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    Cigna

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    UNKNOWN LSA
    This settlement note summarizes medical claims submitted by Fazli Saifuddin and their family members from the United Nations. It details the amounts claimed, amounts covered by insurance, and reimbursements paid. For Fazli Saifuddin's claim, no payment was made as an invoice was missing. For Saifi Fariba's claim, $18.62 was paid for a diagnostic exam and $19.29 for analyses, with $350 and $363 co-payments required. Additional documents are needed for full processing of some claims.

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    Cigna

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    UNKNOWN LSA
    126 views7 pages
    This settlement note summarizes medical claims submitted by Fazli Saifuddin and their family members from the United Nations. It details the amounts claimed, amounts covered by insurance, and reimbursements paid. For Fazli Saifuddin's claim, no payment was made as an invoice was missing. For Saifi Fariba's claim, $18.62 was paid for a diagnostic exam and $19.29 for analyses, with $350 and $363 co-payments required. Additional documents are needed for full processing of some claims.

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    This settlement note summarizes medical claims submitted by Fazli Saifuddin and their family members from the United Nations. It details the amounts claimed, amounts covered by insurance, and reimbursements paid. For Fazli Saifuddin's claim, no payment was made as an invoice was missing. For Saifi Fariba's claim, $18.62 was paid for a diagnostic exam and $19.29 for analyses, with $350 and $363 co-payments required. Additional documents are needed for full processing of some claims.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    126 views7 pages

    Cigna

    Uploaded by

    UNKNOWN LSA
    This settlement note summarizes medical claims submitted by Fazli Saifuddin and their family members from the United Nations. It details the amounts claimed, amounts covered by insurance, and reimbursements paid. For Fazli Saifuddin's claim, no payment was made as an invoice was missing. For Saifi Fariba's claim, $18.62 was paid for a diagnostic exam and $19.29 for analyses, with $350 and $363 co-payments required. Additional documents are needed for full processing of some claims.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 7
    At a glance
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    The settlement note provides a summary of medical claims submitted and reimbursed. It also defines various terms used and updates balances.

    Medical expenses were claimed for FAZLI SAIFUDDIN, SAIFI FARIBA, FAZLI ALTAF, FAZLI LAILA and FAZLI SOHILA on various dates in July 2019.

    The 'Covered' column shows the portion of each claimed expense that is eligible for reimbursement under the medical plan. Some items like vitamins were not covered.

    Settlement date: 17/07/2019 Page: 1/7

    Settlement note n°: 000004 Personal ref. n°: 414/00374


    Main plan member: FAZLI SAIFUDDIN Questions? +60 3 2032
    Organisation: The United Nations 5333

    YOUR SETTLEMENT NOTE


    This document explains how we processed your claims. You’ll find a summary below and detailed information on the next pages.
    Please check the document carefully to make sure all information is correct. If you have questions simply call us at +60 3 2032 5333.

    Your claims

    ACTION REQUIRED
    PATIENT DATE YOU CLAIMED WE PAID
    FROM YOU?

    FAZLI SAIFUDDIN 13/07/2019 1,985.00 AFN 0.00 USD Yes

    SAIFI FARIBA 13/07/2019 8,173.00 AFN 43.23 USD Yes

    FAZLI ALTAF 13/07/2019 6,103.00 AFN 57.40 USD No

    FAZLI LAILA 13/07/2019 4,534.00 AFN 26.74 USD Yes

    FAZLI SOHILA 13/07/2019 3,203.00 AFN 27.08 USD No

    AMOUNT CLAIMED 23,998.00 AFN This is the sum of the amounts claimed per currency.

    For more information please see the ‘Payments’ section at the end of
    AMOUNT PAID 154.45 USD
    the document.

    Your action is required. For detailed information please check the icons in the section ‘Details of
    ACTION REQUIRED your settlement note’.
    You can upload missing documents and provide extra information on your personal webpages.

    Comment(s)

    We would like to ask you, for future claims, to ensure that you mention all the expenses you are claiming on your claim form.

    To guarantee a secure transfer of funds and to avoid bank charges, reimbursement of your medical expenses will be done via
    payroll (within the next two payroll cycles). As the timing of your reimbursement depends on its processing by payroll, we
    kindly ask you to allow two payroll cycles before contacting your mission focal point for MIP reimbursements.

    Cigna International Health Services Sdn. Bhd. • www.cignahealthbenefits.com


    672662-X 3B-15-3A, Level 15, Block 3B Plaza Sentral • Jalan Stesen Sentral 5, Kuala Lumpur Sentral • 50470 Kuala Lumpur • Malaysia
    Settlement date: 17/07/2019 Page: 2/7
    Settlement note n°: 000004 Personal ref. n°: 414/00374
    Main plan member: FAZLI SAIFUDDIN Questions? +60 3 2032 5333
    Organisation: The United Nations

    The Words we use

    TERM THIS MEANS

    Date format All dates in this document are shown as dd/mm/yyyy. For example: 07/02/2018 means 7th February 2018.
    Claimed Amounts claimed by you or the health care provider.
    Not covered Amounts that are not eligible for reimbursement by the medical plan.
    Covered Amounts that are eligible for reimbursement by the medical plan and that are used as the basis for the calculation of your reimbursement.
    Countervalue Conversion into the medical plan currency of the amounts shown in the ‘Covered’ column.
    Other insurance Amounts that are covered by another insurance plan or by a national health security system.
    Basic reimbursement Standard amount paid according to your medical plan.
    (The basic label is to distinguish from a possible Stop-loss reimbursement.)
    Stop-loss reimbursement Amount paid by the medical plan on top of the basic reimbursement, once the stop-loss limit has been reached (= maximum amount of co-payments you have
    to pay for covered medical expenses in a calendar year).
    Total reimbursement Amount that is paid to you according to your medical plan.
    (= basic reimbursement + stop-loss reimbursement, if applicable)
    Your co-payment Portion of the covered medical expenses that is not reimbursed by the medical plan, and thus remains at your charge.

    DETAILS OF YOUR SETTLEMENT NOTE Not sure you understand the terms used in this
    table? Check ‘The Words we use’.

    Your claim for FAZLI SAIFUDDIN dated 13/07/2019 (date of birth 30/11/1981)

    OTHER BASIC STOP-LOSS TOTAL YOUR CO-


    TYPE OF CARE CLAIMED - NOT COVERED = COVERED COUNTERVALUE
    INSURANCE REIMBURSEMENT REIMBURSEMENT REIMBURSEMENT PAYMENT

    Invoice from PHARMACY dated 12/07/2019


    Medical treatment - 12/07/2019 1,985.00 AFN 1,985.00 AFN(1) 0.00 AFN 0.00 USD 0.00 USD 0.00 USD 0.00 USD 0.00 USD 0.00 AFN

    TOTALS 1,985.00 AFN 0.00 USD

    More Information
    (1) We noticed that an invoice was missing from your claim. Could you send it to us so we can process it as well ?

    Cigna International Health Services Sdn. Bhd. • www.cignahealthbenefits.com


    672662-X 3B-15-3A, Level 15, Block 3B Plaza Sentral • Jalan Stesen Sentral 5, Kuala Lumpur Sentral • 50470 Kuala Lumpur • Malaysia
    Settlement date: 17/07/2019 Page: 3/7
    Settlement note n°: 000004 Personal ref. n°: 414/00374
    Main plan member: FAZLI SAIFUDDIN Questions? +60 3 2032 5333
    Organisation: The United Nations

    Your claim for SAIFI FARIBA dated 13/07/2019 (date of birth 05/10/1982)

    OTHER BASIC STOP-LOSS TOTAL YOUR CO-


    TYPE OF CARE CLAIMED - NOT COVERED = COVERED COUNTERVALUE
    INSURANCE REIMBURSEMENT REIMBURSEMENT REIMBURSEMENT PAYMENT

    Invoice from AMIRI MEDICAL dated 12/06/2019


    Diagnostic examin. - 12/06/2019 1,750.00 AFN 1,750.00 AFN 23.27 USD 0.00 USD 18.62 USD 0.00 USD 18.62 USD 350.00 AFN

    Analyses - 12/06/2019 1,813.00 AFN 1,813.00 AFN 24.11 USD 0.00 USD 19.29 USD 0.00 USD 19.29 USD 363.00 AFN

    Invoice from AMIRI MEDICAL dated 12/06/2019


    Medicines - 12/06/2019 858.00 AFN 858.00 AFN(1) 0.00 AFN 0.00 USD 0.00 USD 0.00 USD 0.00 USD 0.00 USD 0.00 AFN

    Invoice from AMIRI MEDICAL dated 12/06/2019


    Doctor's fee - 12/06/2019 500.00 AFN 500.00 AFN 6.65 USD 0.00 USD 5.32 USD 0.00 USD 5.32 USD 100.00 AFN

    Invoice from AMIRI MEDICAL dated 02/07/2019


    Medicines - 02/07/2019 3,252.00 AFN 3,252.00 AFN(1) 0.00 AFN 0.00 USD 0.00 USD 0.00 USD 0.00 USD 0.00 USD 0.00 AFN

    TOTALS 8,173.00 AFN 43.23 USD

    More Information
    (1) Could you send us a medical prescription (less than a year old) for the medication? This will allow us to
    process your claim.

    Your claim for FAZLI ALTAF dated 13/07/2019 (date of birth 17/07/2001)

    OTHER BASIC STOP-LOSS TOTAL YOUR CO-


    TYPE OF CARE CLAIMED - NOT COVERED = COVERED COUNTERVALUE
    INSURANCE REIMBURSEMENT REIMBURSEMENT REIMBURSEMENT PAYMENT

    Invoice from AMIRI MEDICAL dated 02/07/2019


    Analyses - 02/07/2019 3,813.00 AFN 3,813.00 AFN 47.99 USD 0.00 USD 38.39 USD 0.00 USD 38.39 USD 763.00 AFN

    Invoice from AMIRI MEDICAL dated 02/07/2019


    Medicines - 02/07/2019 1,790.00 AFN 402.00 AFN(1) 1,388.00 AFN 17.47 USD 0.00 USD 13.98 USD 0.00 USD 13.98 USD 680.00 AFN

    Invoice from AMIRI MEDICAL dated 02/07/2019


    Doctor's fee - 02/07/2019 500.00 AFN 500.00 AFN 6.29 USD 0.00 USD 5.03 USD 0.00 USD 5.03 USD 100.00 AFN

    TOTALS 6,103.00 AFN 57.40 USD

    Cigna International Health Services Sdn. Bhd. • www.cignahealthbenefits.com


    672662-X 3B-15-3A, Level 15, Block 3B Plaza Sentral • Jalan Stesen Sentral 5, Kuala Lumpur Sentral • 50470 Kuala Lumpur • Malaysia
    Settlement date: 17/07/2019 Page: 4/7
    Settlement note n°: 000004 Personal ref. n°: 414/00374
    Main plan member: FAZLI SAIFUDDIN Questions? +60 3 2032 5333
    Organisation: The United Nations

    More Information
    (1) I'm sorry to let you know that the expense(s) you submitted can't be reimbursed because your medical plan
    doesn't cover vitamins: Theravit

    Your claim for FAZLI LAILA dated 13/07/2019 (date of birth 15/06/2004)

    OTHER BASIC STOP-LOSS TOTAL YOUR CO-


    TYPE OF CARE CLAIMED - NOT COVERED = COVERED COUNTERVALUE
    INSURANCE REIMBURSEMENT REIMBURSEMENT REIMBURSEMENT PAYMENT

    Invoice from AMIRI MEDICAL dated 12/06/2019


    Diagnostic examin. - 12/06/2019 1,188.00 AFN 1,188.00 AFN 15.80 USD 0.00 USD 12.64 USD 0.00 USD 12.64 USD 238.00 AFN

    Analyses - 12/06/2019 825.00 AFN 825.00 AFN 10.97 USD 0.00 USD 8.78 USD 0.00 USD 8.78 USD 165.00 AFN

    Invoice from AMIRI MEDICAL dated 12/06/2019


    Medicines - 12/06/2019 1,704.00 AFN 1,704.00 AFN(1) 0.00 AFN 0.00 USD 0.00 USD 0.00 USD 0.00 USD 0.00 USD 0.00 AFN

    Invoice from AMIRI MEDICAL dated 12/06/2019


    Medicines - 12/06/2019 180.00 AFN 180.00 AFN(1) 0.00 AFN 0.00 USD 0.00 USD 0.00 USD 0.00 USD 0.00 USD 0.00 AFN

    Invoice from AMIRI MEDICAL dated 12/06/2019


    Medicines - 12/06/2019 137.00 AFN 137.00 AFN(1) 0.00 AFN 0.00 USD 0.00 USD 0.00 USD 0.00 USD 0.00 USD 0.00 AFN

    Invoice from AMIRI MEDICAL dated 12/06/2019


    Doctor's fee - 12/06/2019 500.00 AFN 500.00 AFN 6.65 USD 0.00 USD 5.32 USD 0.00 USD 5.32 USD 100.00 AFN

    TOTALS 4,534.00 AFN 26.74 USD

    More Information
    (1) Could you send us a medical prescription (less than a year old) for the medication? This will allow us to
    process your claim.

    Your claim for FAZLI SOHILA dated 13/07/2019 (date of birth 12/04/2006)

    OTHER BASIC STOP-LOSS TOTAL YOUR CO-


    TYPE OF CARE CLAIMED - NOT COVERED = COVERED COUNTERVALUE
    INSURANCE REIMBURSEMENT REIMBURSEMENT REIMBURSEMENT PAYMENT

    Invoice from AMIRI MEDICAL dated 02/07/2019


    Diagnostic examin. - 02/07/2019 438.00 AFN 438.00 AFN 5.51 USD 0.00 USD 4.41 USD 0.00 USD 4.41 USD 88.00 AFN

    Cigna International Health Services Sdn. Bhd. • www.cignahealthbenefits.com


    672662-X 3B-15-3A, Level 15, Block 3B Plaza Sentral • Jalan Stesen Sentral 5, Kuala Lumpur Sentral • 50470 Kuala Lumpur • Malaysia
    Settlement date: 17/07/2019 Page: 5/7
    Settlement note n°: 000004 Personal ref. n°: 414/00374
    Main plan member: FAZLI SAIFUDDIN Questions? +60 3 2032 5333
    Organisation: The United Nations

    OTHER BASIC STOP-LOSS TOTAL YOUR CO-


    TYPE OF CARE CLAIMED - NOT COVERED = COVERED COUNTERVALUE
    INSURANCE REIMBURSEMENT REIMBURSEMENT REIMBURSEMENT PAYMENT

    Analyses - 02/07/2019 450.00 AFN 450.00 AFN 5.66 USD 0.00 USD 4.53 USD 0.00 USD 4.53 USD 90.00 AFN

    Invoice from AMIRI MEDICAL dated 02/07/2019


    Medicines - 02/07/2019 1,815.00 AFN 513.00 AFN(1) 1,302.00 AFN 16.39 USD 0.00 USD 13.11 USD 0.00 USD 13.11 USD 773.00 AFN

    Invoice from AMIRI MEDICAL dated 02/07/2019


    Doctor's fee - 02/07/2019 500.00 AFN 500.00 AFN 6.29 USD 0.00 USD 5.03 USD 0.00 USD 5.03 USD 100.00 AFN

    TOTALS 3,203.00 AFN 27.08 USD

    More Information
    (1) I'm sorry to let you know that the expense(s) you submitted can't be reimbursed because your medical plan
    doesn't cover: Chymoral Forte, Abocal, Neurobion (vitamin/supplement)

    Cigna International Health Services Sdn. Bhd. • www.cignahealthbenefits.com


    672662-X 3B-15-3A, Level 15, Block 3B Plaza Sentral • Jalan Stesen Sentral 5, Kuala Lumpur Sentral • 50470 Kuala Lumpur • Malaysia
    Settlement date: 17/07/2019 Page: 6/7
    Settlement note n°: 000004 Personal ref. n°: 414/00374
    Main plan member: FAZLI SAIFUDDIN Questions? +60 3 2032
    Organisation: The United Nations 5333

    Update on your balances

    You can check the status of the most frequently used balances real-time on your personal webpages or in the Cigna Health Benefits
    app.

    Balances for SAIFI FARIBA

    START DATE PREVIOUS BALANCE THIS REIMBURSEMENT CURRENT BALANCE

    Reimbursement limit
    01/01/2019 25,669.50 43.23 25,626.27
    Yearly maximum

    Balances for FAZLI ALTAF

    START DATE PREVIOUS BALANCE THIS REIMBURSEMENT CURRENT BALANCE

    Reimbursement limit
    01/01/2019 25,643.23 57.40 25,585.83
    Yearly maximum

    Balances for FAZLI LAILA

    START DATE PREVIOUS BALANCE THIS REIMBURSEMENT CURRENT BALANCE

    Reimbursement limit
    01/01/2019 25,669.50 26.74 25,642.76
    Yearly maximum

    Balances for FAZLI SOHILA

    START DATE PREVIOUS BALANCE THIS REIMBURSEMENT CURRENT BALANCE

    Reimbursement limit
    01/01/2019 25,669.50 27.08 25,642.42
    Yearly maximum

    Balances for family

    START DATE PREVIOUS BALANCE THIS REIMBURSEMENT CURRENT BALANCE

    Reimbursement limit
    Stop loss - out-of-pocket 01/01/2019 673.31 38.60 634.71
    amount

    We've made one payment

    WE’VE MADE A PAYMENT TO FAZLI SAIFUDDIN

    Amount in currency of payment: 154.45 USD Payee type: Plan member

    Payment method: Payroll

    Payment details

    Cigna International Health Services Sdn. Bhd. • www.cignahealthbenefits.com


    672662-X 3B-15-3A, Level 15, Block 3B Plaza Sentral • Jalan Stesen Sentral 5, Kuala Lumpur Sentral • 50470 Kuala Lumpur • Malaysia
    Settlement date: 17/07/2019 Page: 7/7
    Settlement note n°: 000004 Personal ref. n°: 414/00374
    Main plan member: FAZLI SAIFUDDIN Questions? +60 3 2032
    Organisation: The United Nations 5333

    Reference: SETTLEMENT DD17/07/19 Payee name: FAZLI SAIFUDDIN


    REIMBURSEMENT OF MEDICAL EXPENSES Payee type: Plan member
    O/REF: 414 0A 00374 UN MIP Payee address: UNAMA ADMIN BUILDING UNOCA COM
    Payment type: Individual payment Payee city: KABUL
    Payee country: AFGHANISTAN

    Currency exchange rates

    We applied the following exchange rates to process your claims. The date and financial institution selected to set exchanges rates are
    specific to your plan.

    INVOICE DATE EXCHANGE RATE

    12/06/2019 1 AFN = 0.01329982 USD

    02/07/2019 1 AFN = 0.01258653 USD

    12/07/2019 1 AFN = 0.01258653 USD

    Cigna International Health Services Sdn. Bhd. • www.cignahealthbenefits.com


    672662-X 3B-15-3A, Level 15, Block 3B Plaza Sentral • Jalan Stesen Sentral 5, Kuala Lumpur Sentral • 50470 Kuala Lumpur • Malaysia

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