MEDICAL BENEFITS SUMMARY

Client Name: OUTSOURCE TECHNIQUE LIMITED

Insurer: CIC Insurance Company
Period of Insurance: 26TH June 2019 to 25th June 2020
Postal Address: P.O. Box 12702-00100
Contact Person Loise. G. Kariuki
Email loise@otl.co.ke
Physical Location 96 Riverside Lane off Riverside Drive

The overall benefit limits are as detailed in the table below;

Benefit Scope Limit

Inpatient Per Family 750,000
Outpatient Per Family 100,000
Maternity Per Family 200,000
Last expense Per Family 75,000

*All benefits are insured.

All waiting periods will be waived.

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 A. INPATIENT COVER
BENEFITS
Overall Inpatient Limit
Overall Services Offered
Accommodation
Pre-existing, Chronic and
HIV/AIDs cover
Congenital & Neonatal
Conditions
1st Ever Emergency Caesarean
section
Maternity – (Normal delivery,
Subsequent & Elective
Caesarean sections, Maternity
related complications)
Psychiatry
Inpatient non-accidental dental
cover
Inpatient non-accidental optical
cover
Post Hospitalization benefit
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LIMITS SCOPE
As per table above Accidents and illnesses
The services below are covered. For conditions with sub-limits, the Sublimit of Inpatient
services shall be covered up to the specified sub-limits
• Hospital Accommodation Charges (Bed charges net of
NHIF)
• Doctor’s (Physician, Surgeon & Anesthetist) fees.
• ICU/HDU and Theatre charges.
• Prescribed 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
• Organ transplant
 Ward bed Sublimit of Inpatient
 Admission is subject to availability at the time of admittance
 Cost of upgrade to a higher room limit will be borne by the
member
 Bills will be paid net of NHIF & members not registered
will bear the NHIF cost
Kshs. 500,000 per family per annum. Sublimit of Inpatient
Newly diagnosed Chronic conditions will be covered up to the full
inpatient limit per family within the first year and revert to the above
sublimit upon renewal.
Kshs. 300,000 per family per annum Sublimit of Inpatient
Will cover for any treatment as a result of birth defects or any
condition that is traced to developmental stages before birth. Also
covers treatment for babies born prematurely (before 36 weeks) &
ailments before discharge
Kshs. 250,000 per family per annum for principal member & spouse 1st CS and Maternity
as a sublimit within the Inpatient Limit are mutually exclusive
Kshs. 200,000 per family per annum and cannot be claimed
Applicable for principal members and spouses only. at the same time
Covers for treatment as a result of mental disorders up to Sublimit of Inpatient
20% of the inpatient per family
Kshs. 300,000 per family per annum Sublimit of Inpatient
-Excludes cost of cleaning, filings, extractions, crowns, caps, etc.
Covers for inpatient treatment as a result of an eye related illness, Sublimit of Inpatient
including removal of cataracts up to Kshs. 300,000 per family
-Excludes laser eye surgery
-Covers for follow-up reviews following an admission and must be Sublimit of Inpatient
related to the cause of the admission.
 -Scope of cover includes change of materials/ bandages, consultation,
physiotherapy.
-The benefit operates on reimbursement basis (100% subject to
reasonable and customary charges)
-Covered up to Kshs. 20,000 for 4 weeks after discharge.
Lodger Fees for accompanying Covers for accommodation and meals for a guardian accompanying a Sublimit of Inpatient
guardian dependant below the age of 12 years
Last Expense -A cash benefit payable to the nominated beneficiary. Stand-alone
-Benefit is payable within 48 hours, subject to provision of complete
documentation.
-It shall exclude death as a result of excluded / exempted conditions.
-Repatriation of mortal remains is not covered
Kshs. 75,000 per family
Territorial Limit Kenya, Uganda, Tanzania, Rwanda and South Sudan
Smart Card usage is dependent on cross country portability. Where portability does not exist,
then member will pay & claim
Cover Outside Territorial Limit Covered on reimbursement up to 60 days per trip for emergency illnesses and accidents
occurring when a member is on business or leisure travel upon prior notification to the
company.
Overseas Referral  CIC shall allow overseas referral for cases. CIC has obtained credit facilities with some
select hospitals in India. Members of the scheme have these hospitals at their disposal
on credit terms. Should a member be referred to a hospital where CIC does not have
credit facilities, the subsequent claim shall be settled on reimbursement basis.
 Elective overseas referral shall be settled on reimbursement and subject to a local
equivalent.
 Overseas referral excludes referral to USA, Western Europe, Canada and Australia
Evacuation Emergency road and air evacuation covered subject to pre-authorization and up to the overall
inpatient limit/ sublimit if applicable.
Home nursing car Provided for within inpatient cover at no additional premiums
Terrorism, Political war and Covered up to the full limit subject to the claimant not being an active participant.
Violence

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 B. OUTPATIENT COVER
The below are covered under the outpatient benefit:

Overall Benefit As per table above

Consultation Up to the overall cover limit as per negotiated rates with providers. Specialists (except for
the appointed Paediatricians and Obstetricians) will only be seen on referral from General
Practitioners for outpatient services.
Drugs, Tests, Radiology Up to the overall cover limit
Pre-Existing, Congenital, Chronics Covered to the full limit
&HIV/AIDS
Antenatal & Postnatal care Covered
Vaccines KEPI & KEPI baby friendly vaccines for babies from Birth to 1.5 years up as listed below;
a) BCG – Tuberculosis
b) HEP B – Hepatitis B
c) HIB – Meningitis (Haemophilus influenzae type B)
d) OPV – Oral Polio Vaccine
e) MMR – Measles Mumps Rubella
f) IPV – Injectable Polio Vaccine
g) DTap – Diphtheria Tetanus a cellular pertussis
h) DT – Diphtheria Tetanus
i) ROTA virus
Medical Check-ups Covered for principal members & spouses up to Kshs 10,000 per family within outpatient
limit
Co-pays Not applicable

C. EXCLUSIONS

• Cosmetic surgery unless caused by accident

• Weight management treatments and drugs.
• Hazardous sports e.g., bungee jumping, paragliding
• Family planning/infertility related treatment
• Treatment other than by registered medical practitioner
• Self-referred or self-prescribed treatment.
• Self-prescribed scaling, crowns, bridges, orthodontics, and dentures.
• Nutritional supplements unless prescribed as part of medical treatment.
• Alternative treatment - Chiropractors, Acupuncturist, Herbalist.
• Drunkenness, drug addiction, Intentional self-injury, attempted suicide.
• War and Kindred risks (whether war be declared or not).
• Participation in Riot, Strike and Civil commotion.
• Naval, Military or Air force operations.
• Expenses recoverable under any other insurance e.g. NHIF, GPA, WIBA.
• Beauty treatment in nature cures clinics or health hydros.
• Diagnostic equipment (e.g. Glucometers, BP machines etc) and hearing aids.
• Experimental treatment.
• Laser surgeries and correction of eye sight.

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 D. ELIGIBILITY, IDENTIFICATION & ADMINISTRATION
Item
Eligibility Principal Members:
Joining age: 18 to 66 years. Existing members remain in the scheme up to the age of seventy (70).
Dependents:
 1 legal spouse between age 18 to 66 at entry
 Own children, legally adopted and foster children aged from birth to 18 years. Children over the age of 21
but below 25 years will be covered under their families with proof of schooling
New born:
 Must be a term baby, at least 37 weeks at birth. Cover incepts from birth.
 Premature babies and neonatal illnesses shall be covered under the neonatal benefit

Identification Smart Cards shall be provided at no additional cost for new members. Cost of replacement shall be Kshs. 500/=
per card for lost & broken cards
Claims  A member will be required to fill a claim form to be used by the provider when forwarding bills. In
Administration case of referral the provider will also give a claim form. All claims will be settled directly to the
service providers. In any case of allowable reimbursement, we will refund 100% of the costs subject to
reasonable & customary charges.
 Members who choose to be admitted by non-panel doctors where CIC panel doctors are available will
be reimbursed up to 80% of the customary and reasonable amount. Note that this shall be waived in
emergency situations or in cases where access to our access to CIC providers has been compromised.
 Outpatient reimbursement claims shall be refunded 100%, subject to customary and reasonable rates.
All invoices sent for reimbursement must have the below attached;

 Claim form duly signed by both the member and the provider and stamped by the provider.
 Copy of prescription, Laboratory tests and X-ray services done with breakdown of each if not
indicated in the claim form.
 Receipts of payment made stamped by the provider.

 Maximum allowable time for submitting claims shall be 60 days.

Premiums -Premium shall be refunded for mid-term exits on pro-rata basis subject to no claims recorded.
Invoicing -All premiums are refundable
-Additional members’ premiums shall be prorated

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E. PREMIUM TABLE

Benefit Inpatient Outpatient Maternity Last expense

Limit 750,000 per family 100,000 per family 200,000 per family 75,000 per family
M 24,912 36,021 23,265 750
M+1 36,286 56,261
M+2 42,756 66,932
M+3 48,272 77,424
M+4 54,293 87,834
M+5 60,958 93,100