Settlement date: 21/10/2022 Page: 1/3

Main plan member: KAZEMI Personal ref. n°:

MOHAMMAD SARWAR 479/8808940
Organisation: WFP Questions? +32 3 293 18 41

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 +32 3 293 18 41.

Your claim

ACTION REQUIRED
PATIENT DATE YOU CLAIMED WE PAID
FROM YOU?

KAZIMI ABDUL LATIF 19/10/2022 46,854.00 AFN 0.00 USD No

AMOUNT CLAIMED 46,854.00 AFN This is the sum of the amounts claimed per currency.

AMOUNT PAID 0.00 USD No payment was made.

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.
Catastrophical Reimbursement made under the so-called major medical expenses or catastrophic expenses.
reimbursement
Total reimbursement Amount that is paid to you according to your medical plan.

Cigna International Health Services BVBA • www.cignahealthbenefits.com

Plantin en Moretuslei 299 • 2140 Antwerpen • Belgium • RPR Antwerpen • VAT BE 0414 783 183
 Settlement date: 21/10/2022 Page: 2/3
Main plan member: KAZEMI MOHAMMAD SARWAR Personal ref. n°: 479/8808940
Organisation: WFP Questions? +32 3 293 18 41

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

Your claim for KAZIMI ABDUL LATIF dated 19/10/2022 (date of birth 24/07/1996)

OTHER BASIC CATASTROPHICAL TOTAL

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

Invoice from FMIC dated 29/08/2022

Medical treatment - 27/08/2022 46,854.00 AFN 46,854.00 AFN (1) 0.00 AFN 0.00 USD 0.00 USD 0.00 USD 0.00 USD 0.00 USD

TOTALS 46,854.00 AFN 0.00 USD

More Information
(1) We will contact you with more information about this settlement note.

Cigna International Health Services BVBA • www.cignahealthbenefits.com

Plantin en Moretuslei 299 • 2140 Antwerpen • Belgium • RPR Antwerpen • VAT BE 0414 783 183
 Settlement date: 21/10/2022 Page: 3/3
Main plan member: KAZEMI Personal ref. n°:
MOHAMMAD SARWAR 479/8808940
Organisation: WFP Questions? +32 3 293 18 41

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

29/08/2022 1 AFN = 0.01109508 USD

Cigna International Health Services BVBA • www.cignahealthbenefits.com

Plantin en Moretuslei 299 • 2140 Antwerpen • Belgium • RPR Antwerpen • VAT BE 0414 783 183