The United Nations Mutual Insurance Society Against Sickness and Accident (UNSMIS) takes a zero-tolerance approach to any form of fraud. Fraud jeopardizes the long-term financial viability of the insurance scheme and results in higher costs for insured staff, retirees, and dependents, as well as for all participating organizations, funds, offices, and programs. In short, it threatens the long-term solvency of your medical insurance scheme.

In accordance with the global Anti-Fraud and Anti-Corruption Framework (ST/IC/2016/25—available here), as an integral part of UNOG, UNSMIS has the duty to ensure that “the promotion and maintenance of a culture of integrity and honesty constitute a fundamental requirement for combating fraud and corruption, and a primary responsibility of management and staff at all levels.” This applies to all insured members of UNSMIS.

As an insured staff member, you are responsible for the submission of reimbursement claims for yourself and your insured family members. It is your duty to ensure that all claims include true and correct information, are submitted in good faith, and that all material facts are proactively disclosed. A material fact is one that can alter the profile of the claim.

Various actions may be considered fraudulent behaviors and may result in administrative sanctions as well as the suspension of your right to UNSMIS coverage. Such actions include, but are not limited to, false claims, document falsification, providing misleading information, withholding information related to these claims, requesting double reimbursement from different insurers, and using funds received from UNSMIS for settling claims for purposes other than the payment of said medical expenses.

Examples of fraud:

• Requesting reimbursement for expenses already reimbursed by another private insurance or social security scheme. Failure to disclose the material fact that reimbursement has already been made by another source may be considered fraudulent. The correct approach is to specify which part of the submitted expenses has already been reimbursed so that UNSMIS can act as a complementary insurer and reimburse the out-of-pocket expenses if they are reimbursable according to the Internal Rules.
• Receiving the funds for a past treatment but with a yet unpaid bill (e.g., 30-day grace period), and then using the money for any purpose other than the settlement of said bill. By doing so, insured members compromise the image of UNSMIS and the United Nations. As an insured member, it is your responsibility to ensure that all medical expenses for yourself and your family members are properly settled, whether they are submitted to UNSMIS or not.
• Receiving reimbursement for medical expenses submitted to UNSMIS and then agreeing, after the reimbursement, with the provider on a (further) discount or instalment payment of the invoice(s).
• Manually altering and/or forging any requested documentation submitted to UNSMIS for the settlement of medical expenses. This includes medical bills, prescriptions, sick leave certificates, medical reports, among other things.
• Colluding with a medical provider to issue fake, altered, or incorrect prescriptions, reports, invoices, and certificates. This also includes cases where the insured member and the medical provider seek to alter invoices and actual amounts paid to avoid any out-of-pocket amounts.

The above are only some of the examples and is to be considered in no way an exhaustive list.

In addition to the Anti-Fraud and Anti-Corruption Framework, paragraph 8/h of Rule VIII of our Internal Rules also specifies that the Executive Committee “… may decide that a member or an insured person has lost all or part of their right to benefit from the Society, or that this right will be totally or partially suspended…

• … if an insured person fails to comply with the provisions of … [the] Statutes and Internal Rules;
• … if it is established that the person concerned has attempted fraudulently to obtain benefits to which he or she was not entitled;
• … if a member or one of the persons protected by the Society refuses to undergo a medical examination prescribed by the Committee or by the Medical Adviser;
• … if the member is late in paying the premiums due after separation from service.”

Suspected cases of fraud or abuse must be reported. Article 1.2 (c) of the Staff Rules states that “staff members have the duty to report any breach of the Organization’s regulations and rules to the officials whose responsibility it is to take appropriate action...” Please refer to the Anti-Fraud and Anti-Corruption Framework for information on how to report fraudulent acts and to ensure protection against retaliation.

We also wish to inform you that we may occasionally conduct spot checks and request additional information that we would not normally request. This is part of our efforts to prevent and detect fraud and should in no way be considered an accusation or insinuation. We seek your full cooperation. Failure to provide the requested documents will delay the processing of your claim.

What does UNSMIS do to combat fraud?

Simple procedural updates have been implemented to enforce its rules and regulations which include but are not limited to the following:

UNSMIS implements numerous measures to ensure that rules and regulations are properly applied, including, but not limited to…

• … the requirement and verification of original documents in case of online reimbursement claims if the submitted documents are not completely legible;
• … the insistence on submitting proof of payment in the case of unusual reimbursement claims, as well as for cash payments exceeding USD 500.-;
• … the occasional random audit of claims to verify the originality of submitted documents;
• …informing insured members and other stakeholders.