From: admissions@cigna.

com
Sent (GMT): 10/05/2016 10:47:46
To: admission@hopitalrosaire.org
CC1:
CC2:
Subject: 414/4B/00951/4668274 FARAH SAMIR A.- GUARANTEE OF PAYMENT
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GUARANTEE OF PAYMENT
Admission of SAMIR FARAH (12/07/1947)
Admission date: May 2016 (Out-patient)
Our reference: 414/00951 (please mention in all correspondence)
Provider code: 10350
We confirm that your patient, mentioned above, has medical coverage through our
intermediary. Hereafter, you will find the benefits applicable for all reasonable and medically
necessary expenses. Please verify these benefits and admission details. Should you have
any questions regarding this guarantee, please contact our office.
Please note that if no estimate has been provided by the hospital before the patients
admission, the hospitalisation costs are subject to limitation, in accordance with
1
reasonable and customary charges in the country of care.

OUT-PATIENT TREATMENT (As prescribed by Dr. Medawar) : 80%

Please note that there is a maximum reimbursement per calendar year.

The actual balance amounts to 37,353.6 USD
Any portion of the expenses or medical services and supplies which exceed the regular and
customary charge for similar services or supplies rendered remain at the patients charge.
Remark:
The costs will be reviewed upon receipt of the detailed invoices with breakdown
including the values (e.g. K and ARE) and points. Costs are only accepted up to the
agreed tariffs and referencing to the Nomenclatures des Actes Mdicaux.
IMPORTANT !!
General exclusions
- Any balance due after our payment is at the charge of the patient.
- Personal comfort items (e.g. drinks, telephone charges, ) are not covered and should be
billed directly to the patient. In this respect, please make sure to make note of the patients
contact details.
- For robot surgery: prior approval is required. Please send our Medical consultant a medical
report with information on the diagnosis and planned treatment and a justification why robot
surgery is preferred to standard surgery in this case.
Plan specific exclusions
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By reasonable and customary we mean that the charges are those which would usually be invoiced by the

majority of providers of treatment in the country in which you are providing treatment and the charges do not
exceed what you would normally charge.

Some plan specific exclusions may apply. In any case, the patients medical scheme does
not provide cover for :
- Spa cures, rejuvenation cures, cosmetic treatment;
- Consequences of a voluntary or intentional act committed by the beneficiary, e.g., a brawl,
except in the case of self-defence;
- Any portion of the expenses for medical services and supplies that exceeds the regular and
customary charge for the services or supplies;
- Motor-vehicle racing or dangerous competitions in respect of which betting is allowed
(normal sports competitions are covered);
- Home help, family help or similar household assistance, and fees of persons who are not
qualified nurses;
- Any charges for services or supplies that have not been prescribed or approved by a
physician;
- Hospital charges for telephone, television, or for persons other than the patient, etc.;
- Infertility treatments;
- Any voluntary surgeries which are not done for medical reasons (e.g. elective plastic
surgery);
- Food and dietary products (other than those normally provided during hospitalization),
cosmetics and toilet articles;
- Expenses for travel and accommodations except for charges for professional ambulance
service used to transport the insured participant between the place where he or she is
injured by an accident or stricken by disease and the first hospital where the treatment is
given;
- Self-testing devices, except for diabetes.

This guarantee of payment is valid for the indicated out patient treatment.
Any extension of stay is subject to a request for further approval. All requests should be
accompanied by an explanatory report as well as a cost estimate, and can be sent to the
attention of our medical consultant, either by separate envelope to the address mentioned
below or by e-mail to medicalboard@cigna.com.

Billing address: Cigna Provider Claims - PO Box 19612 Greenock PA15 9DB - Scotland
Billing email: bills@cigna.com

To obtain a settlement, following documents must be submitted to our

offices:
- the itemized original invoices + copy of this Guarantee of Payment.
- a medical certificate/report revealing the diagnosis and the performed treatment.
Upon receipt, reimbursement will be made. To allow us to effect payment by transfer, please
provide full banking details including IBAN & BIC code (Europe) or ABA code (United States
of America). Any balances left after our payment remain at the patients charge.

Abdallah ISSAM AJAMI (Mr)

Communication Officer
Customer Services

Direct Phone + 32 3 217 65 72

Fax + 32 3 663 28 57
www.cignahealthbenefits.com