THE CO-OPERATIVE INSURANCE COMPANY OF KENYA LIMITED INSURED OUTPATIENT SCHEME PROPOSAL PRESENTED TO: KENYA FOREST SERVICE
2 Outpatient cover benefits for KFS The benefits stated in this Schedule, except Dental and Optical, are within the overall outpatient cover limit per family. No. Benefit description 1 Overall outpatient cover limit per family (combined for both illness and accident ) BOARD OF DIRECTORS KFS 1 KFS 2-4 KFS 5-9 KFS 10-14 100,000 150,000 100,000 75,000 50,000 2 Outpatient Consultation as per negotiated rates 3 Prescription drugs (Prescriptions above 5,000 require preauthorization) 4 Prescribed routine laboratory tests 5 Radiology (X-ray and Ultrasound) - CT Scan and MRI require preauthorization) 6 Pre-existing chronic conditions and cancer. 7 Newly diagnosed chronic conditions after 4 months of cover 8 HIV/AIDS and related opportunistic conditions 9 Maternity cover ANC (Max 1 U/S Scan) & PNC only (up to 6 weeks post natal) 10 Psychiatry and psychotherapy 11 Outpatient Oncology/Cancer diagnosed after 4 months of membership 12 Immunizations (KEPI) 13 Dental cover 30,000 30,000 20,000 15,000 15,000 14 Optical cover 30,000 30,000 20,000 15,000 15,000 Outpatient services offered The following expenses are covered subject to the medical limit stated above:
3 Medical services (subject to medical limit) Outpatient consultation with General Practitioners Prescribed drugs/medication and dressings (A prescription above Kshs 5,000 must be pre-authorization). HIV/AIDS related conditions and prescribed ARV s. Specialist s consultations, strictly on referral basis Outpatient surgery Diagnostic laboratory and radiology procedures (X-rays, laboratory services, etc). Routine free child immunization and vaccinations (KEPI). Routine antenatal check-ups. Post natal care up to six weeks post-delivery(with not more than two scans). Pre-existing, Chronic and recurring conditions. Health education. Counseling. Dental services(subject to Dental limit) Dental consultation. Dental treatment expenses (anaesthetist s fees, operating theatre). Dental exclusions shall include: i. Expenses arising from replacement or repairs of old dentures, bridges and plates unless Directly caused by accidental injury. ii. Expenses relating to orthodontic treatment of a cosmetic nature unless directly caused by a disease or accident. Optical services(subject to optical limit) Eye consultation - including refraction and eye examination. Check up of glasses Post surgical follow up reviews. Prescribed glasses (frames and contact lenses) subject to the optical limit. Optical exclusions shall include: i. Replacement of frames unless directly caused by accidental injury to an eye. ii. Replacement of lenses unless prescribed by a qualified Ophthalmologist as Necessary. Access to services
4 Scheme members will access medical services through a countrywide network of medical service providers (see attached the panel list). Each member of the scheme (including dependants) will be issued with a Photo Card for identification when seeking services. The card must be produced in order to access outpatient services without inconvenience. 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, in which case CIC must be notified within 24 hours of receiving service. Notification can be done through the medical helpline, email or any other effective method. Invoices for non-panel doctors will be paid in line with current rates as recommended by The Kenya Medical Practitioners and Dentists Board. Any extra charges above the recommended rates will be bone by the member. PROVIDER PAYMENT AND OUTPATIENT REIMBURSEMENT CLAIMS CIC has put in place efficient credit arrangements with contracted medical service providers. Treatment bills are send 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 24 hours of receiving service. The following documents are required for outpatient claim reimbursement: - Original hospital invoices, with expenses clearly broken down into Pharmacy, Lab, etc. - Original hospital/doctors receipts. - Letter from KFS lodging the claim. Fully documented claims will be reimbursed within 7 days. Premium payable Please see attached herewith the Outpatient Premium quotation schedule. Outpatient exclusions The policy will not pay expenses incurred in connection with any of the following: Treatment of obesity and slimming preparations. External aids and appliances.e.g. Hearing aids, BP machines, glucometers etc. Voluntary participation in riots, demonstrations, unrest and public or other war. Travel expenses other than ambulance costs.
5 Holidays for recuperative purposes. Non-prescription drugs, homoeopathic drugs, alternative medicine and hormonal replacement therapy, vitamins, tonics and mineral supplements. Stop smoking aids. Infertility, artificial insemination and enhancement of fertility. Injuries sustained whilst participating in professional sporting activities. Injuries sustained while participating in speed contests with the assistance of any type of mechanical apparatus including, but not limited to motor vehicle racing, motor cycle racing of any description, boat racing and ski racing, aircraft racing, diving and aerobatics. Injuries sustained whilst participating in activities which are in the Company s view inherently hazardous including, but not limited to martial arts, parachuting, hang gliding, paragliding, bungee-jumping, advanced mountain climbing, river-rafting, kayaking as well as other activities where the member or dependant deliberately exposes himself or herself to substantial danger. Self-inflicted injury or illness, such as attempted suicide, alcoholism, and drug abuse. Patent foods and skin cleansing remedies such as shampoos. Experimental treatment where one willingly participates as subject of medical research. Procedures of experimental nature not accepted by the medical profession (acupuncture, chiropractic treatment). Herbal treatment. Specialists fees unless referred by a General practitioner. Cosmetic procedures or beauty treatment / surgery in nature cure clinics, health hydros, sanitaria unless as a result of accidental injury(eg bat ears, face lifts, revision of scars). Bills incurred by doctors or hospitals not appointed by CIC Insurance as preferred providers. Treatment other than by a registered medical practitioner. Costs in excess of the annual cover benefit entitled to a member. General medical examinations and check-ups not incidental to diagnosis of an illness or injury, such as for insurance, physical fitness, or inoculations for international travel. Non-adherence to medical advice or negligence of a member.