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Complainant * :	Insurance Company Member Group HR Medical Center/ Hospital Pharmacy Broker Authority Other
Complainant Type * :	IP Concerns OP Concerns Reimbursement Concerns Network Concerns Pharmacy Concerns Unawareness of the policy conditions Call Center Concerns DHA/Insurance Authority Concerns
Name of Complainant :
Card Number : *
Email : *	( Communication purpose )
Emirate ID :
Mobile No :
Date of Complaint :
Name of Patient :
Policy Details :	Maxcare ID : Employee ID :
Company Name :
Insurance Company Name :
Intermediary Name :
Complaint category :	Select Denial of coverage Rejection of claim Accuracy of documentation provided Delays in process Administrative or operational process or procedures Product dissatisfaction or suitability Changes to policy terms Service provided by staff or departments Select Refund Reimbursement Approvals Issue of Cards Addition or deletion of members Select Exclusions Conditions Renewal Premium Network coverage Select Efficiency Attitude Behavioural Knowledge
Grievance Description: *
Is this a repeat complaint :	Yes No
Escalated for outside deliberation or arbitration :	Yes No
Complaint fully upheld :	Yes No
Complaint partially upheld :	Yes No
Complaints denied (prior to any external escalation) :	Yes No
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