Questions and Answers Final Response - Life and Medical Insurance Coverage-U.S Mission Saudi Arabia.pdf

Life and Medical Insurance Coverage for Locally Employed Staff of U.S. Mission Saudi Arabia

Solicitation Number 19SA7021R0004

Questions and Answers

Q1: Solicitation reference C.1.2 Annual Maximum limit, the maximum annual reimbursement per covered individual per contract year, not including expenses defined under Exclusions and Limitations (C.1.3) and C.1.1.16, Catastrophic Coverage, or those covered under C.1.1.15, HIV/AIDS, and

C.1.1.21 Excess Coverage is equivalent to SAR 500,000.

Please explain difference between item No. C.1.1.16 and C.1.1.21?

Can insurance company quote new premium for each section (if it will exercise) based on nature of case?

A1: Please refer to the complete definitions per the solicitation for C.1.1.16

Catastrophic Coverage and C.1.1.21 Excess Coverage. C.1.1.16

Catastrophic Coverage is a benefit provided to all eligible participants and the additional coverage level is made available due to a catastrophic event, C.1.1.21 Excess Coverage is an optional benefit where eligible participants must select Excess Coverage individually and pay 100% of premium for

Excess Coverage. Excess Coverage is a rider to the contract, the employee enrolls directly with the vendor and pays the premium directly to the vendor.

The USG will not be responsible for collecting these premium payments.

Please submit premiums in proposal based on requirements in Solicitation to ensure technical acceptability of the offer.

Q2: Solicitation reference C.1.3 Exclusions and Limitations. Do standard exclusions apply under each health benefit covered?

Please specify specific exclusions related to each benefit covered.

A2: Please see Solicitation section C.1.3 Exclusions and Limitations. Items described in C.1.3 are not covered. Exclusions may be amended if provided in an off-the-shelf plan and is the lowest-cost and technically acceptable.

Q3: Solicitation reference C.1.1.11 Dental Care: Minimum Coverage. Please clarify if the orthodontia limit of SAR 9,000 is a sub-limit of overall dental limit.

A3: Dental and Orthodontia have separate caps (or limits). Orthodontia coverage is a separate limit than general dental coverage. It is not a sub-limit within the overall dental limit (SR 12,000). These are two separate benefits and two separate maximum caps.

Q4: For the group life insurance, can we obtain a copy of the list of individuals including date of birth, employee number, and occupation for each employee for all options?

A4: In accordance with Privacy laws, we are prohibited from providing this information for the group life or medical insurance.

Q5: Could you please provide claims records for the last 5 years?

A5: Group life insurance claims records from 2016-2020 will be provided upon request and posted on Beta.SAM.gov.

Medical insurance claims records from 2018-2020 will also be provided upon request and posted on Beta.SAM.gov.

Q8: What are the benefits per level of coverage or classes?

A8: The offeror must propose as per scope of work. The solicitation sets minimum benefit levels and proposals that meet or exceed the minimum coverage levels are technically acceptable and may make a proposal more competitive. One of the goals of setting minimum coverage levels is to enable vendors to bid with existing off the shelf plans.

Q9: Group Life, can we obtain details of any work-related travel to hostile / unsafe locations, i.e., Iraq, Yemen, Syria, etc.?

A9: Mission local staff do not travel regularly to these countries for work-related reasons. If the company has standard language in their commercial insurance products that addresses travel to areas of conflict, it should be presented in their offer.

Q10: Health Insurance, can you provide current network of medical providers?

A10: The offeror must propose as per scope of work.

Q11: Health Insurance, will coverage be extended outside the Kingdom of Saudi

Arabia (KSA)? If yes, will it be on a reimbursement basis or direct billing?

A11: Please see solicitation reference C.1.1.17 Out-of-Country Medical Treatment and C.1.1.18 Out-of-Country Medical Travel in Section C. Please include details regarding direct billing or reimbursement for coverage extended outside Saudi Arabia.

Q12: Medical Insurance, Existing Table of Benefits?

A12: Please submit as per the Scope of Work.

Q13: Medical Insurance, what is the inception date of the contract?

A13: The inception date is July 1, 2021 per Solicitation, Section F.2.

Q14: Kindly provide the 700 unified number (if applicable)?

A14: U.S. Embassy number is 7001068233.

Q15: Life Insurance, please provide us employees list in excel format with their desired sum insured for each employee?

A15: Please see solicitation reference (Part II Group Life Insurance sub-section

C.2.1) in Section C, scope of work.

Q16: Will there be a checklist for both covers to make sure all requirements are met? If yes, could you share it with us?

A16: Please refer to Section C, Scope of Work for both Life and Health insurance.

Q17: Are the required documents and declaration available in a separate document individually, or do we have to extract them from the solicitation?

A17: The offerors must provide the required documents as per the Solicitation requirements.

Q18: Solicitation reference C.2.1.3 Partial and Total Disability coverage.

No waiting period is defined for Partial disability due to sickness. Generally waiting period varies from 6 months to 12 months period.

Please specify your requirement on waiting period.

A18: In the event the employee is partially or totally disabled, the employee will receive partial and total disability coverage in accordance with compensation table provided in Saudi Arabian Laws. For required responsiveness to claims and reimbursement to claimants, see H.4 in the solicitation.

Q19: Solicitation reference C.2.1.3 Partial and Total Disability coverage.

There is no compensation scale for Partial and Total Disability cover under

KSA law. Please confirm that standard Continental Scale is acceptable or provide your compensation scale of benefit to use for this coverage.

A19: Standard Continental Scale is acceptable.

Q20: Solicitation reference C.2.4.1. Entry age for New employees is restricted to age 60. Please advise termination date for employee under Life insurance coverage.

A20: The termination date for employee under Life Insurance coverage is upon separation of the employee from service.

Q21: Solicitation reference C.2.2- Life Insurance Benefits Conditions and

Limitations. Standard exclusion always applies to Life insurance coverage.

Please advise your applicable exclusions under each type of life insurance coverage.

A21: No benefits shall be payable if an employee's death or other insurance event was caused directly or indirectly by war. War shall be defined as declared or non-declared war or any martial operations or invasion, hostile acts of foreign powers, rebellion, riot, civil war, uprising, mutiny, operations by military or usurpatory authorities, martial law or state of siege or any other similar event or reason for declaring martial law or war. A terrorist attack shall not be considered war.

No benefit shall be payable under this contract if the employee's bodily injuries have been caused directly or indirectly and totally or partially by:

1. Violating the law or in resisting detention or arrest,

2. Participation in competitions involving the use of wheeled vehicles, horses, boats, or water skis,

3. An accident resulting from the employee being under the influence of alcohol, drugs or other toxic substance unless administered by a physician.

Death because of a disease or physical or mental infirmities and medical or surgical treatment thereof (except pyogenic infection due to an accidental cut or wound) shall be considered a natural and not an accidental death.

Suicide will not be covered.

Q22: Solicitation reference C.2.1 Group Life Insurance Coverage: Passive war and Terrorism coverage is not requested under this life insurance solicitation.

Please advise if you need coverage for Passive War and Terrorism

A22: Please kindly refer to the Scope of Work. Technical acceptability will be determined based on the requirements put forth in the Solicitation.

Printed By: CGAYASPagei of 3 i

Amount of Outstanding Claims at Period End

M

Amount of Outstanding f Claims at Period End

500,000

6,800 31 March 2021 7001068233 15 April 2021

Number of Outstanding Claims at Period End

, , i| i

Number of Outstanding Claims at Period End

13,371,541.60 13,371,541.60

818,980.09 1,301,818.52

950.719.29 1,187,690.43 1,196,321.83 1,040,840.95 1,222,529.63 1,106,542.29 1,238,457.01 1,133,755.95 994,555.73 1,179,329.88

Amount of Paid Claims

III1' V ^- •'•

Amount of Paid Claims

In-Patient Limit Optical Limit Dental Limit Claims Processed to Group Sponsor Number ifie^SoifDate <

14,850 14,850 1,066 1,222 1,225 1,401 1,389 1,343

1,427 1,304 1,331 1,186

1,097

Number of Paid Claims

Number of Paid Claims

.. .i^i™.ijlf l i l , i i ljf !il l ili l i l i i i i—1

, i ii ^ r ir- i i i 1,947 1,952 1,951 1.944 1,936 1.921 1,915 1.902 1,906 1,921 1,927 1,929 1,956i

Number of Lives Insured

Number of Lives Insured

Total SubTotal

Jun-2019 J May-2019

Apr-2019 ^ Mar-2019 r Feb-2019 r;J Jan-2019

1 Dec-2018 Nov-2018 " i i ,1

, ,!i ih i "i!

I

> Oct-2018 Sep-2018 in Aug-2018 Jul-2018

Number of Lives at start Last Policy Year

Monthly Claims

SubTotal

; 1 i , i p fjumber of Lives at start Prior Policy Year SubTotal i

I ill , Number of Lives at start Policy Year - 2 years prior

Annual Claims

30 June 2019 01 July 2018 7001068233

Embassy of the United States of America

Deductible Class Type Policy Expiry Date Policy Inception Date Group CR Number BfblipName "

Health Insurance - Claims Experience Form m̂alath

Printed By: CGAYASPage 2 of 3

Amount of Outstanding Claims

Number of Outstanding Claims

152,570.12 173.025.91 173,497.36 174,809.70 184,307.44 203695.10 206,116.75 250.508.70 268,29661 269.954.62 330,043.85 350.510.92 361,797.82 442,783.45 486,901.48 511,296.94 724,266.2/ 1,286.228.54 1,028,906.82 2,068,844.59

Amount of i Paid Claims

1,471

Number of ' Paid Claims

Bugshan Hospitali i , lCi: : i ! l i i . ! i ,a , : i ! , i,,,' . ,,,S?C,*tt^^i,^ ,, . , ... ,i ,,i,,. , i ,̂ .y.ltilllJtj, l i l , l l l .L,m ,C. ' ,, ,,^

Kingdom Hospital i fprocare Riaya Hospital - Khobar JThe Eye Consultants - Riyadh , 11 ^Dr.Bakhsh Hospital ~ Sharatta ' ' 1

| Al Mouwasat Hospital -Alkhobar Dr.Ghassan N. Pharaon Hospital l iTbe Eye ConsuEtants - Jeddah iConsulting CtiniGs , Al Dawaa Pharmacies Olaya Medical Center

'Al Worood Medical Center Al Hammadi Hospital- AlSwaidy \ i if • ' i i ••

AIMana General Hospitals -Khobar >! | King Fahad Medical City ,, Reimbursement Claims t Dr.Sodman Fakeeh Hospital Dallah Hospital-AINakheol A! Hammadi Hospital - At Olaya Specialized Medical Center Hospital -1

Provider Name

^ Last Policy Year f <- -.' -MVN*->iin '• - Top 20 Utilised Providers (By limiunt) In Last Policy Year ' ' :'

Amount of l r| Outstanding Claims ;

Number of Outstanding Claims

13,371,541.60 935,921.78 283,183.21 1,109,551.18 3,100,049.57 7.942,835.4

Amount of Paid Claims

14,850

1,479

12.138

Number of Paid Claims

Total ' Maternity Optical Dental Inpatient Outpatient

Benefit

1 ""Itdst Policy Year '"'"' ' f!fif?58j|

" •• • ' 'Amountof 'la, ^Outstanding Claims,, ,|Number of • ;>ftjputstansl!n^C!!msjj,, Amount of Paid Claims j

Number of Paid Claims , Total ' "' Maternity i Optical ••!••• Dental ' Ihpatient butpatient

Benefit

| , "Prior Policy Year """,;^-i••"•'•-' ^--".{,: ,T.'.: : : ^*:-s^|!j

Amount of Outstanding Claims

Number of Outstanding Claims

Amount of Paid Claims

Number of Paid Claims

Total Maternity Optical Dental Inpatient 1 ' ' Outpatient ' ,

• ' Benefit

, Policy Year - 2 years prior ^" *''" m" "' '• Breakdown by Benefit

It i i'1'il lri I ll tl1 I'l l '!m i l l!, " " j 500,000

6,800

31 March 2021 7001068233 15 April 2021

[Tn-Patient Limit Optical Limit Dental Limit Claims Processed to Group Sponsor Number Report Bchi'^*

30 June 2019 01 July 2018 7001068233

Embassy of the United States of America

Deductible Class Type 3olicy Expiry Date

"Policy Inception Date Group CR Number Srbup'Narffef*?"*'*

Health Insurance - Claims Experience Form

ElbS malath

Printed By: CGAYASPage 3 of 3

Signature & StampDate:

Pollcvholder Confirmation:

We (The Insured / Policyhoider) confirm to the best of our knowledge that the Information provided above is correct

Signature & Stamp (Authorized Person)Date:

For Insurance Companv/TPA Use:

Notes IIIPITISI

^^. ^^ i ^^^ • ^

„ 1 ( WS*

No No

Any differences from Last Policy Year (Yes/No/Not jj

Yes No No

Attached (Yes/No)

Total Number of Pages•liM^ i i irn iWh',.—.• - .. .--. •

1 -,-*• -•'•••• Last Policy Year Prior Policy Year policy YSaf- 2 years prior

Policy Year

1 •' ... Benefit Schedules '

Malath Platinium VIP Network

Preferred ' r Provider Network

SAR.15000

Maternity Benefits

SAR 500

Optical Benefits

SAR. 6800

Dental Benefits

Pnvate Room Maximum SAR. 1500

" ^ > Dally Rdom* Board at Malath Appointed PPn

10% Max SAR 100

Out-patient Co- Insurance / Deductible

SAR. 500000

Overal Annual Maximum Limit

Benefit Class - VIP . a,-Table of Benefits.. ._ -

- . ' 7 500,000

6,800

31 March 2021 7001068233 15 April 2021

In-Patient Limit Optical Limit Dental Limit Claims Processed to Group Sponsor Number Report Date

30 June 2019 01 July 2018 7001068233

Embassy of the United States of America

Deductible Class Type Policy Expiry Date Policy inception Date Group CR Number 'Group Name maldh

Printed By: CGAYASPage 1 of 3

... -a

77,679.37 3.931.12

69,044.98 2,842.98

260.50 1,160.95

438.84

' ,llli l l l i ii, Jl l.llIll..I..i

Amount of Outstanding j Claims at Period End t l "l1F"irr,- -jt

Hi.UiiLi,j...,......., J

Amount of Outstanding • Claims at Period End u.i,l i , , ! Jii ^.,,Hi it i, iJ uiU ,iUn lJ i , i l, Number of Outstanding Claims at Period End i'l" "l" r virr ip'iT1'

., 1 1.. . i. .1.1. ^._ ji^u.lIk..

* ^*^ ^1! l" "'" '"Tff l "1 w1

Number of Outstanding Claims at Period End

12,329,350.82 12,329,350.82

921,488.27 638,238.82 571,314.69

917,086.46 1,345,153.18 1,334,443.69

1,043,534.60 1,241,861.14 914,608.78 848,038.11

1:126,119 85

Amount of Paid Claims

1.,1 . 1 'LIJIlLliil, .111, .

13,747 13,747 1,058

1,348 1,227 1,434 1,426

1,457 1,239 1,036 1,106

Number of Paid Claims

I i h . i . i n . i . m I h . i u I . i . mjIL i i ,,ny^+.i^rj lit I I ! I ll, ,i.

I

Amount of Paid Claims

Number of Paid Claims

1,943 1,942 1,944 1,941 1,933 1,950 1,953 1,949 1,948 1,962 1,961 1,947 1,964

Number of Lives Insured

• ||I|'VT>' ' ' 'II

.iil,u,:. u^ .

'I ' l l l l ' I IT i ' l 'l , , >^ ^

,i...I,>,, 1 Number of Lives Insured

.^ill,...Total '''̂ . ..A.^.J. kl iU.,1, ^M^^i l P f i l l l i f l ,^

SubTotal Jun-2020 May-2020 '

"I Apf-2020 Mar-2Q2D

' Feb-2020 Jan-2020 ' "I Oec-2019 n Nov-2019 |' Oct-2019

|" Sep-2019 ''

\ Aug-2019 JUl-2019

Number of Lives at start Last Policy Year

\ Monthly Claims

SubTotal

If i 1 '>'• . . i

I

Number of Lives at start Prior Policy Year i , SubTotal

I 1

Number of Lives at start Policy Year - 2 years prior

I, • •'*' ''" p ' Annual Claims

I, • '„ >„,.-,, r t^T •?.•••-" :-.^•.• • . . • • | 500,000

6,800

31 March 2021 7001068233 15 April 2021

In-Patient Limit Optical Limit Dental Limit Claims Processed to .Group Sponsor Number Report Date

30 June 2020 01 July 2019 7001068233

Embassy of the United States of America

Deductible ' [' Class Type Policy Expiry Date Policy Inception Date , Group CR Number SrouPNamVrfP' 'T'~w

Health Insurance - Claims Experience Form

•Eik-2 malafh insuronct

Amount of Outstanding Claims

Number of Outstanding Claims

148,804.44 152.431.00 183.011.40 176,863.06 207,932.24 216,117.15 241,137.84 248.696.53 318.526.25 333.584.11 349,449.28 365,937.84 377,025.27

470.450.64 662,169.94 673,497.84

1.034,348.79 959,174.69

1,062.135.70 1,932.021.52

Amount of Paid Claims

1.538

Number of Paid Claims

Al Hantmadi Hospital - Al Nozha Al Worood Medical Center My Clinic International Medical Co.

r l • •

Dt.Ghassan N. Pharaon Hospital New Jeddah Clinic Hospital ' ' "*

'•King Fahad Medical City JJOIaya Medical Center United Doctors Hospital

'Consulting Clinics 'Kingdom Hospital ' ' I Al Dawaa Pharmacies I, .Reimbursement Claims ^The Eye Consultants • Riyadh ;̂ \ Hammadi Hospital-AiSwaidy "" Dr.Sotman Fakeoh Hospital i Al Mana Senerai Hospitals . Khobar

^Dallah Hospttai • Al Nakheel ^" Ji' ,i , , „!

A! Mouwasal Hospital - Alkhobar ' | P Hammadi Hospital-Al olaya Specialized Medical Center Hospital -1

Provider Name

Last Policy Year B- -•"-'--"I'-ril''Top 20 Utilised Providers (By^Sn^) in List Policy Year •" '

77,679.37 4,582.15

2,084.15 njm.or ii Amount of . ' 11!

jllputstanding Claims'..i||

Number of Outstanding Clairps ,^, 12,329,350.82 928,130.03 239,149.29

933,382.80 2,611,844.32 7,616 844 38

: Amount of Paid Claims

13,747

1,232

11,299

Number of '" Paid. Claims,. ;^

^^l^i'^.-t,,^^^.̂ , ,^M..:?....^.isa^Uti l l Ol , UL^^ra^,.^,1 , .nJi.S ~ v "It

Maternity Optical Dental jnpatient Outpatient ' ^ i < Benefit

^1 '• last Policy Yeir •:>--^sw?/mm,,,,0Km-j, Amount of ^ Outstanding Claim^,,jj

Number of Outstanding Claims

Amount of

fl. Paid Claims

Number of ^aitJ Cl^ims;, Total Maternity ' Optical i Dental tnpatient ' Outpatient , Benefit

Prior Policy Yeaf •<:,. "" ' " r. •'•••••• '.•.' !

Amount of Outstanding Claims , Number of Outstanding Claims

Amount of Paid Claims

Number of p<Hdr9!flm<i, „

Total Maternity Optical Dental Inpatient Outpatient

Benefit

Policy Year - 2 years prior F' ' "-' "•' ' " ' ' ''ll ' Breakdown by Benefit ' ' ii i , ' ^

500,000

6,800 31 March 2021 7001068233 15 April 2021

Patient Limit tical LimitOp

In-

Dental Limit Claims Processed to Group Sponsor Number ^ptoffDat^"'*

' ,. ^^^-Si'1)'™t^ * \^W

30 June 2020 01 July 2019 7001068233

Embassy of the United States of America

Deductible Class Type Policy Expiry Date Policy Inception Date Group CR Number WiipNaWtS"—'HT-s

Health Insurance - Claims Experience Form insuran^*

Printed By: CGAYASPage 3 of 3

Signature & StampDate:

Pollcvholder Confirmation:

We (The Insured / Pollcyholder) confirm to the best of our knowledge that the Information provided above Is correct

Signature & Stamp (Authorized Person)Date:

For Insurance Companv/TPA Use:

' ^ Notes ^ "1

No

NO

Any differences from Last Policy Year (Yes/No/Not

Known)

Yes No No

Attached (Yes/No)

Total Number of Pages

Last Policy Year Prior Policy Year Policy Year - 2 years prior

Policy Year

S • • '. • ... - Benefit Schedules""""' "

Malath Platimum VIP Network il'i i | i l n i 'j i"- preferred • " Provider Network

SAR 15000

' Maternity Benefits

SAR. 500

"'•Optical'.; ,*:

Benefits

SAR. 6800

DentaT™" Benefits

Pnvate Room Maximum SAR. 1500

—!—w Daily Room & Board at Malath Appointed PPn

10% Max. SAR 100

Out-patient Co- ' Insurance / Deductible

SAR. 500000

Overat Annual Maximum Limit

PPPY

Benefit Class-VIP

Table of Benefitsr

500,000

6,800 31 March 2021

7001068233 15 April 2021

In-Patient Limit Optical Limit Dental Limit Claims Processed to Group Sponsor Number

"ReportDate i ' ' ••_--• •• ^s^^*j!l!'^ ~

30 June 2020 01 July 2019 7001068233

Embassy of the United States of America f

Deductible Class Type Policy Expiry Date Policy Inception Date Group CR Number Group Name "*" " ' "*"f

Printed By: CGAYASPage 1 of 3

358,786.53

143,556.42 82,995.83 75,849.27 55,860.01

525 00

Amount of Outstanding Claims at Period End

. . ..^.ilill l lUl li!,..,'

"rr^~:- 'I

Amount of Outstanding •" Claims at Period End

500,000

6,800

31 March 2021 7001068233 15 April 2021

Number of Outstanding Claims at Period End i4 ., . ... A,.,"M,U,,ii ,* ^J

'"y*""" * , Number of Outstanding Claims at Period End

6,581,229.07 6,681,229.07

1,004,644.84 1,122,214.56 1,137,984.95 1,176,944.66 1,061,977.22 1,077.462 84

Amount of Paid Claims

. ^™ 4.1

1'

Amount of Paid Claims

In-Patient Limit Optical Limit Dental Limit Claims Processed to Group Sponsor Number Report DateI, 6,694 6,694

1,071 1,093 1,181 1,129 1,153 1,067

Number of Paid Claims

"i"

Number of Paid Claims pi, ^/ . • •',.

1,949 1,944 1,946 1,944 1,946 1,942 1,948i,-.

Number of Lives Insured

IW""" * * IP" 1 ""1' 1

... ji.ltL... r

Number of Lives Insured

SubTotal T

Dec-2020 ' ' l'l ,!,i ' ' Nov-2020

Oct-2020 Sep-2020

\Aug-2020 Jul-2020

^lumber of Lives at start Last Policy Year

Monthly Claims

SubTotal

Number of Lives at start Prior Policy Year SubTotal

I i

T

Number of Lives at start ^olicy Year - 2 years prior

30 June 2021 01 July 2020 7001068233

Embassy of the United States of America r- , ••-, • ;: • • ,"i- , , i• • -;• l 'TTfljiji Annual Claims f Deductible Class Type I Policy Expiry Date ^olicy Inception Date

Group CR Number '}.

Group Nani'ei"'?"'1'pnlf!

Health Insurance - Claims Experience Form

^all-jo d—,—oi—-i—i—l

1,295.00

40,588.40

175.114.30

117.329 38

Amount of Outstanding Claims

Number of Outstanding Claims

75,058.43 51,229.40 97,607.24 109,290.35 113,433.76 139,755.62

146,262.00 161,691.64 167.479.72 179,414.86 185,250.70 186.492.14 181,626.49

161,030.66 212,461.16 250,929.29 291,821.20 355,067.94

380,890.63 979,835.96

Amount of Paid Claims

Number of Paid Claims

Al Worood Medical Center \ i ' iI^n,.: . .. , inuiL.-. , .... i,,-,n. .,..ii,i...i .'—n i uhJii i ' i I h i ih ^t^a

IDr. Samir Abbas Hospital ' The Eye Consultants - Riyadh I Olaya Medical Center , TJr.Bakhsh Hospital - Sharaf a ' .Saudi German Hospitals Group - Riyadh tOonsultEng Clinics ' Kingdom Hospital Reimbursement Claims tProcare Riaya Hospital - Khobar iSi • , 1 skew Jeddah Ctmc Hospital tAI Hammadi Hospital - Al Swaidy ' ! Dr.Soiiman Fakeeh Hospital Al Hammadi Hospital - Al Olaya Al Moumasat Hospital - Alkhobar Al Hammadi Hosprtai - Al Nozha "Al Dawaa Pharmacies sAIMana General Hospitals-Khobar ^ Dallah Hospital - Al Nakheel '

J

Specialized Medical Center Hospital -1 Provider Name i

Last Policy Year ""* ' , " v " r Top 20 Utilised Providers (i^AmOUrif) in Last Policy Year

358,786.63 10,783.19

8,093.70 123,031.37 216,878.27

Amount of Outstanding Claims

-.;'- Number of jj^putstapding Claims

6,581,229.(57 298,137.31 127,313.05

464.666.86 2,209,318.75 3,481,793.10

Amount of ., Paid Clafmf ^;

Yalr-W^c-.M-^- •• " •••--"*•:• •-*••

Amount of , Outstanding Claims |^

Number of Outstanding Claims

Amount of Paid Claims

6,694

5,435

Number of:

Paid Claim^ ;t\Benefit

' Last Polfc*

Number of Paid Claims

E*" . . , i.„,, Maternity Optical Dental ^npatient Outpatient f, l

Wai Maternity Optical Dental Inpatient ^utpatient

Benefit

Prior Policy Year ''" ' '" "'^ "''!

Amount of JOutstanding Claims JNumber of

Outstanding Claims Amount of

Paid Claims Number of

Paid Claims ,m,, , in Total Maternity Optical Dental Inpatient

Benefit Outpatient

Policy Year-2 years prior j Breakdown by Benefit ' i ^\

"'mu^ i'i'i . • , fni! i "itiiK?"'W^ 500,000

6,800

31 March 2021 7001068233 15 April 2021

In-Patient Limit Optical Limit Dental Limit Claims Processed to Group Sponsor Number "Report Date

"\ J lull Illi *•* ii i " - ' —.,*."

30 June 2021 01 July 2020 7001068233

Embassy of the United States of America

[PT'1 1"'"J-iV:-• i' i . * Deductible Class Type Policy Expiry Date Policy Inception Date Group CR Number Group Name

Health Insurance - Claims Experience Form

Insuronc^

Printed By: CGAYASPage 3 ofJ

Signature & Stamp

Pollcvholder Confirmation:

We (The Insured I Pollcyholder) confirm to the best of our knowledge that the Information provided above is correct

Signature & Stamp (Authorized Person)Date:

For Insurance Companv/TPA Use:

"•" fotl""V'"tP*t1J. ^t ^, H f^Sfif^ .4i.J. . r. J. ^l &J-

- -I No No

Any differences from Last Policy Year (Yes/No/Not

Known)

*r

Yes No No

Attached (Yes/No)

Total Number of Pages I^ ' fast Policy Year l^rlor Policy Year Policy Year-2 years prior

Policy Year

.""•."• • ' ' Benefit Schedules

Malath Platimum VIP Network

Preferred 1 Provider Network

SAR. 15000

Maternity Benefits

SAR 500

Optical Benefits

SAR. 6800

Dental Benefits

Pnvaie Room Maximum SAR. 1500

Dally Room 4 Board at Malath Appointed PPn

Benefit Class-VIP

J Table of ^^enefits

10% Max SAR 100

Out-patient Co insurance^ Deductible

SAR 500000

Overal Annual Maximum Limit

: PPPY

500,000

6,800 31 March 2021

7001068233 15Apnl2021

In-Patient Limit Optical Limit Dental Limit Claims Processed to Group Sponsor Number RejWTOate ' ' '

' --'ilffftfiiff'1 ; r/'siu,;r;|j

30 June 2021 01 July 2020 7001068233

Embassy of the United States of America i Deductible Class Type Policy Expiry Date Policy Inception Date Group CR Number JSKJIp'NImo ' ""•' ""I

^licit-II ^imS j-^-^j/i inrO j^LjII WIF U.J3 i A-irA-AA ^LJ LilaJ www.malath.com.sa

OJ^g^JI OJIjJ till 11 HO I1V0

Customer Service Centre P.O.Box 99763 Riyadh 11625 Kingdom of Saudi Arabia Toll Free: 800 128 0088 Fax:+966 11 215 1675

He

This certificate is issued at the request of the Insured without prejudice to the terms, conditions, limitations and exceptions of the above mentioned policies.

Signed for and on behalf of Malath Cooperative Insurance Co.

NIL

NIL

Natural Death

Natural Death

Accidental Death

Natural Death

Nature of Claim

320,720

320,720

641,440

320,720

Paid Amount, SAR

No. of

Paid Claim

Outstanding Amount, SAR

No. of

Outstanding Claim

Ol-July-2020 to

30-June-2021

Ol-July-2019 to 30-June-2020

Ol-July-2018 to 30-June-2019

Ol-July-2017 to 30-June-2018

Ol-July-2016 to

30-June-2017

Period of Insurance

2020-2021

2019-2020

2018-2019

2017-2018

2016-2017

Policy Year

It is hereby confirmed that up to date of this certificate, below claims are registered under Group Term Life Insurance policy issued to the "Embassy of The United States of America, Riyadh, Saudi Arabia".

Name and Address of the Insured : Embassy of The United States of America Riyadh - Kingdom of Saudi Arabia

Date: 18 April 2020

TO WHOM IT MAY CONCERN

malath insurance

U=4- (jTJgLcjJI ^xabll daLclg ^,| niil I a[ *~ go ~i n Jl f\ ^jijl jj n pg r.,i fi/i ,tj .,in /i-

H-mVAV ci.^ ^ngr.nJLj I"--,-.- a ^ig

Malath Cooperative Insurance and Reinsurance Co .

Saudi Joint stock company with a paid up capital of Saudi Riyal 300,000,000 C.R. No . 1010231787