Mother or Child Illness Claim Form – Claimant’s Statement

2. Original copy of Letter of Authorisation / Consent X 3

3. Diagnostic Test reports: Diagnostic test report to confirm Japanese Encephalitis

4. Cerebrospinal fluid (CSF) culture report

5. CT / MRI Brain report

6. Discharge Summary / Discharge Note

Other Documents

· Full Passport Book for non- Malaysian/incident outside Malaysia & Singapore
· ALL Diagnostic reports in addition to specific reports as stated

Creutzfeldt-Jakob Disease（克雅二氏）

Mandatory Documents

– CTC Of Life Assured’s NRIC & Policyowner’s
– CTC Of Absolute Assignee’s NRIC (if different from Life Assured)

Fill In By DOCTOR
– Confidential Medical Certificate (Great Lady Rider / Mother or Child Illness)
– must be completed by Specialist in the related field of specialty

Fill And Prepare By CLIENT

1. Great Lady Rider/Mother or Child Illness Claim Form – Claimant’s Statement

2. Original copy of Letter of Authorisation / Consent X 3

3. Diagnostic Test reports: Diagnostic test report to confirm Creutzfeldt-Jakob disease

4. Electroencephalogram (EEG) report

5.Cerebrospinal fluid (CSF) report

6. CT / MRI Brain report

7. Discharge Summary / Discharge Note

Other Documents

· Full Passport Book for non- Malaysian/incident outside Malaysia & Singapore
· ALL Diagnostic reports in addition to specific reports as stated

Malaria（疟疾）

Mandatory Documents

– CTC Of Life Assured’s NRIC & Policyowner’s
– CTC Of Absolute Assignee’s NRIC (if different from Life Assured)

Fill In By DOCTOR
– Confidential Medical Certificate (Great Lady Rider / Mother or Child Illness)
– must be completed by Specialist in the related field of specialty

Fill And Prepare By CLIENT

1. Great Lady Rider/Mother or Child Illness Claim Form – Claimant’s Statement

2. Original copy of Letter of Authorisation / Consent X 3

3. Diagnostic Test reports: Diagnostic test report to confirm Malaria

4. Blood – Light Microscopy Blood Film test for Malaria Parasite

5. Discharge Summary / Discharge Note

Other Documents

· Full Passport Book for non- Malaysian/incident outside Malaysia & Singapore
· ALL Diagnostic reports in addition to specific reports as stated

Dengue Hemorrhagic Fever（登革出血热）

Mandatory Documents

– CTC Of Life Assured’s NRIC & Policyowner’s
– CTC Of Absolute Assignee’s NRIC (if different from Life Assured)

Fill In By DOCTOR
– Confidential Medical Certificate (Great Lady Rider / Mother or Child Illness)
– must be completed by Specialist in the related field of specialty

Fill And Prepare By CLIENT

1. Great Lady Rider/Mother or Child Illness Claim Form – Claimant’s Statement

2. Original copy of Letter of Authorisation / Consent X 3

3. Diagnostic Test reports: Diagnostic test report to confirm Dengue infection

4. Dengue Serology test report

5. Full Blood Picture with Hematocrit report

6. Blood – Liver Function Test report

7. Blood test to confirm Metabolic Acidosis

8. Chest X-ray report

9. Ultrasound Abdomen &/ CT Abdomen report

10. Discharge Summary / Discharge Note

Other Documents

· Full Passport Book for non- Malaysian/incident outside Malaysia & Singapore
· ALL Diagnostic reports in addition to specific reports as stated