ABOUT THIS EDITION
Dear Insured Member,
We are delighted to present the November edition of the bimonthly UNSMIS newsletter!
In this issue we will discuss the following:
- Fraud prevention / mitigation
- Retirement – After-Service Health Insurance (ASHI)
- Affiliation conditions for children above 18
The newsletter will be sent to insured members via email, will be published on the website and will appear as a pop-up window on the eClaims Portal.
We hope you find this newsletter helpful.
Kind regards,
The UNSMIS Team
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FRAUD PREVENTION AND MITIGATION
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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.
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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.
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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 is not to be considered an exhaustive list.
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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.”
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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.
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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.
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RETIREMENT – AFTER-SERVICE HEALTH INSURANCE (ASHI)
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As a member of the United Nations Staff Mutual Insurance Society against Sickness and Accident (UNSMIS), you may have the option to apply for After-Service Health Insurance (ASHI) coverage upon retirement. This coverage is governed by Rule V of the Society’s Internal Rules (click HERE for further details).
Below are the salient points you should be aware of:
Eligibility and enrolment
To be eligible for ASHI, it is essential that your active-service coverage in a contributory health insurance plan of the United Nations continue without interruption between your active service and retirement. This means you must be insured at the time of retirement.
Eligible members are those 55 or older with a fixed-term or permanent appointment, and eligible for a retirement benefit from the UN Joint Staff Pension Fund (UNJSPF). A 10-year vesting period is required for staff recruited after 1 July 2007. ASHI is also available to those receiving a disability pension under the Regulations of the Pension Fund or compensation for disability awarded under appendix D to the Staff Rules.
For more details, please refer to ST/AI/2007/3, dated 1 July 2007
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Enrolment in ASHI is not automatic.
An application must be submitted to unsmisaffiliations@un.org within 31 days following separation from service. Failure to apply within this period will result in ineligibility for ASHI.
Premium rates during retirement
Premiums are based on a total pension, including lump sum, representing a minimum of 20 years of service for staff recruited before 1 July 2007, and 25 years for those recruited after said date. The organization covers two-thirds of the premium, with one-third deducted from your pension. For the applicable percentages and flat rates for Specially Protected Persons (SPP), please see HERE.
Provisions for deferred pension
If you defer your pension, coverage can be extended by contacting UNSMIS and paying the premium through bank transfer in advance. During this period, the premium is split equally between you and the organization. A deferred pension does not automatically extend your coverage. Please write to unsmisaffiliations@un.org before your planned separation to ensure all the necessary can be done to secure continuity of coverage.
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Coverage details
ASHI benefits are the same as those during active service. One of the pillars of UNSMIS is solidarity, with particular focus on intergenerational solidarity.
Dependents’ eligibility
Please note that only family members who are enrolled under the coverage of a Staff Member at the time of separation are eligible for continued coverage under the ASHI plan in accordance with the eligibility criteria laid out in ST/AI/2007/3. Non-dependent spouses, secondary dependents, and children over a certain age, may continue to be covered if affiliated as such under ASHI on the condition that they have participated in the plan for at least 12 months prior to the insured members date of retirement.
Family members may not be added to the plan after retirement. Children may remain covered as long as they qualify as Specially Protected Persons; under the age of 30, unmarried, in full-time education, or not in regular employment.
As a member, it is your responsibility to inform UNSMIS about any changes that may impact your child(ren)’s eligibility for coverage (e.g., children completing their studies, starting regular employment, becoming married, etc.). Once you retire, if insured family members are disaffiliated, they cannot be re-enrolled in the plan.
Both spouses working for the UN
If your spouse is an active UN staff member and you retire first, they may become the main subscriber to the health insurance plan, adding you and your children under their coverage. However, there are important details to consider:
- Enrolment: If you choose to enrol under your spouse’s health insurance plan upon retirement, you may not request ASHI with UNSMIS later. Your continued coverage will depend on your spouse’s eligibility for ASHI at their separation.
- Eligibility Risks: If your spouse separates from the organization before qualifying for ASHI, neither you nor your spouse will be eligible for ASHI coverage.
If you wish to become a dependent of your spouse, please liaise with your HR focal point before your retirement, ideally when you begin the administrative preparations for your separation from service.
Divorced spouses
If a divorce occurs while you are still in active service, your spouse may be covered for a maximum of 12 months at the SPP premium rate applicable, to be paid in advance. If the divorce happens after retirement, the spouse may continue to be covered for life as an SPP at the applicable premium rate.
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Disaffiliation
ASHI coverage is for life, as long as the insured member wishes to keep it. If the main member requests the disaffiliation of a dependent or their own termination of ASHI, they must either inform us with three months’ notice or during the annual affiliation campaign in June. Retirees will be requested to sign a form provided by UNSMIS where they acknowledge that once disaffiliated they will no longer be allowed to re-enrol in ASHI.
Important reminders
Please keep banking and contact details updated, especially upon retirement.
Family members should be informed about your medical insurance, its benefits, limitations and procedures to submit claims
Additionally, UNSMIS should be notified if retired members start a new employment.
For further details, refer to administrative instruction ST/AI/2007/3, dated 1 July 2007, or contact UNSMIS directly.
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TIPS & TRICKS - AFFILIATION CONDITIONS FOR CHILDREN ABOVE 18
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In this article, we explain the affiliation conditions for children above the age of 18, highlighting the importance of informing us about any changes that affect their eligiblity for coverage.
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Members under the Temporary Plan (on short-term contract / temporary contract of less than 3 months) may not cover their children under UNSMIS.
Insured members with contracts of over 3 months are eligible to cover their children as dependents or as Specially Protected Persons (SPP):
- Unmarried children under the age of 21 years dependent on the staff member within the meaning of the Staff Rules can be insured as dependent family members.
- Children aged 18 or over in continuing dependency on account of permanent invalidity within the meaning of the Staff Rules or the Regulations of the United Nations Joint Staff Pension Fund can be insured as dependent family members.
- Unmarried children under the age of 21 not recognized as dependents by the United Nations can be insured as SPP’s.
- Unmarried children over 21 and under 30 years of age in full-time attendance at a school or university, or not in regular employment can be insured as SPPs.
If you are employed by an organization that uses Umoja, enrolment is done through Umoja’s Employee Self-Service (ESS) platform. For a step-by-step guide on how to select the right health insurance plan and how to enrol members of your family, please see the relevant job aid ( available here).
If you are employed by UNHCR and wish to add any eligible children to your coverage, please contact UNHCR HR.
If you are employed by any other UN organization, and you wish to add any eligible children to your coverage, please fill out the affiliation form ( available here) and send it to your HR focal point.
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Enrolment–time periods
- Within 31 days of entry on duty (EOD)
- Within 31 days of arrival of the family member at the staff member's duty station
- Within 31 days of recognition as dependent
- During the UNSMIS annual enrolment campaign held every year during the month of June
Premium contributions for dependents
The premiums are payable for the full month for each month of the calendar year. Hence if an individual becomes affiliated on the 10th day of any given month for example, the premium for the month will be paid in full with no pro-rata calculation. Premium contributions for the Main Plan are a certain percentage of the salary/pension depending on the number of dependents covered, while SPPs are covered for a flat premium. For further information on premiums, please visit our webpage.
This also applies when seperating: coverage is until the last day of the month in which an insured members and/or family members are seperated or disaffiliated.
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Disaffiliation of dependents
In case you wish to terminate the UNSMIS coverage of your dependent(s), you may do so during the 'annual enrolment campaign' (in this case, the change will be effective from 1 July in the year of your request) or you may request their disaffiliation at any time but you will be required to give a full 3 month notice.
As a member, it is your responsibility to notify your relevant HR colleagues or UNSMIS if your dependent is no longer eligible for coverage (i.e. your child has gotten married or has begun regular employment). If they begin regular employment, please also share their employment contract with us/HR.
In case they are no longer eligible, the coverage of the dependent will be terminated as of the last day of the month of the qualifying event.
- If you are employed by an organization that uses Umoja, disaffiliation is done through Umoja’s Employee Self-Service (ESS) platform. You may reach out to your HR focal point for assistance, if necessary.
- In case you are a staff member of UNHCR, you may submit the opt-out request for your dependent directly within Workday, or notify the relevant HR colleagues in case your child is no longer eligible for coverage through raising a CASE in Workday.
- In all other cases, please reach out to your HR focal point.
Your child will be disaffiliated automatically upon reaching the age of 30 as of the last day of the given month.
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