Emergency Health Insurance Plan Claim Form
To submit a claim, you will need to download and complete the form and ensure the form is signed and dated before submitting. Please submit your claim form to mycanadaplan@gallivan.ca with your documentation (medical and invoices) to support your claim.
You must include a copy of the emergency room report and all hospital records if the treatment was received at a hospital. Remember to keep a copy of all documents emailed for your records.
For assistance with your claim form and connecting to the insurer, please email mycanadaplan@gallivan.ca or complete the Contact Form, one of our team members will get back to you within 24 -48 hours.
Important:
- All claims must be reported to the mycanadaplan Powered by Morcare within 30 days of occurrence.
- Written proof of claim must be submitted within 90 days of occurrence.
- You are responsible for all fees charged for any supporting documentation.
- Failure to complete and sign the form in its entirety or submit supporting documentation will delay claim processing.
How to submit claims
- Complete a Claim form
- Download the Claim form
- Complete the form electronically or print and fill out each section
- Fill out all required fields
- Once complete, print completed form, Sign and Date in Pen (all claim forms must be signed and dated to be processed)
- Gather your information related to your medical visit
- Collect all medical reports, documents, ER Tests, Referrals, follow up required; Confirmation of Receipt(s); anything that you received during your appointment
- Make a clear photocopy of your documents and scan (keep your originals)
- Submitting the Claim:
- Submit a claim form when one has been requested by the insurer following a direct billing invoice submitted by the provider (clinic or hospital); the insurer will contact you for follow-up
- Submit a claim form when you have paid out of pocket for your medical visit
- Once your form is completed and applicable documents copied, email them to mycanadaplan@gallivan.ca
- Follow up Status:
- Check your email for follow up documentation from the insurer email claimsia@iaassist.com that may be required by the Claims Department to process your claim. They will explain to you exactly what is missing from your submission.
- Provide any requested information as soon as possible.
- Need Help? Complete the Contact Form to the mycanadaplan Powered by Morcare team for assistance with questions or additional documentation related to your submitted claim.
- If your claim is denied, an explanation about the exclusion(s) will be provided by email from the insurer.
Tip* Before leaving the clinic, or medical visit request a copy of your medical records, tests, referrals, follow up or doctor’s notes that were applicable. This will help in processing your claim, otherwise the insurer will have to request you to complete an authorization form signed by you to obtain your medical records to process your claim.