Corporate Health Covers

The success of a medical scheme is determined by how the scheme is structured, the coverage, providers - hospitals and clinics and the scheme rules.

The policy can be structured in ANY of the three ways; depending on cost and other administrative overheads.

1. Fully Insured Scheme: This is the arrangement where the risk is transferred in full to an insurer/underwriter who shall be the risk carrier.
2. Self-Funded Scheme: This is where the organisation acts as the risk carrier and settles the bills incurred from a set fund.
3. Hybrid Scheme: This is where the Inpatient policy is insured while the Outpatient policy and Supplementary benefits – Maternity, Dental and Optical are self insured/self funded.

 

INSURED SCHEME

Under the Insured schemes, a group can either structure their policy under the following option:-

1. Corporate Insurance - (Insurance with high premiums and high cap coverage with access to high end, category A & B, Hospitals for companies with more than 10 employees)
2. Micro Insurance (Corporate Insurance with low premiums and low caps / coverage with access to low cost providers for companies with more than 10 employees)
3. SME Insurance – ((Insurance with high premiums and high cap coverage with access to high end, category A & B, Hospitals for companies with less than 10 but more than 5 employees)

 

Advantages of an Insured Scheme

Risk transfer from yourselves to an insurance company.

Protection against adverse claims trends

 

Limitations of an Insured Scheme

They have restrictive policy conditions.

Out Patient scheme costs are high due to high frequency of use

 

SELF-FUNDED SCHEMES

Schemes where no form of cover is purchased, but rather the employer sets aside a fund for payment of medical expenses incurred by staff members. The fund may be administered by either the company itself directly or by a scheme administrator such as Eagle Africa Insurance Brokers at a management fee.

Scheme benefits and limitations are determined by the employer.

 

Advantages of a Self-Funded Scheme

Ease on cash flow. Expenditure is spread throughout the year rather than up front premium or membership fee payment.

Flexibility of scheme rules. The employer decides on the benefit limits and scheme rules to be applied.

Limitations of a Self-Funded Scheme

The employer bears the risk of any adverse claims experience or catastrophe.

Increased tendency to overuse or misuse since claim payment decisions lie with the employer, especially for schemes administered directly by client.

SCOPE OF COVER

1) INPATIENT COVER

The cover/benefit provides comprehensive and flexible hospitalization (inpatient) cover, which includes the following services:

• Hospital Accommodation Charges
• Doctor’s (Physician, Surgeon & Anesthetist) fees.
• ICU/HDU and Theatre charges.
• Drugs/Medicines, Dressings and Internal Surgical appliances.
• Pathology, X-ray, Ultrasound, ECG and Computerized Tomography, MRI Scans.
• Radiotherapy and Chemotherapy.
• In-patient Physiotherapy.
• Emergency Road and Air Evacuation subject to overall cover limit.
• Day care surgery
• Home nursing care

2) OUTPATIENT COVER (Optional)

The outpatient cover/benefit caters for all routine outpatient services subject to policy terms and conditions, which include the following services,

• Routine outpatient consultation,
• Diagnostic Laboratory and Radiology services,
• Prescribed physiotherapy.
• Prescribed drugs and dressings.
• Vaccines: KEPI & Baby Friendly vaccines. (were covered)
• Chronic, Pre-existing conditions & HIV/AIDS including cost of ARVs covered up to the full out-patient cover limit per person per annum.

3) DENTAL COVER: (Optional)

• The Cost of Dental Consultation resulting in treatment expenses, inclusive of Anesthetist’s fees
• Hospital and Operating Theatre cost,
• Fillings
• Extraction
• Root canal
• Scaling necessitated by a medical condition and prescribed by our appointed dentist once a year

4) OPTICAL COVER: (Optional)

• Outpatient ophthalmologists expenses
• Cost of Prescribed frames and lenses up to the optical cover limit
• Contact lenses

Optical Exclusions: Laser correction of eyesight, Antiglare lenses, Plano (flat) lenses.

 

BROKERAGE SERVICES OFFERED

• Set up of computerized membership accounts for all scheme members.
• Vetting and reimbursement of all claims incurred by the members.
• Vetting and settling of all claims from the credit facility providers.
• Pre-authorization and confirmation of hospital admissions.
• Control of staff benefits entitlements.
• Cost negotiations with medical service providers.
• Industry bench marking and cost control.
• Set up of network of providers and facilities.
• Full administration of credit facilities – settling of bills and account reconciliation.
• Administration of In Patient credit facilities in all the major NHIF accredited hospitals.
• Maintenance of the membership registers with the hospitals.
• Maintenance of expenditure, diagnosis and treatment statistics.
• Preparation of various management & expenditure reports and member statements
• Facilitation of medical quality control audits.
• We Provide constant analysis and advise on market trends

 

 

 

For any payments please pay through  Safaricom Paybill Number 513100