PremierDentalCarePlanClaimForm2013 14Novartis Essay

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Premier Dental Care Plan


Please ensure that ALL sections on PAGE TWO of this claim form are completed in BLOCK CAPITALS
Complete a new claim form for each insured person. You should complete Section A. Your dentist or an authorised member of their practice should complete Sections B, C or D as appropriate. Please note that you may claim either under the NHS charge structure or the private, but not both for the same treatment as this constitutes double billing.
Overseas Cover
If you require treatment whilst abroad, please obtain a detailed receipt (if this is not completed in English a charge for translation will be levied and deducted from your claim settlement) and submit it with your claim form. Reimbursements will be related to your selected level of cover and the individual benefits listed.
Settlements will be made in Pounds Sterling.

Accidents/Sports Injury
Cover is provided for dental treatment arising from accidental injury (including participation in sports), subject to your individual treatment limits. Insurance Benefits relate to treatment rendered at the time of the accident which is intended to ease pain and stabilise the damage sustained in the accident. The benefit does not include subsequent rehabilitation treatment.
In the event of you needing dental treatment following an accident or a sports injury, you must inform the claims administrator within 7 days of the accident or as soon as reasonably possible.

1. Make an appointment with the dentist of your choice. Check the treatment cost first; remember that you will be liable for any costs above the amount shown in your Benefit Schedule or any treatment not covered in the Terms of your Policy.
2. Once the treatment has been completed ensure page 2 of this form is fully itemised showing all treatments received. Your dentist or an authorised member of the practice should complete the relevant sections.
3. Settle the bill in the manner required by your dentist – Remember to obtain a receipt before you leave.
4. Send the fully completed claim form – PAGE TWO ONLY – together with the original payment receipts to DENIS UK LIMITED.
a) Please ensure that completed claim forms reach us within 60 days of completion of each item of treatment. Please note that benefits will not be paid in respect of claims which arrive beyond this period.
b) Always keep a copy of the claim form, dentist invoice and receipts.
5. Reimbursement will be made to the principal insured in Pounds Sterling and paid by cheque or directly into your bank account.
Your member number must be included, the tooth numbers must be entered where applicable and the dentist must be identified by his/her GDC number on the claim form
Denis UK Limited
PO Box 6809, Basingstoke, Hampshire, RG24 4NH
Phone: 0800 633 5037
Fax: 0800 633 5038 e-mail:

Data Protection Act – information uses
For the purpose of the Data Protection Act 1998, the data controller in relation to any personal data you supply is PTI
Insurance Company Limited.
Insurance Administration
Information you supply may be used for the purposes of insurance administration by the insurer, its associated companies and agents. It may be disclosed to the Financial Services Commission and other regulatory bodies for the purposes of monitoring and/or enforcing the insurer's compliance with any regulatory rules/codes. Your information may also be used for offering renewal, research and statistical purposes and crime prevention.
It may be transferred to any country, including countries outside the European Economic Area for any of these purposes and for systems administration. In assessing any claims made, the

Should you have any queries regarding your claim please call the
Dental Claims Helpline on 0800 633 5037 (between the hours of 9am and 5pm Monday to Friday), where experienced staff will be pleased to assist