CIC GENERAL INSURANCE LTD

Transcription

1 CIC GENERAL INSURANCE LTD KENYA FOREST SERVICE STAFF MEDICAL SCHEDULE OF BENEFITS Note: All the benefit limits contained on this schedule are within the overall annual limit per family or per person. No. Benefit description BOARD OF KFS 1 KFS 2-4 KFS 5-9 KFS DIRECTORS 1 Annual overall limit per family or per person 2,000,000 1,500,000 1,000, , ,000 (combined for both illness and accident ) 2 Hospital accommodation - Bed limit entitlement net of NHIF rebate per day General ward bed Pre-existing and chronic 3 conditions and HIV/AIDS related illnesses Maternity for child 4 delivery and pregnancy related complications, applicable to principal members or their spouses. 5 Congenital defects/genetic disorders for children under 7 years of age/ Neonatal complications for new born babies at birth where the parent(s) are already ed 6 First Emergency caesarean operation including Ectopic pregnancy Last Expense or funeral 7 for principal members only. Standard Private room Kshs 20,000 Standard private room Kshs 20,000 Standard private room Kshs 10,000 General ward bed 750, , , , , , , , ,000 50, , , , , , , , , , , , , , , ,000 Last Expense or funeral for dependants only. 50,000 50,000 50,000 50,000 50,000 1

2 8 9 psychiatry / psychotherapy treatment 300, , , , ,000 Emergency Air evacuation within East Africa subject to pre-authorization 10 Emergency local road ambulance services leading to admission Overseas for a maximum of sixty (60) consecutive days outside East Africa while on holiday or business visit during any one period of insurance, for emergency illness or injury. This is on reimbursement basis. Accident caused dental and optical expenses 13 Non-accident ophthalmologic surgery 250, , , , , Non-accident maxillofacial surgery excluding routine dental procedures. Non-accident dental surgery, subject to written preauthorization Post Hospitalization Benefit for accident and surgical admissions within thirty days after discharge 250, , , , ,000 50,000 50,000 40,000 35,000 30, Professional fee for specialist doctors (Physicians, 2

3 18 19 Surgeons, and anesthetists). Theatre charges - surgical, ICU / HDU charges. In-patient prescribed physiotherapy, chemotherapy and radiotherapy In-patient prescribed drugs/medicines and dressings (including prescription on discharge for a maximum of two weeks). Internal & external surgical implants, appliances, joint replacements and prostheses. External aids on prescription(wheel chair, corsets/walking frames, crutches Inpatient diagnostic tests for therapeutic purposes (X-rays, pathology, ECGs, MRI scans) 50,000 40,000 30,000 30,000 20, Gynecological surgery. Day care surgery for minor surgical treatment that may not necessarily require admission, subject to pre-authorization. Major organ transplant excluding the cost of organ donor. Basic accommodation cost for one resident mother or guardian during admission of children under 7 years of age. limit limit limit limit limit ELIGIBLE MEMBERS Employees / Directors and their spouses, with a maximum age of 66 years at the inception of. No maximum age for existing adult members so long as they are still in the service of the employer. 3

4 The Policy s one legal spouse for each employee. Additional spouses can be ed separately on request as principal members. Own and legally adopted children are ed from birth to the age of 21 years subject to the following conditions: i. The child must have been medically discharged from the hospital after birth at term (38 weeks). ii. CIC must be notified by a duly filled Application form to include the child on within seven days from birth, whereby the additional premium is charged. Children above 21 years of age but below 25 years will continue to be ed under their families if proof is provided to show that they are full time students at university or regular college. In the absence of proof and upon request, children above 21 years can only continue on as principal members. ENHANCED COVER This quotation is for an ENHANCED medical, which means that includes medical expenses arising from pre-existing conditions, chronic ailments and HIV/AIDS related illnesses. Chronic conditions are those conditions that require one to be on medication for a long time and include (but not limited to) Hypertension, Diabetes, Asthma, Kidney failure or renal problems, Cancers/tumors, Leukemia, Heart conditions, Chronic airway disease, Stroke (cerebral vascular accidents), Arthritis / oesoarthritis, Nerve disease, diseases of the thyroid gland, Thrombosis, cirrhosis (liver diseases), renal failure, eczema and HIV/AIDS related illnesses. Pre-existing conditions are conditions that the member has been treated for before joining the with CIC Insurance and include the above named chronic ailments. Other illnesses falling under this category include dysfunctional uterine bleeding, deep venous thrombosis, peptic ulcers decease, backache/lumbago, hemorrhoids, lumps/growth, scars, scheduled surgery (e.g removal of implants), and uterine fibroids/menorrhagia. 4

5 At the inception of new members of the scheme will be required to declare any pre-existing and recurrent conditions on the Application form to be filled by each employee. The enhanced benefit must be purchased for the entire scheme population and not part thereof. The enhanced benefit applicable per staff category is shown on the schedule of benefits and is within the overall limit per family. HOSPITAL ACCOMODATION Members will access accommodation in appointed hospitals as specified in the schedule of benefits, net of the N.H.I.F rebate amount for each day admitted. Members who choose executive hospital suits such as North wing, Jeans ward and pavilion will be required to top up on daily bed excess charges.. LAST EXPENSE COVER (FUNERAL CASH) The Last Expense benefits applicable to different categories of members are shown on the Schedule of benefits. The last expense applies to Principal members and their dependants. The benefit s the cost of funeral arrangements in the event that the principal member or dependant dies from any cause when the policy is in force. The sum insured is payable within 24 hours on working days after receiving the Burial permit, irrespective of whether the member has exhausted his/her annual medical limit or not. The Last expense benefit is within the overall annual limit per family or per person. EMERGENCY AIR EVACUATION AND ROAD AMBULANCE SERVICES The Policy s Emergency Air evacuation within East Africa subject to the annual limit. Air evacuation services are offered in partnership with ICAA and must be pre-authorized and facilitated by CIC. 5

6 Cover also includes emergency local road ambulance services leading to admission. In the event that the patient needs to be transferred to another hospital that will adequately meet his/her treatment requirements, CIC will arrange and facilitate the transfer subject to approval by the attending doctor. When in need of these services members can call the medical help lines for preauthorization and quick facilitation. Air evacuation and road ambulance expenses are payable subject to the overall annual limit per family or the person. OVERSEAS EXTENSION OF COVER The Policy provides for overseas extension of for a maximum of sixty (60) consecutive days for any one visit outside East Africa while on holiday or business, for emergency illness or injury. Members will be required to notify CIC every time they are traveling outside East Africa. Valid claims that may be incurred during such overseas visits are paid on reimbursement basis, subject to the overall limit per family or per person. EMERGENCY OVERSEAS REFERRAL The Policy allows overseas referral for medical conditions whose treatment is not available locally, subject to a second opinion from an independent specialist appointed by CIC. Referrals are restricted to India and South Africa, and expenses ed are treatment, travel expenses for the referred patient and one accompanying person in the economy class, subject to overall limit (hotel accommodation costs are not ed). A written pre-authorization must be obtained from CIC and claims are paid on reimbursement basis. POST HOSPITALIZATION BENEFIT (PHB) 6

7 This benefit s follow-up consultation and treatment expenses incurred after discharge from hospital, where the cause of hospitalization was either an accident or surgery already ed by CIC. The benefit is available for thirty (30) days from the date of discharge. Post hospitalization claims incurred within the thirty days are paid on reimbursement basis. The benefits applicable are specified on the schedule of benefit and are within the overall annual limits per family or the person. WAITING PERIOD The waiting period will not apply. ACCESS TO SERVICES Scheme members will access medical services through a countrywide network of medical service providers. The list of appointed service providers can be obtained from the CIC offices. The policy holder and each of his/her dependants are issued with photo card for identification when seeking admission. The card must be produced to the hospital in order to access in-patient services without being required to pay a deposit. Access is strictly limited to appointed medical service providers. CIC will not be liable for bills incurred by use of non-panel service providers except in emergency circumstances where CIC is notified within 48 hours through the medical helpline. Invoices for non-panel doctors will be paid in line with current rates as recommended by Kenya Medical Practitioners and Dentists Board. Any extra charges above the recommended rates will be bone by the member. The admission procedure is as follows: Planned or scheduled admission procedure 7

8 The attending doctor makes the decision to admit and fills the CIC Admission pre-authorization form. The filled form should be faxed, ed or delivered to CIC at least 48 hours (two days) to the planned date of admission for timely authorization and undertaking of payment. The forms are available at the admission desks in all appointed hospitals. In the event that the condition or ailment falls under policy exclusions, CIC will notify the employer through the scheme contact in time before the admission date for alternative arrangements. The member should identify himself or herself properly to the Hospital using the postcards and the national identity card. In case that the member does not have the card, then the hospital should be informed that he /she is ed by CIC. CIC has case management nurses who work closely with hospitals and attending doctors to ensure that everything is smooth regarding patient management. The member or guardian should ensure that the N.H.I.F membership card is availed to the Hospital before the discharge date. The member should confirm and sign the hospital bill on discharge. Emergency admission procedure In the case of emergency, the member is admitted to the nearest hospital for treatment. If able the member should identify himself or herself properly to the Hospital using the photo card and national identity. The guardian or admitting hospital/doctor should notify CiC Insurance using the most appropriate means not later than 24 hours after admission(through our medical help lines). If necessary subject to recommendation by the attending doctor, CIC may make arrangements for the transfer of the patient to a better equipped hospital. The Hospital should immediately fill the Admission Authorization form and fax it to CIC. CIC will then give a written authorization to the Hospital undertaking to pay the resulting medical expenses if the condition is ed under the policy. In case the condition falls under policy exclusions, CIC will notify the employer promptly for alternative payment arrangements. The member or guardian should ensure that the N.H.I.F Membership card is availed to the Hospital before the discharge date. 8

9 The patient or guardian should confirm and sign the hospital bill on discharge. CLAIMS SETTLEMENT Members are treated and discharged without incurring own expenses as CIC has put in place efficient credit arrangements with medical service providers. Treatment bills are sending directly to CIC for settlement. Reimbursement claims are not allowed except in real emergency circumstances where an appointed provider is not accessible. In such a situation the member or next of kin must call CIC using the medical helpline for authorization within 12 hours of the event. The following documents are required for reimbursement claims: - Original hospital billing/invoice statement. - Original hospital/doctors receipts. - Hospital Discharge Summary. - Letter from the hospital confirming admission. Fully documented claims will be reimbursed within 7 days. EXCLUDED MEDICAL EXPENSES Medical expenses arising directly or indirectly from war, participation in riots, civil commotion, rebellion, terrorism, and other warlike activities. Expenses as a result of overseas referral for treatment confirmed and certified by a qualified medical practitioner as available locally (in East Africa). Dental checkups and Optical expenses relating to eye testing, cost of eyeglasses / contact lenses, cost of hearing tests & deaf aids unless as a result of accidental injury leading to hospitalization or day case treatment, subject to the schedule of benefits. Medical examinations and check-ups not incidental to diagnosis of an illness or injury, unless stated otherwise on the Quotation Schedule. Self-inflicted illness or injury, including drug abuse, alcoholism and attempted suicide. Expenses arising from non-adherence to medical advice. Illnesses or injury arising from experimental treatment where one willingly participates as a subject of medical research. Medical expenses arising from participation in military training and related operations. Expenses arising from cosmetic or beauty treatment / surgery unless as a result of accidental injury. 9

10 Expenses arising from treatment of infertility and impotence, including intra vitro fertilization (IVF). Expenses for which the insured can be reimbursed from any other insurance source, such as N.H.I.F rebate, work injury benefits, personal accident, etc. Claims in respect of a member who willfully fails to make full disclosure of or misstates material facts on the policy application form. Expenses arising from participation in hazardous sporting activities such as league football, rugby, mountain climbing, motor cycling(over 125cc), flying except as a passenger on a registered commercial airline, polo, horse racing, parachuting, etc. This exclusion does not include expenses arising from team building and social sporting activities. Expenses relating to homeopathy, chiropractic treatment, acupuncture and herbal or alternative medicine. Treatment by a person who is not a certified medical practitioner. Medical expenses arising from senility MANAGEMENT OF EXCLUDED EXPENSES During emergency admission the Medical card facilitates admission and immediate access to treatment irrespective of whether the ailment is ed by the policy or not. Normally at the start of CIC Insurance agrees with the client on the procedure for handling cases involving policy exclusions. There are two methods of managing admissions involving policy exclusions: i. The organization establishes a special fund with CIC Insurance to meet the cost of excluded claims expenses. CIC Insurance will manage the fund at no cost to the client. ii. CIC Insurance refers to the client each admission relating to policy exclusions. MAIN FEATURES OF THE CIC COVER CIC Insurance is the preferred underwriter of Medical insurance for many corporate organizations due to unique features listed below: The policy has a broad scope of with well blended benefits. Services are accessed through a photo card or Smart card,( the client can choose from the two) supported by a wide network of Medical service providers ing all major towns of Kenya. Flexibility in the administration of based on our co-operative spirit in service delivery. 10

11 Fastest claims payment. The policy has no maximum age for existing members as long as they are employees or directors of the Employer organization. Air evacuation and road ambulance services are ed within the overall annual limit without additional premium charge. Newly born children can join immediately (from birth) subject to specified conditions. Cover is extended to include the East African countries on reimbursement basis. The has no ceiling on the ward bed cost, as long as one is admitted in a panel hospital. We do not restrict members on accessing any hospital in our panel list (free panel access). Adequate for pre-existing conditions, chronic ailments and HIV/AIDS. The policy reimburses expenses incurred in the event of emergency admission in a non-panel hospital. Members can access a panel of specialist doctors in all areas of specialty. INCEPTION OF COVER The procedure below is to be followed in setting up the medical scheme: 1) The Group Proposal form (to be filled by new corporate clients joining CIC Insurance). 2) A complete, current list of staff members and their dependants indicating dates of birth (to be filled by new corporate clients joining CIC Insurance). 3) Payment of the premium due as per tender quotation. 4) Each Employee is required to fill the Membership Application form and attach one passport size photo for each dependant. 5) On receiving dully filled application forms, CIC Insurance will issue Medical Cards to each member for use in accessing services. SPECIAL CLAUSES TO NOTE This quotation will remain valid for 90 days. Details of all the benefits enjoyable under this are shown on the Schedule of Benefits. The premium quoted is guaranteed and will not change or be reviewed during the term of the contract unless agreed by the parties. The annual premium quoted is payable once at the start of. 11

12 The cancellation notice of is thirty (30) days. VICTORIA MUTHURI Prepared by:. Friday, August 02, 2013 Date:. 12