Settlement date: 22/02/2024 Page: 1/5

Main plan member: BEGUM Personal ref. n°:

NURJAHAN 270/424775
Organisation: UNICEF Questions? +60 3 2032
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 claim

ACTION REQUIRED
PATIENT DATE YOU CLAIMED WE PAID
FROM YOU?

BEGUM NURJAHAN 15/02/2024 48,915.00 BDT 245.07 USD Yes

AMOUNT CLAIMED 48,915.00 BDT This is the sum of the amounts claimed per currency.

245.07 USD For more information please see the ‘Payments’ section at the end of
AMOUNT PAID
(= 26,244.00 BDT) the document.

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

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.
Reimbursement Amount that is paid to you according to your medical plan.
Basic reimbursement Standard amount paid according to your medical plan.
(The basic label is to distinguish from a possible Stop-loss reimbursement.)
Stop-loss Amount paid by the medical plan on top of the basic reimbursement, once the stop-loss limit has been
reimbursement 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.

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: 22/02/2024 Page: 2/5
Main plan member: BEGUM NURJAHAN Personal ref. n°: 270/424775
Organisation: UNICEF Questions? +60 3 2032 5333

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

Your claim for BEGUM NURJAHAN dated 15/02/2024 (date of birth 05/05/1962)

OTHER BASIC STOP-LOSS TOTAL YOUR CO-

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

Invoice from SARKEI M dated 04/03/2023

Doctor's fee - 04/03/2023 500.00 BDT 500.00 BDT(1) 0.00 BDT 0.00 USD 0.00 USD 0.00 USD 0.00 USD 0.00 BDT 0.00 BDT

Invoice from DIGILAB dated 04/03/2023

Analyses - 04/03/2023 8,120.00 BDT 8,120.00 BDT(1) 0.00 BDT 0.00 USD 0.00 USD 0.00 USD 0.00 USD 0.00 BDT 0.00 BDT

Medical treatment - 04/03/2023 400.00 BDT 400.00 BDT(1) 0.00 BDT 0.00 USD 0.00 USD 0.00 USD 0.00 USD 0.00 BDT 0.00 BDT

Diagnostic examin. - 04/03/2023 2,100.00 BDT 2,100.00 BDT(1) 0.00 BDT 0.00 USD 0.00 USD 0.00 USD 0.00 USD 0.00 BDT 0.00 BDT

Invoice from PHARMACY dated 05/03/2023

Medicines - 05/03/2023 2,850.00 BDT 2,850.00 BDT(2) 0.00 BDT 0.00 USD 0.00 USD 0.00 USD 0.00 USD 0.00 BDT 0.00 BDT

Invoice from POPULAR DIAGNOSTIC dated 19/04/2023

Doctor's fee - 19/04/2023 1,000.00 BDT 1,000.00 BDT(1) 0.00 BDT 0.00 USD 0.00 USD 0.00 USD 0.00 USD 0.00 BDT 0.00 BDT

Invoice from PHARMACY dated 19/04/2023

150.00 BDT(3)
Medicines - 19/04/2023 4,080.00 BDT 270.00 BDT(4) 3,660.00 BDT 34.86 USD 0.00 USD 27.89 USD 0.00 USD 2,928.00 BDT 1,152.00 BDT

420.00 BDT

Invoice from PHARMACY dated 07/05/2023

Medicines - 07/05/2023 11,160.00 BDT 11,160.00 BDT 106.29 USD 0.00 USD 85.03 USD 0.00 USD 8,928.00 BDT 2,232.00 BDT

Invoice from PHARMACY dated 09/09/2023

Medicines - 09/09/2023 11,160.00 BDT 11,160.00 BDT 102.86 USD 0.00 USD 82.29 USD 0.00 USD 8,928.00 BDT 2,232.00 BDT

Invoice from PHARMACY dated 13/01/2024

Medicines - 13/01/2024 6,585.00 BDT 720.00 BDT(5) 5,865.00 BDT 53.56 USD 0.00 USD 42.85 USD 0.00 USD 4,692.00 BDT 1,893.00 BDT

Invoice from ISLAMI BANK HOSPITAL dated 13/01/2024

Doctor's fee - 13/01/2024 700.00 BDT 700.00 BDT 6.39 USD 0.00 USD 5.11 USD 0.00 USD 560.00 BDT 140.00 BDT

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: 22/02/2024 Page: 3/5
Main plan member: BEGUM NURJAHAN Personal ref. n°: 270/424775
Organisation: UNICEF Questions? +60 3 2032 5333

OTHER BASIC STOP-LOSS TOTAL YOUR CO-

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

Invoice from ISLAMI BANK HOSPITAL dated 13/01/2024

Medical treatment - 13/01/2024 260.00 BDT 260.00 BDT 2.37 USD 0.00 USD 1.90 USD 0.00 USD 208.00 BDT 52.00 BDT

TOTALS 48,915.00 BDT 26,244.00 BDT

More Information
(1) These costs were already processed with settlement note(s) dated 02/06/2023 (4) I'm sorry to let you know that the expense(s) you submitted can't be reimbursed because your medical plan
doesn't cover food supplements : Neuroxen
(2) We noticed that the invoice was not attached in your claim. Could you send it to us so we can process it as (5) I'm sorry to let you know that the expense(s) you submitted can't be reimbursed because your medical plan
well? doesn't cover food supplements :B12 Tab
(3) This product does not contain any pharmaceutical active components. Therefore, we cannot process your
claim.

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: 22/02/2024 Page: 4/5
Main plan member: BEGUM Personal ref. n°:
NURJAHAN 270/424775
Organisation: UNICEF Questions? +60 3 2032
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 BEGUM NURJAHAN

START DATE PREVIOUS BALANCE THIS REIMBURSEMENT CURRENT BALANCE

Reimbursement limit
01/01/2023 19,751.37 195.21 19,556.16
Yearly maximum

Reimbursement limit 01/01/2024 18,383.65 49.86 18,333.79

Balances for family

START DATE PREVIOUS BALANCE THIS REIMBURSEMENT CURRENT BALANCE

Reimbursement limit
01/01/2023 1,329.28 48.80 1,280.48
Medical out-of-pocket expenses

Reimbursement limit 01/01/2024 1,267.47 12.46 1,255.01

We've made one payment

Need to change your payment preferences? You can always do so on your personal webpages or in the Cigna Health Benefits app.

WE’VE MADE A PAYMENT TO NOOR JAHAN BEGUM

Amount in currency of payment: 26,244.00 BDT Payee type: Other

IBAN / Account number: XXXXXXXXXX388 Payment method: Bank transfer

Payment details

IBAN/Account number: XXXXXXXXXX388 Payee name: NOOR JAHAN BEGUM

BIC: DBBLBDDH164 Payee type: Other
ID bank: 8937614 Payee address: HOUSE 19/20, ROAD 12, BLOCK-E
Bank name: DUTCH-BANGLA BANK LIMITED BAWNIABAD MIRPUR
Bank address: MIRPUR CIRCLE 10 Payee city: DHAKA
MIRPUR CIRCLE 10 BRANCH Payee country: BANGLADESH
Bank city: DHAKA 1216
Bank country: BANGLADESH
Reference: SETTLEMENT DD22/02/24
REIMBURSEMENT OF MEDICAL EXPENSES
O/REF: 270 99233 UNICEF MIP
Payment type: Individual payment

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: 22/02/2024 Page: 5/5
Main plan member: BEGUM Personal ref. n°:
NURJAHAN 270/424775
Organisation: UNICEF Questions? +60 3 2032
5333

Currency exchange rates

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

INVOICE DATE EXCHANGE RATE

04/03/2023 1 BDT = 0.00970874 USD

05/03/2023 1 BDT = 0.00970874 USD

19/04/2023 1 BDT = 0.00952381 USD

07/05/2023 1 BDT = 0.00952381 USD

09/09/2023 1 BDT = 0.00921659 USD

13/01/2024 1 BDT = 0.00913242 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