MEGAHEALTH
INSURANCE PROPOSAL
PARENTS & SENIORS
Friday, April 28, 2023
Dear Sir/Madam,
GROUP MEDICAL INSURANCE SCHEME – PARENTS & SENIOR MEMBERS
We have pleasure in setting out below, a description of our proposal based on the terms contained in
your request: -
Scope of Cover
1. Members of up to 80 years are eligible for cover.
2. Covid 19 inpatient and outpatient covered within the overall limits of each benefit respectively.
3. The waiting periods before cover commences are listed below.
a) Thirty (30) days general waiting period.
b) Three (3) months waiting period for pre-existing & chronic conditions & HIV/AIDS,
congenital & prematurity conditions, organ transplant, cancer, inpatient non accidental
related eye treatment, inpatient non accidental related dental surgery/treatment
a. Coverage for Hospitalization (Inpatient Cover)
• Hospitalization Treatment & Services
All necessary and eligible medical treatment and services provided by or on the order of a
Physician to the member when admitted as a registered patient to a hospital
Cover includes nursing care, Intensive care, diagnostic, laboratory or other medically necessary
facilities and services, doctor’s bills, anesthetist’s bills, operating theatre fees, pharmacy,
laboratory, and investigations. This shall include discharge drugs for up to 30 days.
Hospital accommodation subject to NHIF rebate shall covered as indicated below.
Inpatient Limit Bed Limit
10,000,000 SPR up to Kshs 16,500
5,000,000 SPR up to Kshs 13,500
3,000,000 SPR up to Kshs 12,500
2,000,000 SPR up to Kshs 12,000
1,000,000 General Ward Bed
• Day Care Surgery or Treatment
When an insured person is admitted to a hospital and uses a Hospital bed but does not stay
overnight
• Local Emergency Road & Air Ambulance Service
Covers transportation of a seriously ill or injured person from the scene of the accident or medical
event to the nearest hospital or health facility, in order to receive the urgent medical attention
needed.
• Pre-Hospitalization Diagnostic Services
Laboratory, radiology or other necessary medical diagnostic procedures ordered by a physician,
and which results in the member being admitted (on the same day)
• Parent Accommodation
Hospital accommodation costs in respect of a guardian staying with an insured person who is
under the age of 12 years and is admitted to a Hospital as an Inpatient.
• Reconstructive Surgery
Reconstructive surgery following an accident or following surgery for an eligible medical condition
b. Outpatient Services
Members of the scheme will have a choice of medical attendant, but treatment will be restricted to
medical practitioners registered with the Kenya Medical Practitioners & Dentists Board.
Cover will be on cashless basis with our providers and 100% reimbursement panel and non-
panel providers.
The benefit shall cater for medically necessary and eligible medical treatment provided to a member who
is not a registered Inpatient at a Hospital. This shall include.
i. General Outpatient Services
Outpatient services provided by or on the order of a Physician who is licensed as a general
practitioner (One PSA and Pap smear for the employees and their spouses are also included)
ii. Specialist Outpatient services
Outpatient services provided by or on the order of a Physician who is licensed as a specialist or
consultant and to whom the member has been referred by a general practitioner
iii. Outpatient Laboratory and Radiology services
Laboratory testing, radiographic and procedures used to diagnose or treat medical conditions
iv. Outpatient Prescription Drugs and dressings
Drugs and medicine, the use of which is restricted to the order of a physician and prescribed for
use by the member as an outpatient
v. Other Outpatient services
Includes but not limited to Physiotherapy, outpatient surgical operations
c. Dental Cover
This cover is available on credit and re-imbursement basis
The scope of the dental cover includes the following services:
• Dental consultations and gum diseases
• Extractions
• Fillings (except precious metals)
• Scaling
• Dental X-Rays
• Dental Prescriptions
d. Optical cover
This cover is available on credit and re-imbursement basis
The scope of the optical cover includes the following services:
• Eye glasses
• Routine optical consultations
• optometrist consultations and eye examinations
• Prescription of frames. Frames are limited to Kshs. 10,000 a prescription
• Prescribed lenses and replacement of lenses
• Optical Prescriptions
Note - Frames are limited to one pair for every two years
e. Last / Funeral Expense Cover
The sum assured of KES 100,000 per family will be payable within 48 hours of confirmation of death
of a member of the scheme by the employer. This will be covered within the inpatient limit.
f. COVID-19 TREATMENT
SCOPE OF COVER
The cover caters for all necessary medical treatment and services and includes nursing care, Intensive
care, diagnostic, laboratory or other medically necessary facilities and services, doctor’s bills,
anesthetist’s bills, operating theatre fees, pharmacy, drugs, laboratory, and investigations.
a) OUTPATIENT TESTING AND TREATMENT PROCESS
The cover caters for COVID-19 and related Complications. It is an enhancement of the main cover.
• Outpatient testing for symptomatic members covered within Outpatient benefits and shall be
covered to Kes.15,000/-
• All COVID-19 tests must be conducted at Jubilee Health designated testing facilities.
• In line with Government protocol, the tests must be prescribed by a doctor and the patients
should meet the Case definition, (i.e., flu-like symptoms).
• The Jubilee Health panel of providers shall provide treatment and COVID-19 testing
• All COVID-19 treatment and testing are subject to Approval/Pre-authorization by Jubilee Health
Insurance.
b) ADMISSION AND TREATMENT PROCESS
Upon confirmation of COVID-19 test results by the authorized testing facilities.
• Where a member requires hospitalization, the member shall be transferred for admission to their
preferred hospital (Public or Private) as per the agreed provider panel.
• If the member is asymptomatic and as guided by a licensed doctor, they will be required to isolate
themselves at home and as per the government directives. See the Home Protocol section for
more details.
• For private hospitals, the normal Jubilee Health admission process applies.
• Frequent Management and reporting on will be done through the Jubilee care management
team
• Inpatient treatment shall be covered within our panel of providers.
HOME PROTOCOL
Most people with COVID-19 will have mild illness and recover at home without hospitalization. While
home isolating, it is important to remain in quarantine except where one requires to go for medical care.
• Stay home and stay in touch with your doctor.
• Monitor your symptoms. Main symptoms of COVID-19 include fever, cough and difficulty
breathing among other symptoms.
• Seek emergency treatment when you experience any of these warning signs; trouble breathing,
persistent pain or pressure in the chest, new confusion, inability to wake or stay awake, bluish
lips or face. Note that this list is not exhaustive, contact your doctor for a full list of symptoms.
• Call ahead before visiting your doctor.
NB: This is only a summary of the COVID-19 and Complications benefits, for more details refer to
the policy document.
Enhanced II cover – including Pre-existing, Chronic conditions & HIV Opportunistic
Infections
Sub-Benefits under the Enhanced II cover
▪ Pre-existing, chronic and HIV (including ARVs) conditions will be covered within the inpatient
limit as indicated below.
Inpatient Limit Pre-existing, chronic and HIV
10,000,000 1,000,000.00
5,000,000 600,000
3,000,000 500,000
2,000,000 400,000
1,000,000 300,000
▪ Pre-existing, chronic and HIV (including ARVs) conditions will be covered up to the full outpatient
limit
▪ Post hospitalization cover with a sub limit Kshs 20,000 within the inpatient limit, subject to a
maximum of three weeks after discharge.
▪ Pre-terms and congenital conditions will be covered up to Kshs 100,000 within the inpatient
limit
▪ Maternity benefits shall be covered as follows:
o First emergency caesarean section in the lifetime of a female employee/spouse is
covered within the inpatient limit up to a sub limit of Kshs.150,000
o Normal deliveries including the related complications: covered within the maternity limit
o C-section deliveries including the related complications: covered within the maternity
limit
o Pre-natal and post natal care: Covered within the outpatient limit
▪ Routine Immunizations (KEPI) and Baby Friendly Vaccines will be covered within the
outpatient limit for children up to 1.5 (one and a half) years
▪ Inpatient dental and optical hospitalization resulting from an accident will be covered
within the inpatient limit.
▪ Inpatient dental and optical hospitalization resulting from an illness (apart from Laser
eye Surgery) will be covered for up to Kshs. 100, 000 within the inpatient limit.
▪ General health check-ups (including annual PSA and pap smear) will be covered within
the outpatient limit up to a shared limit of Kshs 10,000 for employees and spouses
▪ Psychiatric illness within the inpatient limit.
▪ Counselling covered upon referral by a general practitioner within outpatient.
▪ Mode of identification at the providers: Smart cards at a cost of Jubilee Wellness Card.
Summary of Exclusions under the Enhanced II cover:
▪ Pregnancy confinement, childbirth, maternity benefits, abortion, miscarriage, ante- or postnatal
care, caesarean operation (except for a first caesarean operation which must be certified by an
independent medical examiner as being of vital necessity to the health of the mother and/or
child), expenses resulting from a pregnancy that existed at the inception of this insurance.
▪ Family planning and fertility treatment i.e. costs of treatment related to infertility and impotence.
▪ Intentional self-injury, suicide or attempted suicide, intoxication, drunkenness
▪ Expenses recoverable under any other insurance
▪ Family planning and fertility treatment i.e. costs of treatment related to infertility and impotence.
▪ Cosmetic surgery, massage, or beauty treatment
▪ Naval, Military and Air force operations
▪ Riding or driving in any kind of race
▪ Participation in extreme sports
▪ Stays at sanatoria, old age homes, places of rest etc.
▪ Injury sustained while in a state of insanity
▪ War, invasion, civil war, riots, or act of terrorism
▪ Chiropractors, acupuncturists, or herbalists’ treatment
▪ Unrecognized medical practitioner, provider, or facility
Parents Annual Rates Parents Q 4 Rates Parents Q 3 Rates Parents Q 2 Rates Parents Q1 Rates
Inpatient Premium Per Family Inpatient Premium Per Family Inpatient Premium Per Family Inpatient Premium Per Family Inpatient Premium Per Family
Limit Cover Type One parent Two Parents Limit Cover Type One parent Two Parents Limit Cover Type One parent Two Parents Limit Cover Type One parent Two Parents Limit Cover Type One parent Two Parents
10,000,000 Shared 94,672 175,997 10,000,000 Shared 26,035 48,399 10,000,000 Shared 52,070 96,798 10,000,000 Shared 78,104 145,197 10,000,000 Shared 94,672 175,997
5,000,000 Shared 94,672 175,997 5,000,000 Shared 26,035 48,399 5,000,000 Shared 52,070 96,798 5,000,000 Shared 78,104 145,197 5,000,000 Shared 94,672 175,997
3,000,000 Shared 79,225 147,280 3,000,000 Shared 21,787 40,502 3,000,000 Shared 43,574 81,004 3,000,000 Shared 65,361 121,506 3,000,000 Shared 79,225 147,280
2,000,000 Shared 69,413 129,040 2,000,000 Shared 19,089 35,486 2,000,000 Shared 38,177 70,972 2,000,000 Shared 57,266 106,458 2,000,000 Shared 69,413 129,040
1,000,000 Shared 56,383 104,817 1,000,000 Shared 15,505 28,825 1,000,000 Shared 31,011 57,649 1,000,000 Shared 46,516 86,474 1,000,000 Shared 56,383 104,817
Outpatient Premium Per Family Outpatient Premium Per Family Outpatient Premium Per Family Outpatient Premium Per Family Outpatient Premium Per Family
Limit Cover Type One parent Two Parents Limit Cover Type One parent Two Parents Limit Cover Type One parent Two Parents Limit Cover Type One parent Two Parents Limit Cover Type One parent Two Parents
200,000 Shared 54,488 101,294 200,000 Shared 14,984 27,856 200,000 Shared 29,968 55,712 200,000 Shared 44,953 83,568 200,000 Shared 54,488 101,294
150,000 Shared 50,814 94,464 150,000 Shared 13,974 25,978 150,000 Shared 27,948 51,955 150,000 Shared 41,922 77,933 150,000 Shared 50,814 94,464
100,000 Shared 40,773 75,797 100,000 Shared 11,212 20,844 100,000 Shared 22,425 41,688 100,000 Shared 33,637 62,532 100,000 Shared 40,773 75,797
75,000 Shared 37,490 69,695 75,000 Shared 10,310 19,166 75,000 Shared 20,620 38,332 75,000 Shared 30,930 57,499 75,000 Shared 37,490 69,695
Dental Premium Per Family Dental Premium Per Family Dental Premium Per Family Dental Premium Per Family Dental Premium Per Family
Limit Cover Type One parent Two Parents Limit Cover Type One parent Two Parents Limit Cover Type One parent Two Parents Limit Cover Type One parent Two Parents Limit Cover Type One parent Two Parents
30,000 Shared 12,714 23,636 30,000 Shared 3,496 6,500 30,000 Shared 6,993 13,000 30,000 Shared 10,489 19,499 30,000 Shared 12,714 23,636
20,000 Shared 9,154 17,017 20,000 Shared 2,517 4,680 20,000 Shared 5,035 9,360 20,000 Shared 7,552 14,039 20,000 Shared 9,154 17,017
15,000 Shared 7,374 13,708 15,000 Shared 2,028 3,770 15,000 Shared 4,056 7,540 15,000 Shared 6,084 11,309 15,000 Shared 7,374 13,708
10,000 Shared 4,916 9,139 10,000 Shared 1,352 2,513 10,000 Shared 2,704 5,026 10,000 Shared 4,056 7,540 10,000 Shared 4,916 9,139
Optical Premium Per Family Optical Premium Per Family Optical Premium Per Family Optical Premium Per Family Optical Premium Per Family
Limit Cover Type One parent Two Parents Limit Cover Type One parent Two Parents Limit Cover Type One parent Two Parents Limit Cover Type One parent Two Parents Limit Cover Type One parent Two Parents
30,000 Shared 14,748 27,417 30,000 Shared 4,056 7,540 30,000 Shared 8,111 15,079 30,000 Shared 12,167 22,619 30,000 Shared 14,748 27,417
20,000 Shared 10,510 19,538 20,000 Shared 2,890 5,373 20,000 Shared 5,781 10,746 20,000 Shared 8,671 16,119 20,000 Shared 10,510 19,538
15,000 Shared 8,137 15,127 15,000 Shared 2,238 4,160 15,000 Shared 4,475 8,320 15,000 Shared 6,713 12,480 15,000 Shared 8,137 15,127
10,085
10,000 Shared 5,425 10,085 10,000 Shared 1,492 2,773 10,000 Shared 2,984 5,546 10,000 Shared 4,475 8,320 10,000 Shared 5,425
Covid Benefit
Group Hospitalization Limit 10,000,000
Hospitalization Limit per family (within Inpatient) 500,000 or full IP whichever is lower
Testing Limit per family (Within Outpatient) 15,000
Covid outpatient treatment Covered fully within Outpatient
Premium (Per person) 5,938
Note: Taxes and Levies of 0.45% of the premiums are excluded.
Salient Features:
• Local emergency road and air evacuation for transportation of a sick Member for treatment
from an area where facilities for adequate care do not exist to the next available hospital or
licensed medical facility will be covered within the annual inpatient limit
• Claims related to expenses arising whilst the Member is temporarily abroad and requiring
emergency treatment for an illness or injury that occurs during the period of travel provided that
such period does not exceed six weeks in any one visit will be covered on reimbursement.
Travel and accommodation costs are not covered.
• Treatment costs arising from a condition that warrants treatment overseas because the
treatment is not available in Kenya will be covered on reimbursement. However, the following
overseas hospitals are available on credit. (Under recommendation of the attending doctor
subject to authorization from Jubilee)
• Aga Khan University Hospital - Karachi Pakistan
• Prince Aly Khan Hospital - Mumbai, India
Important Notes:
• Any member / family reaching 100% utilization of any benefit will automatically be discontinued
from receiving credit for that benefit.
• Health talks will be arranged on a regular basis
• All premiums shown are on annual basis and payable annually in advance. ITL (0.2%), IPCF Tax
(0.25%) and Stamp duty have been included in the totals above.
• We have a countrywide network of providers, a selection of which can be availed depending upon
the location of members.
• All premiums must be paid to The Jubilee Insurance Company Ltd and an official receipt
obtained for the same. Jubilee Insurance shall not be liable for any premium payment made to
third parties which does not reach us.
• Our quotation is valid for 30 days
Thank you for giving Jubilee an opportunity to provide a proposal for the medical insurance. Do not
hesitate to contact the team below in case of any query/clarification.
Business Development Team
o Gerishon Njuguna –
[email protected] o Eric Avulala -
[email protected]We look forward to a favorable response to our proposal.
Yours sincerely,
Gabriel Gichinga
Actuarial department - Medical
The Jubilee Health Insurance Limited
