INDIVIDUAL MEDICAL COVER

Medical Insurance

Types of Medical Schemes

• Indemnity (Insured) Schemes
• Self-Funded Schemes
• Managed Care Schemes (Health Management Organisations).
• International Covers
• Individual Covers (non-corporate)

General Terms and Conditions of Cover

General Policy exclusions and Limitations

Quotation Requirements

• Corporate Clients
• Non-Corporate Clients

At Serian Insurance Agency, we work round the clock to ensure that we have Medical cover products for all. No one is too small or too big for us. We can structure your Medical scheme to any of the following five categories:

• Indemnity (Insured) Schemes
• Self-Funded Schemes
• Managed Care Schemes (Health Management Organisations).
• International Covers
• Individual Cover (non-corporate).

Under each of the categories we offer scheme setup, underwriting, claims processing and consultancy services.

Types of Medical Schemes

• a). Indemnity (Insured) Schemes
• b). Self-Funded Schemes
• c). Managed Care Schemes (Health Management Organisations).
• d). International Covers
• e). Individual Covers (non-corporate)

a). Indemnity (Insured) Schemes

• A specified premium charge is used to purchase a specified benefit limit.
• Benefits and premiums can be either per family unit or per individual insured members
• The medical service is obtained from providers (doctors, chemists ,hospitals etc.) on credit then the bills are then settled or reimbursed under the insured benefit.
• The covers are underwritten by insurance companies and administered by Serian Insurance Agency
• Please complete our proposal form to enable us structure a scheme for you.

b). Self-Funded Schemes

• These are 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 and their dependants. Serian Insurance Agency Administers the fund their clients at minimal management fee
• Scheme benefits and limitations (rules) are determined by the employer.

Please complete our proposal form to enable us structure a scheme for you.

c). Managed Care Schemes (Health Management Organisations).

• These are health providers who work independently of Insurance Companies.
• Their main aim is to offer managed care
• specified membership fee enables the member to access certain benefits offered by the H.M.O.
• The actual out patient treatment is offered at the H.M.O. clinics and (as opposed to use of third parties)
• In Patient treatment is out sourced but is administered and approved by the H.M.O. medical personnel.
• Their In Patient covers may however be underwritten by an insurance company.
• At Serian Insurance Agency, we deal with all local H.M.O.'s

Please complete our proposal form to enable us structure a scheme for you.

d). International Covers

• These are covers that offer worldwide coverage without any geographical limitations.
• They have their own terms and conditions of cover.

Please complete our proposal form to enable us structure a scheme for you.

General Terms and Conditions of Cover

The following medical fees and/or expenses are covered under these schemes, subject to the specified annual benefit limits:

• Accident & Illness hospitalization -Surgeon’s, Physician’s and Anesthetist's fees and the charge for use of an Operating theater.
• Diagnostic consultations or Specialist’s, Pathologist’s and Physiotherapist’s fees.
• Registered Private Doctor’s fees and the cost of prescribed drugs and dressings.
• X-rays, Electrocardiograms, Encephalograms, Audio grams, Radiotherapy or Chemotherapy.
• Surgical appliances prescribed by a Registered Medical Practitioner.
• Charges arising from the use of an ambulance, cost of other transport or air fares for journeys within Kenya, incurred in cases of emergency in an attempt to save human life.
• For the Insured Person’s maintenance in any Hospital or Nursing home or Sanatorium.
• For fees arising from the attendance of a qualified Nurse at the residence of the Insured Person, when confined to bed by a doctor’s directive.

General Policy exclusions

• Period of Cover - Annual
• Eligible Members Employee, Spouse and dependant
• Children (must be biological children or legally adopted)
• Age limits - 0-6 months – 65 years (18 Years for children but can be extended to age 25 if the child is a student and residing with the parents).
• Waiting period (new members only) - 14/28 days after cover commences.
• Claims notification period - Up front or within 48 hours on admission/60 days of illness
• Visits abroad - Up to 6 weeks in any one year.
• Mid-term deletions / Cancellations - No return premium/return premium
• Pre-existing & chronic conditions.
• Congenital (Birth) defects. War and kindred risks. General health check ups.

General Policy Limitations

• Cosmetic surgery unless caused by an accident
• Treatment other than a registered Doctor of medicine.
• Intentional self injury, drunkenness, dissipation, psychoneurosis.
• Racing, Polo, Professional Football, Winter sports, hunting and mountaineering.
• Hearing Aids.
• Expenses recoverable under any other Insurance e.g. NHIF, GPA
• Venereal Diseases (Syphilis, Gonorrhea)
• HIV/AIDS related illnesses
• Dental unless cover is purchased separately as a rider
• Optical unless cover is purchased separately as a rider
• Maternity other than 1st Caesarean Section. However cover for this can be purchased as a rider to cover normal delivery and Maternity related complications

Quotation Requirements

Corporate Clients

1. Name of organisation
2. Population breakdown (Employees & Dependants) including family sizes & ages where possible.
3. Budget
4. Claims experience if previously insured/covered.

Non-Corporate (Individual Policies)

• Names of individuals to be covered
• The dates of birth