Attachment 6 Claims History ORE Staff (U.S. Embassy).pdf
PDF 298 KB Posted
- Solicitation number
- 19GE5024R0067
About this file
This document contains claims history information for the U.S. Embassy's locally employed staff health insurance policy for the periods of February 1, 2021 to February 1, 2022, February 1, 2022 to February 1, 2023, and February 1, 2023 to December 9, 2023 under policy number XC01021551916. It shows the types of claims filed and the total amounts paid out per year for services such as dental, optical, gynecology, laboratory, medication, and various medical procedures.
The related federal contract opportunity is a pre-solicitation notice for a Request for Proposal (RFP) to provide health insurance coverage for locally employed staff at the U.S. Embassy in Paramaribo, Suriname. The resultant Indefinite Delivery Indefinite Quantity (IDIQ) contract will have a base period of one year with four option years. The successful contractor must be knowledgeable in written and spoken English. The solicitation will be posted on SAM.gov and will use Simplified Acquisition Procedures with full and open competition.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| 19GE5024R0067 0002.pdf | ||
| Attachment 7 Claim report Retirees U.S. Embassy.pdf | ||
| 19GE5024R0067 0001.pdf | ||
| 19GE5024R0067.pdf | ||
| Attachment 3 Form W-14 Instructions.pdf | ||
| Attachment 1 Price Proposal Breakdown.xlsx | XLSX spreadsheet | |
| Attachment 2 Form W-14.pdf | ||
| Attachment 4 Employee Statistics 2024.docx | DOCX document | |
| Attachment 5 Past Performance and Experience.pdf | ||
| Pre-Solicitation Notice - 24R0067.pdf |
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Text version
Schade overzicht per soort declaratie ORE Staff (U.S. Embassy) Verzekeringsjaar: 01 februari 2021 - 01 februari 2022
Polisnummer: XC01021551916
Opvraagdatum : 09 december 2023
Soort Declaratie Bedrag in SRD beugel gebit 23,100.00
Optische zorg 1,850.00
Gynaecologie 1,628.40
Honorarium artsen 512.75
Medicatie 604.99
Patholoog-anatomie 100.00
27,796.14
Verzekeringsjaar: 01 februari 2022 - 01 februari 2023
Polisnummer: XC01021551916
Opvraagdatum : 09 december 2023
Soort Declaratie Bedrag in SRD
CT-Scan/ MRI 4,250.00
Dermatologie 5,165.70
Huisartsen verrichtingen 428.84
Honorarium artsen 950.00
Laboratorium 2,430.50
Medicatie 9,178.34
Rontgen 1,830.00
24,233.38
Verzekeringsjaar: 01 februari 2023 - 09 december 2023
Polisnummer: XC01021551916
Opvraagdatum : 09 december 2023
Soort Declaratie Bedrag in SRD
Huisartsenverrichtingen 0.00
Honorarium artsen 960.00
Laboratorium 224.20
Medicatie 2,587.00
3,771.20
Verzekeringsjaar: 01 februari 2021 - 01 februari 2022
Polisnummer: XC01021551908
Opvraagdatum : 09 december 2023
Soort Declaratie Bedrag in SRD
Ambulance 852.00
Anaesthesiologie 15,458.00
Optische zorg 103,826.32
Cardiologie 4,010.00
Chemotherapie 4,479.00
Chirurg 3,835.00
CT-Scan/ MRI 2,960.00
Dermatologie 2,765.60
SEH kosten 200.00
ECG (ElektroCardioGram) 369.00
Echo 10,002.00
Paramedische zorg 9,960.00
Gastroscopie 1,116.00
Gynaecologie 29,407.40
Huisartsenverrichtingen 4,194.21
Heupprothese 84,014.82
Honorarium artsen 19,165.33
Honorarium tandartsen 111.46
Injektie 350.00
Inspannings ECG 50.00
Internist 8,270.00
Kinderarts 43,189.10
KNO-arts 4,910.00
Laboratorium onderzoek 27,271.20
Medicatie 126,645.76
Neurologie 590.00
Nierdialyse 80,080.00
Oogheelkunde 2,787.60
Operatie 19,645.00
Opname 195,765.00
Orthopedie 8,936.00
Patholoog-anatomie 900.00
Rontgen 12,138.50
SEH consult 50.00
Specialist 24,741.00
Tandheelkundige behandeling 62,008.30
Urologie 448.40 x20 weekendconsult 76.50
915,578.50
Verzekeringsjaar: 01 februari 2022 - 01 februari 2023
Polisnummer: XC01021551908
Opvraagdatum : 09 december 2023
Soort Declaratie Bedrag in SRD
Ambulance 500.00
Anaesthesiologie 11,795.00
Bloed en bloedprodukten 16,421.86
Brilglazen 201,104.40 idem als 2021-2022
Brilmontuur 64,386.72
Cardiologie 6,888.75
Chirurg 21,192.00
CT-Scan/ MRI 31,549.00
CTG (CardioTocoGram) 552.00
Dermatologie 6,397.00
Paramedische zorg 8,192.50
SEH kosten 50.00
ECG (ElektroCardioGram) 579.00
Echo 8,491.00
EEG (Elektro-EncefaloGram) 135.00
Gehoorprothese 30,830.00
Gynaecologie 41,691.05
Huisartenverrichtingen 2,454.27
Honorarium artsen 44,740.00
Honorarium tandartsen 18,773.04
Injektie 85.00
Inspannings ECG 25.00
Internist 6,795.00
Kaakchirurgie 3,290.50
Kinderarts 3,728.26
KNO-arts 7,672.00
Kunst- en hulpmiddelen 3,000.00
Laboratorium onderzoek 35,776.28
Lenzenpakket 7,614.00
Logopedie 225.00 long behandeling 1,709.00
Medicatie 646,767.72
Neuro-Psychologie 285.00
Neurologie 5,424.94
Nierdialyse 195,140.00
Oogheelkunde 10,417.50
Operatie 32,436.00
Opname 191,596.00
Orthopedie 171,300.84
Orthopedisch schoeisel 4,010.00
Partus 18,550.00
Patholoog-anatomie 520.00
Revalidatie 420.00
Rontgen 9,316.00
Scopieën ( diversen ) 870.00
Specialist 10,951.00
Spirometrie 100.00
Urologie 3,420.00
Verbandmiddelen/Materiaal kosten 100.00
Wondbehandeling 50.00
1,888,317.63
Verzekeringsjaar: 01 februari 2023 - 09 december 2023
Polisnummer: XC01021551908
Opvraagdatum : 09 december 2023
Soort Declaratie Bedrag in SRD
Optische zorg 31,646.64
Chirurg 1,680.00
CT-Scan/ MRI 3,960.00
SEH kosten 300.00
Echo 9,050.00
Paramedische zorg 5,430.00
Gynaecologie 620.00
Huisartsenverrrichtingen 2,100.00
Honorarium artsen 34,150.00
Honorarium tandartsen 2,630.06
Internist 3,040.80
KNO-arts 6,931.00
Laboratorium 28,152.75
Medicatie 105,209.81
Oogheelkunde 420.00
Patholoog-anatomie 743.00
Rontgen 3,597.00
Spoedconsult 400.00
Tandheelkundige behandeling 14,375.00
254,436.06
Schade overzicht Ore Staff
Periode : 01/02/2020 - 01/02/2021
Polisnr. : XC01021551916
Klantnr. Naam Tot. schade in US$
17125790786 Rachman, Louise Leginah 3,411.86
24125790783 Held, Kenneth 1,001.21
26105090785 Rachman, Soekarmin 6,849.28
31076290782 Held, Sandra 695.76
X260288262863 Wirjosemito-Loor, Stephanie 51.38
Totaal 12,009.49
Schade overzicht U.S. Embassy
Periode : 01/02/2019 - 01/02/2020
Polisnr. : XC01021551908
Klantnr. Naam Tot. schade in US$
01036590803 Blagrove, Gilberto 1,151.54
01090090852 Karijodimedjo, Rachiano 152.56
01116390847 Jubitana, Mildred 4,639.43
01126190846 Jubitana, Iwan 417.24
02010090813 Budel, Rachid 608.98
020213128625 Kertopermono, Amberleigh 133.84
020387127910 Tjon-Poen-Gie, Kimberley 398.45
02077690833 Frangie, Rachidie 236.83
02079990933 Del Prado, Juan 207.66
02089990869 Limburg, Juan 151.13
02105990819 Randamie de, Astrid 1,901.50
02106090824 Mangoendiredjo, Sophie 590.16
021084137897 Snijders, Raphael 87.01
02120790837 Ghisaidoobe, Jare Daniel 152.56
021211127913 Cramer, Dean Nicholai 114.77
03026190911 Van Excel, Patrick 139.18
04040790876 Obergh, Jadon 186.44
04120994210 Obergh, Zemirah 160.31
05017190791 Amat-Kromodikoro, Diana 1,074.74
050185127911 Cramer, Dino 402.17
05026990914 Warning, Ernest 2,221.02
05056290871 Kartopawiro, Sartina 345.37
05060590920 Welles, Toviel 326.35
05070990891 Sastrodihardjo, Kate Ariell 162.35
050979127914 Elliot-Vinkwolk, Chevallie 377.31
05115990848 Karijodimedjo, Robby 295.85
05120290917 Warning, Margareth 204.80
05126290865 Kornaat, Soetinah 770.34
05129997019 Hill, Shawn 162.46
060157121825 Bergen-Groenewoud, Dulcine 1,007.29
06026490804 Blagrove-Obergh, Diana 13,785.04
06030690934 Del Prado, Charissa 152.56
06038290855 Kertopermono, Roel 463.64
06039990930 Alli, Sherwien 152.56
060513137908 De Meza, Nathan 471.74
06115890900 Tjon-Akon, Faridy 297.15
06127090822 Dijks, Judith 953.45
06128590856 Kertopermono, Charlene 508.87
07026190789 Alli, Faizan 942.03
07026190838 Goedschalk, Lloyd 6,469.32
07046490893 Soekhai, Lailoenisa 338.87
07076490814 Buyne, Noël 1,231.54
07077390829 Eind, Bryan 722.48
07079690794 Amat, Ghavin 42.87
07116497016 Hill-Peerwijk, Ingrid 872.45
07118190875 Obergh-Naarden, Sabrina 1,008.33
07126090903 Tsai Meu Chong, Claudia 2,392.25
08068090854 Kromopawiro, Cheryl 1,821.04
09036497017 Hill, Eric 152.56
09059790935 Eind, Phylicia 167.04
09067590878 Pawiro-Amatredjo, Jennyfer 950.11
10076790868 Limburg, Noël 276.22
10080490857 Kertopermono, Gordon 191.88
101064142715 Ganpat, Tarawatie 1,009.01
10117590921 Karijoredjo, Jo-Ann 1,285.38
11047290867 Lee van on, Maureen 647.17
11087493675 Eind-Bourne, Audrey 432.70
120579152378 Ghisaidoobe-Persaud, Nandanie 208.41
12066390811 Budel-Graanoogst, Jenny 871.42
121179146141 Mohan, Jayant V. 941.30
12120090924 Welsh, Cherilyn 174.01
13020090795 Amat, Gabriël 49.60
130482104021 Long, Danielle 318.86
13095390870 Mertopawiro, Wagini 557.15
13107490860 Kromoredjo, Ruben 256.06
13125890864 Kornaat, Errol 468.02
140175137901 Liem Kon Tja, Charmain 845.03
140314138962 Cramer, Alex 52.77
14048290841 Grootfaam, Jason 274.33
15028390842 Grootfaam-Westerveld, Marilyn 529.47
15037690861 Kromoredjo, Milly 298.10
160685150248 Best, Maureen J. 1,609.48
17047390888 Sastrodihardjo, Ryan 1,002.78
17070690880 Pawiro, Jade 370.66
170914143143 Kertopermono, Keyan 99.52
17100390925 Welsh, Chantal 180.74
17120390809 Bottenbley, Micha-el 152.56
171210103300 Grootfaam, Jaydon Matthew 208.74
180299137902 Wong, Janae 248.70
180301127912 Playfair, Michel 152.56
18046291185 Tirtodikromo, Nita 291.27
18120390821 de Randamie, Jayden 446.60
18127090918 Welles, Romeo 438.15
191111113575 Gemin, Zemirah 138.88
19116690929 Yard, Riboet 299.76
19120790890 Sastrodihardjo, Cheyne 205.48
19127590853 Kartoredjo, Mervin 3,321.53
20046693913 Kertosemito, Soeparman 1,403.15
20065190906 Tsie A Foeng-Barrow, Marilyn 1,270.52
20110390796 Amat, Gilijamo 49.60
21020490936 Eind, Pharrell 164.15
210212137896 De Meza, Mason 335.40
21047790877 Pawiro, Dwight 213.10
210682137895 Hoffman, Vanessa 701.36
21088190874 Obergh, Jermain 274.91
21110790858 Kertopermono, Jean Jair 188.44
21117890859 Kertosemito, Michel 372.03
21129690916 Warning, Jamie 273.01
22106490849 Karijodimedjo- Pherai, Sakila 243.99
22125790926 Wolff, Maximilliaan 569.68
230514140907 Jarmohamed, James 143.91
23066090927 Wolff-Creebsburg, Urmie 1,038.88
23067790835 Ghisaidoobe, Radjesh 261.10
23110890843 Grootfaam, Christy-Ann 199.76
23117890889 Sastrodihardjo, Virginia 620.69
240100137903 Wong, Dean 165.48
24050090879 Pawiro, Dwayne 465.71
24056690815 Buyne-Dilrosun, Lilian 512.22
24059890818 Buyne, Shaquille 344.31
25066490810 Budel, Jerry 211.65
25096190910 Exel van, Anne 559.49
25097990834 Gemin, Andy 167.27
26017290931 Haas, Lucia 295.25
26017690937 Gemin-Limon, Sheila 244.51
26040890863 Kromoredjo, Rihoney 340.56
26086290839 Goedschalk, Rosita 651.70
261013135069 Gemin, Ithamar 186.47
26126890831 Elliot, Niel 318.90
261280110225 Best, Nawin 572.57
27026990790 Amat, Eddy 1,027.20
27065890801 Balker, Lucia 240.77
28037890808 Bottenbley-Kalloe, Charity 216.37
28114690823 Dipokromo, Kliwon 228.47
29075790896 Tirtodikromo, Hendrik 797.86
30096390892 Soekhai, Johnny Ismael 1,906.61
31017290807 Bottenbley, Kenneth 167.24
310314139495 Frijmersum, Enzi 74.73
X010278194993 Wagino, Ricardo P. 82.69
X010316237459 Renfrum, Jayron 67.10
X010416257973 Noordzee, Achira 8.78
X010617225887 Elliot, Zander 295.38
X020112246842 Jones, Asarel 19.05
X021017231236 Cramer, Kelsey A. 59.88
X021084193474 Chotoe - Ramsaran, Wandana 713.87
X030148198233 Bergen, Imro H. 772.23
X030789254904 Mijnals, Samantha 1,825.35
X040170239541 Burgzorg, Roy 210.00
X040195257972 Roye, Santusia 76.92
X050283250197 Rijaard-Naipal, Shyreen 1,761.90
X050376193480 Groenewoud, Patrick C. 198.84
X050607250198 Rijaard, Zayed 60.21
X050713193496 Soekhlal, Jiya 330.08
X050914193492 Saman, Neil A. V. 309.08
X051183246847 Soerohardjo, Marjorie 476.76
X060207228235 Mussendijk, Jeanique 141.23
X060311250199 Rijaard, Ziyanah A. 274.21
X061212229409 Chan-Jon-Chu, Jhemyma 73.40
X061217233953 Darsan, Ananya 169.86
X070818248809 Westenburg, Rumicio R.M. 82.29
X070868220522 Ronokasto, Soejono 723.34
X070979219528 Kamsoeri, Andy 62.76
X071212262860 Caster, Maddox 13.45
X080118262925 Dubos, Izaak 13.45
X080219255646 Kartoredjo, Taufiq 81.95
X080313226303 Renfrum, Jasmia 63.34
X080390262498 Holder, Akeem 26.11
X080478246841 Jones, Colin 19.05
X080692204314 Hardjopawiro, Sjarmain 1,043.50
X080717227911 Snijders, Alexander 138.08
X080798193482 Groenewoud, Raoel Andy 168.99
X090286219529 Olf, Jorny M. 289.36
X090711228238 Westenburg, Irella 164.65
X090994229413 Eersteling, S 98.45
X091271203616 Inta, Ernesto 434.82
X100692229411 Chan Jon Chu, Xaviëra 248.93
X101217234546 Eersteling, Daniël N. 203.15
X101269193484 Lalta, Indra V. 352.40
X110285252247 Cheuk-Alam, Stephanie 403.40
X110819261512 Kertosemito, Zoë Samirah 67.61
X111091257751 Noordzee, Zouanes 295.19
X111101204318 Kurban, Farizada Virona 57.55
X120214220049 Kamsoeri, Kysha 301.20
X120306264287 Lavenberg, Zoë 6.73
X120577246839 Badri, Usha 331.41
X120969204317 Kurban, Raoul 214.69
X121107188607 Hiffens, Chivaro D. 74.27
X130186229847 Hiffens, Gregory 306.47
X130673229846 Wongsopawiro, Remy S 49.60
X131180203617 Djojokromo, Riciliano 548.60
X140270220523 Ronokasto, Jane 132.61
X140418240748 Stoard, Samaria 108.85
X140418240749 Stoard, Jeremia 164.12
X141285220050 Hovens, Julia 941.55
X150381193485 Marwan, Aloysius W. 152.56
X150388226305 Sakridan, Farzaana 72.72
X150571249325 Poese, Fauzia 127.91
X150784193486 Marwan-Amatjasir, Rosanie V. 485.33
X151208193476 Chotoe, Shawan, A. S. 90.46
X160312204319 Kurban, Fariq R. B. 439.90
X160402193479 Douglas, Jiröemy J. 49.60
X160605250196 Rijaard, Rashad Roché 49.60
X160616231651 Darsan, Shivaansh 185.03
X161164194833 Douglas, Jimmy C. 672.76
X161181231653 Darsan, Jaswant 300.10
X170109193488 Marwan, Nathan S. 154.25
X170191184988 Stoard, Conchita D. 322.49
X170384193473 Chotoe, Shahin D. 418.47
X170410264289 Lavenberg, Chaia 6.73
X170800193483 Groenewoud, Sherony J. 122.80
X170806228228 Baarh, Irnick 49.60
X171212229414 Koedoe, Nywenskely A R 49.60
X171215193489 Marwan, Femke 97.27
X171280228511 Chotkan, Shamkoemar 531.32
X180376228226 Hoepel, Marilva 184.78
X180487229412 Jacob, Wensley 110.32
X181091195029 Van Dalen, Harold 253.35
X190370203615 Markiet, Noortje 212.96
X190489262861 Wasimin, Abigail 53.04
X190499228229 Boschveld, Sade 285.54
X190578197975 Chandoe-Ramdjanamsingh, Bhartie 1,077.68
X191181224730 Kanhai, Mahenderpersad 1,992.62
X191207266148 Sastrodihardjo, Cheyne 55.83
X200380193481 Aminta, Ingrid A. 272.11
X200397220048 Douglas, Cheniva 391.40
X200679228233 Harcharan, Roosnidebie 335.16
X200795194995 Douglas, Marrelyn F. 356.32
X200917230654 Ghisaidoobe, Ian Ray 107.33
X200917230839 Djojokromo, Umayrah A. 54.18
X201102228239 Westenburg, Trustin D 53.55
X201218253798 Best, Hailey 172.84
X210376228236 Westenburg, Milton 49.60
X210885193494 Mangroo, Maduvi R. 169.09
X211272193478 Douglas - Sital, Aroena 845.66
X220109246846 Soewarto, Jaylen 143.98
X220388228237 Westenburg, Michelle 728.44
X220879260195 Babb, Jhonn 25.78
X221011193495 Soekhlal, Nikhil R. 2,905.34
X221209246843 Jones, Gracelynn 24.95
X230271204320 Jarmohamed, Jim C. 89.97
X230893254715 Kromoloso, Priscilla 64.94
X230989229410 Abena, Davinio 61.94
X241091262499 Holder-Malekolkalami, Marjan 365.85
X241159184986 Aroma, Shakuntala 563.37
X250112188608 Stoard, Destany M. J. 86.44
X250680250955 Rijaard, Herman 67.88
X250786231652 Darsan-Jagan, Detie 263.62
X250919262859 Djojokromo, Irfan 41.36
X251215193793 Mohan, Inesh, Jaiden 259.08
X251215193794 Mohan, Ishaan, Josh 156.26
X260479193490 Saman, Roberto- Ray R. 114.74
X261082193493 Soekhlal, Rishi S. 280.56
X261087224729 Renfrum, Congenita C. 145.61
X261190263046 Fernandes, Concettina 171.64
X270417228231 Hoepel, Lorden E 431.61
X270418241114 Saman, Mayra 197.92
X270980246845 Chin-A-Hin, Daniël 535.57
X271118253061 van Dalen, Jeïel 139.98
X271177228227 Boschveld, Irving B 146.56
X280289193491 Sewgobind, Sattvika S. 1,299.93
X280396260867 Mussendijk-Banel, Shanice 316.81
X280406188606 Hiffens, Jenero 138.51
X280606193487 Marwan, Ray D. 168.15
X280679228234 Mussendijk, Roberto 509.94
X281282252246 Hippolyte, Cyriel J.P. 278.40
X290977184987 Atmodimedjo, Patricia 323.84
X291101228230 Baarh, Demy 49.60
X300103220047 Kamsoeri, Don 156.29
X300175224958 Karg, Jane 1,200.64
X300475264288 Lavenberg, Jennifer 193.72
X300481226304 Clowes, Marvin 983.97
X300815193475 Chotoe, Samaira, A. S. 163.81
X301071264286 Lavenberg, Glenn 6.73
X301115191511 Elliot, Chaya Amaris Zemirah 268.95
X301287262862 Caster, Melven 13.45
X310179246840 Jones-Voorn, Lucille 105.85
X310892227912 Linga, Richard 196.36
X311012204315 Djojokromo, Nuraisha 75.91
Totaal 131,583.66
File details come from the government source that posted it. Updated .