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Vanbreda International Group Med


									Vanbreda International Group
Medical Insurance Plan
For UNDP Service Contract Holders

       United Nations
       Development Programme
Contact information
You can reach us 24 hours a day, 7 days a week, 365 days a year!

If you have a question, our multilingual staff can be contacted in several
ways. You can also find the contact information below on your personal

  Toll-free lines
  Wherever feasible, you can contact us through a toll-free number. You can
  find the full list of available toll-free numbers per country on your personal

  For medical claims

  •	 Tel.   + 32 3 217 69 65
  •	 Fax    + 32 3 663 28 55
  •	 E-mail

  For affiliations, membership cards and insurance certificates

  •	 Tel.   + 32 3 217 65 17
  •	 Fax    + 32 3 272 39 69
  •	 E-mail

   Postal address

   Vanbreda International NV
   P.O. Box 69
   2140 Antwerpen

4    Introduction

 5   Your personal webpages

6    Who is covered by the Vanbreda International
     Group Medical Insurance Plan?

6    Where can I find information about medical service

 7   What am I covered for?

8    How can I benefit from Vanbreda International’s
     direct payment service?

10   How can I get reimbursed?

    Welcome to the Vanbreda International Group Medical Insurance Plan.

    This document outlines the benefits and coverage provided for by your
    medical plan, where to find more information as well as which procedures
    you should follow to benefit from Vanbreda International’s direct payment
    service and how to submit claims to obtain reimbursement for your medical

    In case you have questions about the plan, you will find information on
    page 2 on who to contact.

Your personal webpages
On our website you can review your plan information, consult our worldwide
list of medical service providers and our direct payment service and check
how to claim your expenses. This website is exclusively accessible for plan

You can access this website as follows:
•	 go to and click on ‘Member’s Access’;
•	 fill in the standard reference number 244/UNDPSC;
•	 fill in the standard date of birth 01/01/2000.

Once you have claimed with us, you will receive a personal reference number
which you can use to log in. In the last step you will then have to enter your
own date of birth.

    Who is covered by the Vanbreda
    International Group Medical Insurance Plan?
    The decision to affiliate to the Group Medical Insurance Plan is made on a
    UNDP country office level.

    Once a country office has opted to affiliate, the contract applies to all their
    Service Contract Holders on a mandatory basis unless an individual Service
    Contract Holder can show proof of medical coverage (with a national or
    private insurer) prior to the start of their contract with UNDP.

    The plan does not include coverage for dependants.

    Where can I find information about
    medical service providers?
    On your personal webpages, in the ‘Provider List’ section, you can search
    for medical service providers who are part of the Vanbreda International
    network, based on location, type of provider and specialty.

    In case you cannot find a specific provider in our list, contact Vanbreda
    International. They will contact the provider to make the necessary

What am I covered for?
The Group Medical Insurance Plan covers reasonable and customary expenses
resulting from medical attention necessitated through sickness, accident or

The maximum reimbursement is 10,000 USD per individual period of coverage
(equal to twelve consecutive months’ period).

For the detailed, printable and up-to-date description of your coverage, you
can consult your personal webpages.

 Over-all ceiling          10,000 USD / person / year

 Hospitalisation and       100% reimbursement
 day surgery               (bed & board for semi-private rooms, doctor’s fees,
                           drugs and medicine, …)
                       100% reimbursement
 Dental treatment          100% reimbursement
                           Maximum of 600 USD / person / year
 Psychiatric treatment     50% reimbursement
                           Maximum of 600 USD / person / year
                           Maximum 50 visits
 HIV/AIDS                  100% reimbursement for ambulatory treatment
                           (medication, testing, consultation, …) and
                           inpatient treatment

    How can I benefit from Vanbreda
    International’s direct payment service?

    What is direct payment?
    Vanbreda International has agreements with many medical service providers
    and facilities located all over the world. Many of these agreements include
    the possibility of direct payment. This means that when you receive medical
    treatment, the medical service provider sends the invoice directly to Vanbreda
    International. This way you do not have to pay the invoice first and claim the
    expenses afterwards.

    In case of a planned hospital admission, you or the medical service provider
    should send a Cost Estimate form to Vanbreda International at least 5 days
    in advance. This will guarantee a smooth admission and avoid deposit
    requirements. You can ask the medical service provider to complete the form,
    which you can then send to Vanbreda International.

    In case of an urgent admission, the name and telephone number of the
    medical service provider suffice for Vanbreda International’s Customer Service
    Representatives to initiate the direct payment procedure.

    Direct payment agreements between Vanbreda International and local
    hospitals are encouraged for inpatient and longer-term treatments such as
    chemotherapy and haemodialysis.

    Besides direct payment, Vanbreda International negotiated beneficial tariff
    agreements and/or discounts with several medical service providers and
    facilities. Although you may not be aware of this at the time of admission, the
    provider’s billing and Vanbreda International’s settlement will reflect these
    preferential rates, which are to the benefit of both yourself and the Group
    Insurance Plan.

    When does direct payment apply?
    In case of an inpatient hospitalisation, i.e. a hospital admission including at
    least one overnight stay, Vanbreda International can set up a direct payment
    procedure with the medical service providers.

To this end, you should provide the following information to Vanbreda
International’s medical consultant:
•	 the diagnosis and treatment;
•	 the exact dates of admission and discharge;
•	 the detailed cost per type of care.

If the diagnosis and treatment are covered under the terms and conditions of
your Group Insurance Plan and the related expenses prove to be reasonable
and customary, Vanbreda International will send a guarantee of payment to
the medical service provider.

The hospital will send all invoices directly to Vanbreda International for direct
settlement. Only the balance, the part of the cost that is not covered by your
plan, if any, will be at your charge. Vanbreda International will inform you of
the latter amount by means of the corresponding settlement note.

Outpatient expenses however, will have to be paid by you first. You can
afterwards claim reimbursement by means of the Claim form, accompanied
by the original, detailed invoices, the proof of payment and – if possible
– a detailed medical report. This Claim form is available on your personal
webpages in the My Pages section and can be filled in online.

                                                                                                                                       This form, duly completed and signed, should be
                                                                                                                                                         returned prior to admission, to:
                                                                                                                                                                 PRIVATE AND CONFIDENTIAL
                                                                                                                                                                          Medical Consultant
                                                                                                                                                                      Vanbreda International
                                                                                                                                                                                   P.O. Box 69
                                                                                                                                                                             2140 Antwerpen
                        Cost Estimate form                                                                                                                                            Belgium
                                                                                                                                                                         Fax: + 32 3 217 66 20

                        Cost estimate for hospitalisation of                                    Mr            Mrs             Miss
                        Name of (former) member of personnel
                        Vanbreda pers. ref. no.                                /

                        To be completed by the hospital and/or physician
                        Name, address, tel./fax of hospital, name contact person                                               Name, address, tel./fax of physician
                        USA Hospitals: please also mention the area code

                        Diagnosis or reason for admission (1) - (2)

                        Medical report on the illness/treatment in annex (1) - (2)?                                         Yes         No
                        Expected date of admission (d - m - y)                                                          Length
                        Expected date of discharge (d - m - y)
                        Expected costs of the hospitalisation
                        Option A               room:           private                                     price =                       /day
                                                               semi-private                                price =                       /day (mandatory information)
                                                               ward                                        price =                       /day
                                               other hospital expenses                                                  =
                                               (e.g. medicines, x-rays, lab, etc)

                                               doctors’ fees with relevant breakdown (3)                                =
                                               (for USA: please use CPT-code)

                        Option B                          all-in rate =                                               /day

                        Should a letter of guarantee be sent to the above mentioned hospital?                                                           Yes           No

                        Date and signature of (former) member of personnel (4)                                                   Stamp of hospital/physician

                        (1) All information subject to medical secrecy may be sent for the attention of our medical consultant in a sealed envelope.
                        (2) Diagnosis and medical reports should be legible and without abbreviations.
                        (3) In case of surgery, the fee of each member of the surgical team; in case of conservative treatment, the fee of the main treating physicians.
                        (4) In view of a smooth administration of the contract and/or settlement of the insurance claim, and only for that purpose, I hereby give my specific and informed consent regarding the
                        processing of the medical data concerning myself and/or the members of my family (article 7 of the Belgian Law of December 8, 1992 concerning the private life).
                                                                                                                                                                                                                   5.46.171invc (0708)

                        Vanbreda International • P.O. Box 69 • 2140 Antwerpen • Belgium
                        NV • RPR Antwerpen • VAT BE 0414 783 183 • BFIC 13799 A-R

     How can I get reimbursed?
     Fill in a Claim form and submit it with supporting documents to Vanbreda
     International. This Claim form is available on your personal webpages in the
     My Pages section and can be filled in online.

     You can send your Claim form to Vanbreda International using the contact
     details on page 2 or ask your HR contact whether there is a centralised postal
     service available at your country office.

     You should submit your claims with the least possible delay. However, try to
     group small claims before submitting them in order to avoid reimbursements
     of small amounts. Take the precaution of making copies of all your documents
     before sending them.

     Fill in the Claim form as follows
     •	 Submit a separate Claim form for each patient.
     •	 Fill in your full name, date of birth and country office. In case you
        already received the Vanbreda International personal reference number
        (mentioned on your settlement notes), please complete this number as
     •	 If the expenses are covered by another insurance or social security system,
        state the amount reimbursed.
     •	 Use one line per medical treatment.
     •	 Give a detailed description of the nature of the expenses incurred, i.e.
        general practitioners’ and specialists’ fees, prescription drugs, x-rays,
        physiotherapy, etc.
     •	 Indicate the currency in which the expenses were incurred.
     •	 In case of hospitalisation, indicate the date of admission, the diagnosis and
        the treatment or the surgical intervention.
     •	 Each claim must be dated and signed by the contractor.

     Add the following documents
     To ensure a fast claims handling, it is important to join the following
     supporting documentation:

     •	 original and itemized bills as well as proof of payment or the receipted bills
        for medical and surgical fees;
     •	 for prescription drugs, (a copy of) a recent medical prescription should

   be included, showing the name (stamp or preprinted letterhead) of the
   prescribing physician, the recommended supply of medication and the
   medication name or composition;
•	 for outpatient treatments, surgery or inpatient hospitalisations (i.e.
   overnight stay and at least 24 hours admission) for which no prior approval
   was requested or direct payment was arranged, we would need the
   doctor’s prescription specifying and medically justifying the diagnosis and
   the type of treatment or surgery performed;
•	 all documents should clearly show the name of the patient, as well as date
   and detailed price per type of care.

If you are covered by a social security system or another group/individual
insurance contract which intervenes as your ‘primary insurer’, you must first
obtain the reimbursement to which you are entitled under this scheme. Please
send us their original settlement note together with copies of all supporting
documents in order to obtain an additional reimbursement.

Confidential medical information may be sent under separate cover for the
attention of our medical consultant.

                                                                                                      U N DP S e r vi c e Contrac tholders

                       Group health insurance
                       Plan de grupo médico
                       Claim for reimbursement of medical expenses
                       Solicitud de reembolso de gastos médicos
                       Insured person / Asegurado                                          Vanbreda ref. no. / n° de ref.                   244        /
                       Name / Nombre
                       Address / Dirección

                       Date of birth / Fecha de nacimiento (d - m - y/a)                                                       Sex / Sexo                      M             F
                       Project no. / N° de proyecto
                       Period of contract / Período de su contrato
                       Name of the organization / Nombre de la organización

                       Amounts claimed per currency / Cantidad reclamada por moneda
                       Currency               Amount                 Type of expenses / Diagnosis                              Intervention of other insurance
                       Moneda                 Cantidad               Tipo de gastos médicos / Diagnóstico                      Intervención de otro seguro


                       Mode of payment by Vanbreda / Forma de pago por Vanbreda
                         Transfer / Transferencia bancaria                                                                     Mail cheque to / Envíe el cheque a
                       IBAN no. / N° IBAN                                                                                  Name / Nombre
                       Account no. / N° de cuenta
                       Full bank name and address / Nombre completo y dirección del banco
                                                                                                                           Address / Dirección

                       Name account holder / Nombre del titular de la cuenta

                       BIC Code / Código BIC
                       ID Bank / Identificación del banco

                       Please add a copy of your Service Contract with UNDP. / Por favor agregue una copia de su contrato de servicio con UNDP.

                       Signature of the insured person / Firma del asegurado                    In view of a smooth administration of the contract and/or settlement of the insurance
                                                                                                claim, and only for that purpose, I hereby give my specific and informed consent regarding
                                                                                                the processing of the medical data concerning myself and/or the members of my family
                                                                                                (article 7 of the Belgian law of December 8, 1992 concerning the private life).
                                                                                                En vista de una administración fluida del contrato y/o el reembolso de los gastos,
                                                                                                y sólo para este uso, doy por la presente mi consentimiento específico en cuanto al
                                                                                                procesamiento de mis datos médicos o de los datos médicos de los miembros de mi familia
                       Date / Fecha                                                             (artículo 7 de la ley belga del 8 de diciembre de 1992 sobre la protección de la privacidad).
                                                                                                                                                                                                5.46.819invc (0708)

                       Claims may be sent to: / Envíe esta solicitud a:
                       Vanbreda International • P.O. Box 69 • 2140 Antwerpen • Belgium
                       NV • RPR Antwerpen • VAT BE 0414 783 183 • BFIC 13799 A-R


                      P.O. Box 69
                      2140 Antwerpen

Chief	editor:	Wouter	Reggers	•	RPR	Antwerpen	•	VAT	BE	0414 783 183	•	BFIC	13799 A-R

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