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Scope of Cover
Our medical product is an inpatient cover for schemes that have ten (10) principal members and above. We are however willing to quote for smaller companies with less than ten staff members.
The cover indemnifies the insured subject to the overall limit in respect of medical expenses necessarily incurred as the direct result of an insured falling ill or sustaining accidental bodily injury whilst the Insured is admitted as an in-patient in a hospital.
Medical expenses shall include:
- Hospital accommodation in a standard single room on total cover limit of Kenya shillings Two Million (Kshs. 2 Million) and above, accommodation in a general ward bed for overall cover limits below Kenya shillings Two Million (Kshs. 2 Million)
- Doctor’s fees (Physician, surgeon and anaesthetist)
- Operating theatre charges including same day surgery
- Pharmacy, laboratory and other investigation charges
- Physiotherapy
Eligibility Criteria
Any person who is aged between 3 months and 64 years is eligible to join the scheme. The policy will cover dependants, including spouses, own children, legally adopted and foster children aged 3 months and 21 years, or up to 25 years as single members at a discount if there is proof that they are in school and dependent on the parent.
All members aged 45 years and above will be on accident cover only until we receive a detailed medical report and/or examination result.
Waiting Period
There is a waiting period for twenty-eight (28) days) for all non-surgical claims and 120 days for all surgical claims in respect of the Insured, unless the insured is transferring from an existing medical scheme.
Post Hospitalization Benefit
The cover will also provide a post-hospitalization benefit equivalent to ten percent (10%) of the total inpatient bill or Kenya shillings Twenty Five Thousand (Kshs. 25,000/-) whichever is less. This benefit shall cover a period of three weeks after discharge, and be on reimbursement basis.
Funeral Expenses Cover
Should the insured or dependant die during the currency of this policy the company will upon receipt of satisfactory proof of death in writing pay the amount of Kshs. 50,000/- to the designated beneficiary entitled thereto, subject to the overall limit of cover.
Evacuation
The Company will indemnify the Insured in respect of Medical Expenses incurred for the evacuation of the Insured from the point of accident or illness to the Hospital provided that the evacuation leads to inpatient hospitalization.
Cover limits of Kshs. 2,000,000/= and above are entitled to road and air evacuation, including emergency air evacuation for treatment overseas where deemed medically necessary
Cover limits of Kshs. 1,000,000/= to Kshs. 2,000,000/= are entitled to road and air evacuation.
Cover limits below Kshs. 1,000,000/= are entitled to road evacuation only unless air evacuation has been purchased separately
Enhancements
The insured can buy back some policy limitations and exclusions to a sub limit within the overall policy cover:
- Eligibility age
- Maternity cover
- HIV AIDS
- Chronic conditions, e.g. diabetes and hypertension
- Pre-existing conditions
Service Providers
The insured will access provision of medical service from the preferred list of service providers is available on request. A credit facility has been arranged with the providers so the insured will never get to see the bill. We welcome any suggestions from our clients on the panel of preferred providers.
Identification
Our clients will be provided with a photo card for use while accessing services at the appointed service provider facilities.
Claims Procedure
The insured is required to give us prior notification for all cases of planned surgery and/or admission for pre-authorization. Emergency admissions will be authorized at admission. Reimbursement of medical expenses will only be made in cases of a genuine emergency where an appointed service provider is not accessible or available.
Excess
In some instances an excess will apply to be paid for each claim by the insured as specified.
Exclusions
A complete list of exclusions can be provided on request. Costs arising from these shall not be payable by Pacis Insurance Company Ltd.
Premium Quotation
We will be glad to provide a premium quotation on receipt of the following information:
- Scheme size
- Family size and number
- Age profile
- Cover requirements
- Claims experience
The premiums are on annual basis and are payable annually in advance once cover is accepted.
We will be glad to answer any queries you may have on the product.
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