This medical insurance is an indemnity for medical expenses incurred following illness, disease or accidents. It covers inpatient (when hospitalized) and outpatient (without hospitalization) for SMEs and individuals.
Eligibility
- SME- An employer of 5-100 employees (flexibility can be granted)
- Age 18-65 years (extended to 70 years)
- One legal spouse.
- Biologically, legally adopted children below 18 years of age (extended to 25 years in full time schooling for SME).
- Lodger fee for children below 12 years accommodated
- KEPI & Vaccines up to Kshs. 5,000 for children up to 1.5 years
- Annual medical check-up up to Kshs. 10,000
- Individual- One person or family (of 1-5)
- Age 18-65 years (extended to 70 years)
- One legal spouse.
- Members between 50 ' 65 years to get medical examination at their cost ' cover not automatic
- Waiting period for illness - 30 days for individuals and 14 days for SME and No waiting period for accident (option to waive if transferred from existing scheme)
- Biologically, legally adopted children below 18 years of age (extended to 25 years in full time schooling under SME)
- Lodger fee for children below 12 years accommodated
- KEPI & Vaccines up to Kshs. 5,000 for children up to 1.5 years
- Annual medical check-up up to Kshs. 10,000 for Employee and Spouse under SME.
- Pre-existing, Chronic Cases i.e. Maternity' waiting period of 12 months under Individuals.
Benefits
- Medical Expenses when hospitalized
- Treatment without hospitalization
- Last expense ' free benefit of Kshs. 50,000, Kshs. 75,000 and Kshs. 100,000 payable to next of Kin (with-in 48hrs)
- Personal accident cover of Kshs. 500,000 for principal member.
- Offer options to purchase separately (Maternity, Dental and Optical)
Options
Not included in the main cover, but insured has an option to purchase separately;
- Maternity
- Waiting period of 12 months (for individuals), 10 months for SME
- Full term baby (36 weeks), normal and C-section, labor, recovery ward, other ailments and complications
- Pre-natal & Ante-natal outpatient treatment
- Dependent children not eligible for this benefit
- Dental
- Includes consultation, X-Rays, Fillings, Extractions, Prescriptions, Surgical, Anesthetic fees but excludes cosmetic treatment, replacement of old dentures, bridges and plates (unless due to accident)
- Optical
- Includes consultation, Testing, prescribed glasses, frames (1 pair every two years ' maximum Kshs. 10,000), but excludes sunglasses, lenses, replacement of frames below 2 years (unless of an accident)
Exclusions
- Expenses recoverable under other insurances i.e. NHIF
- Hazardous sports
- Cosmetic surgery
- Drugs/Alcohol related
- Family planning
- Food supplements
- Old age homes, places of rest
- Participating in riots or strikes
- STDs (Except HIV)
- Genetic Disorders
- Military / Airforce operations
- Ambulance cost (unless under inpatient cover)
- Pain Management
- Suicide attempts or intentional injury
- Epidemics / Unknown Diseases
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