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Van
Breda International
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Vanbreda insurance benefits summary
1. The Vanbreda Insurance Programme provides for reimbursement of reasonable and customary charges incurred for medical, and hospital treatment that result from illness, accident, or maternity, up to a maximum of $250,000 per insured participant per calendar year. Additionally, expenses related to dental, hearing and vision care are also covered. In addition to the maximum reimbursement per calendar year, certain maxima per treatment, procedure or service may also apply, depending on the type of service, as described in the following paragraphs.
2. The programme reimburses only treatment, supplies, or other services that are widely and generally accepted as medically necessary and appropriate for the condition being treated, and when such treatment, supplies, or other services are prescribed by a licensed, qualified medical professional. Vanbreda International has the fiduciary duty and discretionary authority to determine on behalf of UN what constitutes a covered service or plan benefit under the programme.
3. Medical Expenses are reimbursed under the Basic and Major Medical components. Reimbursement in respect of medical treatment prescribed by or rendered by qualified doctors is equal to 80% of the reasonable and customary charges. (See paragraph 20 below for information about reasonable and customary).
Services rendered by a licensed paramedical professional or, in case of maternity, by a licensed midwife, can be considered for reimbursement, but only upon the prescription of a licensed, qualified medical professional.
The Major Medical component does not apply in the case of dental treatment, outpatient mental health treatment, treatment for substance abuse (alcohol and/or drug), expenses for hearing aids, and expenses for optical lenses.
4. Reimbursement Rates
(a) Under the Basic Medical component, reimbursement in respect of medical treatment prescribed by qualified doctors is calculated at the rate of 80% of the reasonable and customary charges involved, including doctors' fees.
(b) Under the Major Medical component, 80% of the residual unpaid reasonable and customary charges are paid, subject to a calendar year maximum co-payment of $200 per participant and $600 per family. This calendar year maximum co-payment is sometimes called a "deductible".
This means that the participant pays the 20% residual out-of-pocket, up to the calendar year maximum copayment of $200, or $600 in the case of family coverage.
When covered expenses exceed the calendar year maximum copayment amount, the 80% Basic Component still applies, and the Major Medical component automatically reimburses 80% of the residual 20% for the remainder of that calendar year.
5. Example - Medical Expense Reimbursement. The following example illustrates how reimbursement is determined for an individual in respect of Basic and Major Medical coverage (figures are in U.S. Dollars):
United States dollars (i) Basic coverage
Reasonable & customary charges for medical treatment Reimbursement at 80 % Residual 20 % (ii) Major medical coverage 20 per cent residual not reimbursed by basic coverage Less Calendar year maximum copayment = Basis for major medical coverage x 80% = Major Medical Reimbursement
($440 x 80 per cent)(iii) Total reimbursement (recapitulation of (i) and (ii)) Basic Medical coverage Major Medical coverage Total insurance reimbursement Participant's total out-of-pocket expense Total original expense For medical benefits and exclusions please refer to paragraphs 7 - 36 in Annex I of the circular ST/IC/2008/10.