Receive your claim payment faster by updating your bank details on the mySukoon app or on https://medical.sukoon.com/
1. Claimant Details
* Use EFT for faster, safer, and convenient reimbursement.
Principal Member can update IBAN by visiting mySukoon portal on mySukoon app.
For policies where payment is set to ‘group’, the IBAN must be provided by your company on the company’s letterhead along with the HR/Accounts’ email ID
2. Claim Details
1. Is the claim in UAE?
Yes    No
If No, Precise Country
2. Name of Hospital/Dr
/
3. Date of Treatment
4. No.of Invoices
01
5. Total Amount Claimed
6. Currency
AED
For breakdown of Total Amount Claimed, use attached summary table cover sheet to tabulate entries in chronological order
3. Medical Details – To be Completed by the Treating Doctor
1. Is it work related ?
Yes    No
If Yes, Specify
2. Treatment Type
Out Patient
3. Chief Complaints
4. Diagnosis

ICD Code:
5. 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 & Stamp:
Date :
4. Claimant’s Declaration & Authorization
I hereby authorize Sukoon Insurance PJSC (hereinafter referred to as "Sukoon") to wire transfer claim payouts (if any) related to this claim form to the above bank details as updated by me. I understand that Sukoon reserves its right to use any alternate payout option if required. If ever Sukoon credits more amount than the correct benefit amount due to duplicate or erroneous funds transfer, I authorize Sukoon to revise the transaction and withdraw the overpayment. I will not hold Sukoon responsible or liable in any case of non-credit to the above bank account or if the transaction is delayed or not effected at all for reasons of incomplete/incorrect details filed in by me.
 
I confirm that all particulars filled are true, accurate and complete. I confirm that all submitted/uploaded documents are true copy(ies) of the original documents. I also confirm my understanding that I am required to retain the original documents for a period of one year, within which Sukoon may request original documents anytime for verification purposes. In the event I do not provide the original or am unable to provide the authenticity of the submitted documents then Sukoon reserves the right to recover paid claim amounts if any.
 
I hereby authorize (i) the medical provider/other entities to provide & discuss health/treatment details with Sukoon (‘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 options if required; and (iii) to contact me anytime and through any medium for providing claim/other insurance 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.
 
This authorization shall remain valid notwithstanding death or incapacity. This electronic authorization shall be as valid as the original.
Claimaint Name & Signature :
Date :
SUMMARY TABLE OF INVOICES
REIMBURSEMENT CLAIM FORM ATTACHMENT
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: ✔(use tick mark)
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
If you have any enquiries, contact us on:
800 SUKOON (785666)
UAE Toll Free 8 am till 8 pm Monday to Friday, 8 am till 5 pm on Saturday
Fax: +971 (0) 4 238 4769
weserve@sukoon.com