What you need to know about AFYAMED HFIA group Health Insurance COVER

This is a comprehensive inpatient and outpatient medical insurance cover from Housing Finance Group geared to suit various medical needs which are unique to different groups and individuals.

Features

  • Pays for hospitalization medical expenses
  • Provides supplementary benefits within the main covers which includes Pre-existing conditions, Chronic conditions, HIV/AIDS, Maternity, Inpatient Dental & Ophthalmology (eye disease)
  • Funeral expenses cover
  • Enables valid members to obtain quality healthcare from private providers on reimbursement
  • Various options (Plans) available
  • Optical services including eg eye glasses/lenses/frames and eye testing. This benefit is only available to members who purchase the outpatient optical benefit and is subject to preauthorization by Britam
  • Cover available within Kenya. The cover is also available in South Sudan and Rwanda subject to preauthorization and accessing of the panel of provider network
  • Treatment abroad in India or South Africa for treatment not available locally through a scheduled flight on reimbursement. This must be preauthorized by Britam
  • Available in the rest of East Africa on reimbursement only
  • Cover includes costs of organ transplant and related costs up to specified limits. This excludes cost of the donor and donor related costs.

 

Eligibility

  • Minimum age is 1 month for a child joining the scheme as a dependant or as a principal member
  • Maximum joining age is 74 years and members over 75 years are not eligible to join the Banc med scheme.  However, existing member can be on cover until the age of 75 years
  • Children are covered up to 25 years with proof that they are in school (a letter from school or school ID with expiry date will do).  Children over 25 years, whether in school or not are not covered as dependants and will have to take the cover as a principal member.
  • Compulsory requirement for NHIF membership

Inpatient

  • Hospital Accommodation Charges – depending on the category, this is either in a General Ward Bed, a Standard Private Room or an Ensuite Private Room
  • Doctors (Physician, Surgeon & Anesthetist) fees.
  • ICU/HDU and Theatre charges.
  • Nursing Care, Drugs & Dressings
  • Theatre, ICU and HDU
  • Surgical appliances and Internal prostheses
  • MRI, CT Scans, Pathology & Diagnostic tests
  • In-patient Physiotherapy

Outpatient

  • Consultation fees for doctors on the panel
  • Specialist fees (strictly on referral by a General Practitioner)
  • Diagnostic Laboratory and Radiology services
  • Prescribed physiotherapy prescribed by a General Practitioner
  • Treatment by chiropractors and osteopaths on referral by a General Practitioner
  • Prescribed drugs and dressings
  • Alternative Medicine on referral by a General Practitioner
  • HIV/AIDS related conditions and Prescribed ARV’s
  • Routine Immunizations (KEPI)
  • Routine Antenatal checkups (Max 1 U/S exam)
  • Postnatal care up to six weeks post-delivery
  • Chronic and recurring conditions
  • Dental services subject to sub-limits (Routine dentistry excluding dentures, braces crowns and bridges)

 

Are there waiting periods?

YES. They include;

  • 120 days for non-accidental surgery, gynecological and ENT surgery
  • 6 months for disclosed pre-existing, chronic, congenital and HIV/AIDS & related conditions
  • 12 months waiting period for cancer
  • Newly diagnosed chronic ailments are not subject to the waiting period but the amount payable is limited to the sublimit for pre-existing & chronic ailments
  • 12 months for maternity and related conditions and 1st Ever Emergency CS claims
  • Minimum joining age is 30 days for children. Parents must notify insurance of new born babies.
  • All illnesses are subject to 30 days waiting period except accident related cases and covers on transfer
  • Members who are on transfer will have to provide proof eg a renewal invitation letter to enable waiver of waiting periods
  • Organ transplant whether newly diagnosed or pre-existing subject to 2 years waiting period

Why AfyaMed Cover?

  • Minimum exclusions
  • Wide scope of cover, including pre-existing, chronic & HIV/AIDs, maternity, cancer, congenital, dental, C- Section.
  • High Inpatient and Outpatient limits
  • Generous sub- limits
  • Flexible outpatient options
  • Members not subjected to medicals on joining
  • Extensive service provider network
  • Dependant children can be covered on their own, provided the parent proves that they are covered elsewhere eg by an employer and children are not included

 

How To File A Claim

Submit duly executed claim form which can be obtained from the insurer or downloaded in the website within 30 days from date of service.

  1. Ensure you attach the following documents.
  2. The membership number of client and facility visited.
  3. A detailed medical report if it was an inpatient case.
  4. An original invoice and receipts of payment done and keep copies for your own records.
  5. If it’s an inpatient claim an itemized hospital bill will be required.
  6. For overseas claim, letter of approval is normally issued prior to the services and hence a copy of that letter should be attached.
  7. For a last expense/funeral claim, a copy of burial permit/death notification form will be required.
  8. Give reason for seeking reimbursement (since services can be authorized directly with provider without having to pay).
  9. Provide Bank details.

Prescriptions

  1. Prescriptions are fully covered under outpatient.

Emergency Cases

  1. Call the emergency numbers provided on the membership card or sticker for rescue and evacuation.
  2. If you were taken to the hospital by a Good Samaritan ensure you or your family members inform your insurer within 24 hours from the time the emergency occurred.

Getting a Pre-authorization for inpatient cases

  1. After a physician orders for a medical service for a patient, they contact the insurer to determine if they require a prior authorization check to be run.
  2. If so a process is initiated to obtain prior authorization.
  3. The authorization varies from one insurance provider to another.
  4. This will include completion of an authorization form.
  5. If a service is rejected the physician can appeal based on the provider’s medical review process.

Admission procedures

  1. Members present the membership smart card at the hospital’s admission desk for identification.
  2. The hospital checks and confirms membership using the smart card & fingerprints.
  3. Hospital notifies Britam medical personnel of the admission within (24 hours).
  4. Treatment is rendered and upon discharge the bills are forwarded to Britam.

Guide to make when getting treatment-Outpatient treatment.

  1. Walk to a provider with your medical cover card.
  2. Present your membership smart card at the service provider’s (doctor, clinic or hospital) facility’s desk for identification.
  3. Your membership will be checked and confirmed using your smartcard and fingerprints.
  4. Complete and sign the claim form which will be made available at the service provider’s facility. The attending physician/specialist must also complete and sign the claim form. A claim form must be completed for each episode of treatment and for each person.
  5. All bills will be sent by the service provider directly to Britam.
  6. An outpatient co-payment of Kshs 500.00 per visit will apply to the following hospitals and their affiliated clinics; Nairobi Hospitals, Karen Hospitals, Aga Khan Hospitals, Nairobi Women Hospitals, Gertrude hospitals, Mater hospitals, M.P. Shah hospitals. An outpatient co-payment of Kshs 200.00 per visit will apply to all the other providers.

Patients Guide while seeking treatment

  1. They will key you in the system and request for visit fee which varies from insurer to insurer and if again it’s applicable.
  2. You will be requested to wait for your turn.
  3. Once you are called you will go and see the specialist.
  4. If there is lab tests to be done you will proceed to the laboratory.
  5. After the results are out you will go for a review and prescriptions will be given.
  6. Collect your prescription and proceed to the reception where you will be provided with a bill of all the stages you went through and the cost will be deducted from your card. Please always confirm the costing relates to prescriptions and procedures that you have gone through.
  7. You are advised to always sign and request for a copy of the invoice at each given visit.
  8. Collect your card back and leave the premise.
  9. If for one reason or another you lose your medical card seeking emergency treatment call the emergency hotline to obtain pre authorisation from the service provider. There after request for a medical card replacement from your service provider. 


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Date published: 22/09/2017
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