UAP Medical Scheme - kmasacco.com

UAP Medical Scheme (Doctors, their relatives and employees)

KMA SACCO LTD

[TIBA INSURANCE AGENCIES] “Serving all Doctor’s Insurance needs”

A Partner with a Remedy for Financial Security

"Has no waiting period"

Highlights of UAP Scheme • Has served doctors medical insurance needs for over 10 years by providing

superior benefits with no waiting periods at affordable rates. • Inpatient benefits is the main cover. However, a member can add to the main

cover any/two/all of the following benefits; maternity, outpatient and COVID 19 inpatient treatment.

• All medics, their families, relatives and their employees are eligible to join the scheme.

• The cover runs from 8th June to 7th June every year and one can only join between 8th June and 7th August i.e. a 2 month window period.

• Person(s) from birth to sixty-four (64) years can join the scheme. Existing members remain in the scheme and members above 75 years have to be declared at renewal.

• Dependants include spouse, own children, legally adopted and foster children aged from birth to 18 years. Children over the age of 18 but below 25 years will be covered under their families if proof of schooling is provided.


Services Covered Under Inpatient and Day Patient Below services are catered for under inpatient hospitalization and day patient; a) Hospital Accommodation Charges. b) Doctor’s fees; Physician, Surgeon & Anesthetist. c) ICU/HDU and Theatre charges. d) Drugs/Medicines, Dressings and Internal Surgical appliances. e) Pathology, X-ray, Ultrasound, ECG and Computerized Tomography (CT), PET Scan, MRI Scans. f) Radiotherapy and Chemotherapy. g) In-patient Physiotherapy. h) Emergency Road and Air Evacuation subject to overall cover limit. i) Day care surgery. j) Home nursing care.


Inpatient-Services Covered under inpatient and Day Patient Cover Limit (Per Family)

4Emergency Evacuation Within East

Africa Air Ambulance & Road Ambulance

5 Acute Illnesses, and Accidents Full Inpatient Limit

Lodger Fee for Accompanying

Parent/Guardian

Bed

1

2

3

CAT A -Kshs.10,000,000

CAT B -Kshs.7,500,000

CAT C -Kshs.5,000,000

CAT D -Kshs.4,000,000

CAT E -Kshs.3,000,000

CAT F- Kshs.2,000,000

CAT G-Kshs.1,000,000

CAT H-Kshs.500,000

Standard Private Room for members

above 2m Kshs. 20,000/=

General Ward Bed for members

below 2m Max Kes 11,000/=

Children 12 Years and below

Overall Limit


Inpatient-Services Covered under inpatient and Day Patient

6Pre-existing conditions and Chronic

illnesses

CAT A-C 10% of the IP.CAT D-G Kshs.

500,000

CAT H Kshs. 150,000

7

HIV BENEFIT

The client shall enjoy a HIV/AIDS

benefit of 50% of the annual cover

limit taken per grade per family per

annum

maximum Ksh.500, 000 for CAT A to

G and Kshs. 150,000

per family per annum for CAT H. The

benefit shall also offer

one (1) month’s supply of ARV’s at

discharge.

CAT A- G: 50% of Overall

Limit, Max. 500,000

CAT H: 150,000

8 Organ Transplant (cost of donor or securing

the organ is excluded) Kes 400,000

9 Newly Diagnosed Chronic illnessesFull Inpatient Limit, Maximum Kes

5,000,000

10 Psychiatric and Psychological IllnessesKes 150,000

11

Post Hospitalization 21 days after

discharge

(On Reimbursement)Kes 25,000

Contd.


Inpatient-Services Covered under inpatient and Day Patient 12 Congenital Conditions Kes 150,00013 Neo-natal and prematurity Kes 150,000

14 Non - accidental dental in-patient illnesses. Kes 200,000

15Non - accidental Ophthalmic in-

patient illnesses, includes cover for laser treatment.Kes 200,000

16Accident Related Dental and

Ophthalmic treatment Full Inpatient Limit

17External medical supportive

appliances e.g. wheel chairs. Kes 150,000

18 Last Expense Kes 100,000 Per Person

19 Passive War /Terrorism and Political

Violence treatments Kes 500,000

20Home Nursing (Subject to Pre-

authorization) Kes 500,000

Contd.


Inpatient-Services Covered under inpatient and Day Patient 21 First Ever Emergency Caesarean

Section Kes 200,000

22 Maternity Complications before &

after delivery provided This benefit

applies only when maternity is

purchased.A separate pre-

authorization is provided outside of

the

maternity benefit.This benefit cannot

be used as a substitute for maternity

if the mate

CAT A-D Kshs. 200,000

Ambulance Services;Emergency

only

Covered subject to pre-

authorization.

Covid-19 Inpatient scheme benefitsCovered subject to additional

premium payment upon inception of

23

Contd.

Covid-19 Rates

Limit 500,000 1,000,000 2,000,000 3,000,000

Rate Per Person 1,674 2,009 2,678 3,348


Inpatient-Services Covered under inpatient and Day Patient Inpatient Cover

Benefit Limit Family Size RATE Benefit Limit Family Size RATE Benefit Limit Family Size RATE Benefit Limit Family Size RATE

M 57,212 M 53,939 M 52,319 M 51,591

M+1 83,402 M+1 79,036 M+1 76,326 M+1 75,090

M+2 105,662 M+2 100,861 M+2 97,711 M+2 96,041

M+3 126,832 M+3 121,485 M+3 117,791 M+3 115,681

M+4 144,509 M+4 139,054 M+4 135,250 M+4 133,067

M+5 162,186 M+5 156,622 M+5 152,706 M+5 150,451

M+6 179,865 M+6 174,192 M+6 170,164 M+6 167,834

M+7 197,543 M+7 191,760 M+7 187,624 M+7 185,216

M+8 215,220 M+8 209,330 M+8 205,083 M+8 202,600

M+9 237,899 M+9 231,381 M+9 226,506 M+9 223,572

M+10 257,202 M+10 250,407 M+10 245,253 M+10 242,118

M+11 276,507 M+11 269,432 M+11 263,999 M+11 260,664

M+12 295,810 M+12 288,457 M+12 282,745 M+12 279,210

M+13 315,113

Benefit Limit Family Size Benefit Limit Family Size Benefit Limit Family Size Benefit Limit Family Size

M 50,864 M 47,480 M 40,931 M 32,940

M+1 73,853 M+1 69,957 M+1 55,770 M+1 45,362

M+2 94,369 M+2 90,036 M+2 69,304 M+2 57,469

M+3 113,570 M+3 108,803 M+3 81,960 M+3 68,636

M+4 130,883 M+4 126,044 M+4 93,311 M+4 78,867

M+5 148,198 M+5 143,283 M+5 104,656 M+5 89,096

M+6 165,511 M+6 160,524 M+6 116,005 M+6 99,324

M+7 182,821 M+7 177,767 M+7 127,352 M+7 109,552

M+8 200,132 M+8 195,007 M+8 138,701 M+8 119,782

M+9 220,652 M+9 215,072 M+9 152,159 M+9 130,011

M+10 239,000 M+10 233,221 M+10 164,192 M+10 140,240

M+11 257,348 M+11 251,372 M+11 176,224 M+11 150,469

M+12 275,696 M+12 269,522 M+12 188,256 M+12 160,697

Inpatient 1,000,000 Inpatient 500,000

Inpatient 7,500,000 Inpatient 5,000,000 Inpatient 4,000,00010,000,000Inpatient

3,000,000Inpatient Inpatient 2,000,000

Contd.

Maternity Cover


Caters for normal delivery, elective and subsequent caesarean sections. It also covers maternity related complications unless a separate maternity related complications benefit is purchased.

Maternity and first ever emergency caesarian section benefits are mutually exclusive.

Scope Limit

Overall Limits

Normal Delivery, Elective &

Subsequent Caesarean

sections

Kes.100,000/= per family for

principal member and spouse

only.

Rates

Maternity

100,000 (stand

alone Cat 4M

and above

only)

M 25,314

Outpatient


Scope Limit

Overal Limit Kes.150,000/= per familyMedical Check-Ups(Member & Spouse) Kes.10,000 per family

Pre-existing &Chronic Conditions &

Illneses,including HIV,Cancer &

Diabetes To Full Outpatient Limit ARVs covered

Vaccines KEPI & Baby Friendly covered.

Supplements Covered where they have

direct actionin managing a diagnosed

condition.

On Pre-authorization relevant to

condition.

External appliances e.g. ankle

braces,knee braces as medically

indicated

On Pre-authorization relevant to

condition.

Services covered under Medical check-ups.

Where a medical check-up benefit is available, below are covered; Physical

exam,Urinalysis,Haemogram,Blood sugar,ECG,Lipid Profile,PAP Smear,PSA

mammogram.


Outpatient

M 49,239

M+1 90,056

M+2 106,721

M+3 128,316

M+4 146,424

M+5 150,674

M+6 150,674

M+7 150,674

M+8 150,674

M+9 150,674

M+10 150,674

M+11 150,674

M+12 150,674

150,000Outpatient

Contd.


COVID-19 Testing and Treatment • Covid-19 testing and outpatient treatment to be covered within normal

outpatient cover. • Covid-19 Inpatient treatment to be covered both in private and public

hospitals up to Covid-19 Limit issued. • Covid-19 inpatient cover is a rider to the basic inpatient cover.

Limit provided +Rates

Inpatient LimitCovid 19 Limit

provided per family

Rate Per

Person

10,000,000 3,000,000 3,348

7,500,000 3,000,000 3,348

5,000,000 3,000,000 3,348

4,000,000 3,000,000 3,348

3,000,000 3,000,000 3,348

2,000,000 2,000,000 2,666

1,000,000 1,000,000 2,009

500,000 500,000 1,674


Territorial Limit

• Kenya, Uganda, Rwanda, and South Sudan.

• In case of services sought outside these regions, or where a valid provider is not found as regards emergency medical need, the insured member’s claims shall be settled on reimbursement subject to reasonable and customary rates as determined by UAP. Members can submit claims accessed within the first 60 days outside of the territorial scope. The claims must be submitted within 30 days from the date of service.


Overseas Referral • Treatment(s) not available locally will be to a medical facility approved by

the company and excludes Western Europe, Australia, USA, South Africa and Canada.

• UAP has credit facilities in India, and the referral must be approved by the company and respective government department.

• Air fare for patient and accompany person on economy class is payable from the overall cover limit (inpatient), while accommodation and related costs such as taxi are excluded.

• Air fare shall be paid by member and reimbursed by UAP, unless where the UAP has been able to procure a ticket.

• Lodger fee is payable for children within the lodger fee age.

For all your medical insurance needs. Get in touch with us through;

Email: [email protected] Tel: 0715 993874 /0741728292/ 0704 825 300

or visit us at KMA Centre, 4th Floor

Mara RD,Upperhill, Nairobi Website: www.kmasacco.com

UAP Medical Scheme - kmasacco.com

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