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
