AFYAIMARA

FAMILY COVER
An enhanced medical insurance cover for Families.

DO GREAT THINGS EVERY DAY

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General cover scope
AfyaImara Family cover is an enhanced medical insurance cover for Families.

It covers day and inpatient hospitalization, maternity, outpatient treatment, optical

and dental with enhanced limits for chronic conditions including cancer.

Below are the key enhancements offered by AfyaImara Family Cover;

a) Lifetime cover;
- Once you join, you can renew your cover for life.

b) Wide geographical coverage and Hospital Network

- Access to all of Old Mutual General Insurance Company Ltd’s comprehensive
network of hospitals across East Africa.
- Overseas referral is available for conditions not covered locally on accredited
overseas partners.

c) Convenient
- Air evacuation for cover limits above Kshs 1M
- Road evacuation for all cover limits
- Overseas emergency treatment cover of 60 days for limit on reimbursement
for all cover limits.

d) Affordable
- No excess for inpatient cover
- Instalment premium payments for your inpatient cover
- No claim discount (NCD)

e) Comprehensive benefits
- Inpatient limits from Kes 500,000 to Kes 10,000,000.
- Optional outpatient cover from Kes 50,000 to Kes 200,000. This caters for;
o Routine outpatient services, consultations, diagnostics, drugs and
dressings.
o Routine dental and optical services, including cost of frames, lenses.
o Well baby Clinics.
- Covers pre-existing, chronic conditions & HIV/AIDs
- Cover for prematurity, and neonatal conditions
- Maternity cover within inpatient.
- Negotiated attractive and comprehensive maternity packages that cover
delivery.
- Dental & Optical benefits included within the outpatient cover
- Hospitalization expenses including surgeon, physician, theatre, ICU & HDU
fees
- Home Nursing subject to pre-authorisation up to 90 days from discharge
based on the applicable benefit sublimit.
- Diagnostics and physiotherapists fees, prescribed drugs, dressings, surgical
appliances
- Accommodation costs for parent/guardian accompanying child of 12 years
and below
- Covid-19 coverage.

f) Critical Illness Cover Lumpsum cash pay-out of KES 750,000 upon first diagnosis
of cancer, stroke, heart attack, kidney failure or paralysis

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Inpatient Limits
Waiting
Option I Option II Option III Option IV Option V
Period

Overall Limit 500,000 1,000,000 3,000,000 5,000,000 10,000,000

Standard Standard
General General En Suite
Private Private
Bed Ward / Max Ward / Max / Max Kes
Room / Max Room / Max
Kes 8,000 Kes 10,000 26,000
Kes 18,000 Kes 18,000

Lodger Fee for Accompanying

12 Years 12 Years 12 Years 12 Years 12 Years
Parent/Guardian

Emergency Evacuation Within No waiting Road Road Road & Air Road & Air Road & Air
East Africa period Ambulance Ambulance Ambulance Ambulance Ambulance

No waiting To overall To overall To overall To overall To overall

Accidents
period Limit Limit Limit Limit Limit

28 days illness
To overall To overall To overall To overall To overall
Acute Conditions claims/60days
Limit Limit Limit Limit Limit
surgical claims

28 days illness
Newly Diagnosed Chronic
claims/60days 350,000 700,000 2,000,000 2,500,000 3,500,000
illnesses
surgical claims

Chronic, Pre-existing illnesses,

Congenital Conditions & HIV/ 1 year 250,000 400,000 700,000 800,000 1,000,000
AIDS

Organ Transplant (cost of

donor or securing the organ is
excluded). This is in addition to 1 Year 100,000 200,000 200,000 300,000 500,000
the relevant condition’s benefit
allocation.

Psychiatric and Psychological

1 Year 200,000 300,000 500,000 500,000 700,000
Illnesses

Post Hospitalization 21 Depends on

days after discharge (On the condition 20,000 20,000 30,000 30,000 30,000
Reimbursement) Sub-limit

Neo-natal and prematurity

1 Year 200,000 250,000 400,000 400,000 500,000
conditions.

In patient non-accident related

1 Year 150,000 150,000 200,000 200,000 250,000
dental surgery/ treatment

In patient non-accident related

eye treatments excluding
1 Year 150,000 150,000 200,000 200,000 200,000
surgery for refractive errors and
laser treatment

Accident Related Inpatient

No waiting
Dental and Ophthalmological 500,000 1,000,000 3,000,000 5,000,000 5,000,000
period
treatment

Illness related reconstructive/

plastic surgery (excludes
1 Year 200,000 200,000 250,000 300,000 300,000
cosmetic, obstetrics and
gynecology related)

Non accident related

maxillofacial surgery (Excluding
1 Year 200,000 300,000 400,000 400,000 500,000
routine dental surgery and
dental fixtures)

Gynecological surgery 1 year 200,000 300,000 400,000 400,000 500,000

Cost of purchase of internal

Depending on
and external surgical implants,
the Condition 300,000 300,000 400,000 400,000 500,000
appliances, and prostheses
sub-limit
(excluding dental fixtures)

As per illness/
Last Expense - Per Member (as
Accidents 75,000 100,000 100,000 150,000 150,000
a stand-alone benefit)
Clause

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Inpatient Limits
Waiting
Option I Option II Option III Option IV Option V
Period

Overall Limit 500,000 1,000,000 3,000,000 5,000,000 10,000,000

Passive War /Terrorism and No waiting

300,000 500,000 700,000 1,000,000 1,000,000
Political Violence period

Maternity: Normal Delivery,

Elective & subsequent
Caesarean sections, First Ever
Emergency Caesarean Section, 1 Year 50,000 75,000 100,000 150,000 200,000
Ectopic Pregnancy, Maternity
Complications before & after
delivery

28 days illness
Covid-19 Treatment (moderate
claims/60days 250,000 250,000 250,000 250,000 250,000
cases)
surgical claims

Covid-19 Treatment (Critical

cases requiring ICU/HDU)
28 days illness
This is a cumulative amount
claims/60days 500,000 1,000,000 1,000,000 1,000,000 1,000,000
that will be inclusive of any
surgical claims
amounts already paid for in
the treatment of moderate
inpatient cases

Outpatient Limits
Overall Limit 50,000 60,000 100,000 150,000 200,000

Dental Sub-limit Nil Nil 10,000 15,000 15,000

Optical Sub-limit
Frames can only be replaceable once in
every 2 years up to a sublimit of KES 8,000. Nil Nil 10,000 15,000 15,000
Optical exclusions: Plano, photochromatic,
antiglare lenses

Annual Wellness Check-ups Nil Nil 5,000 10,000 10,000

Vaccines KEPI and KEPI Baby Friendly vaccines are covered.

Pre-existing conditions After 1 year waiting period to the full limit

Antenatal and postnatal visits up to 6 weeks

After 1 year waiting period
from delivery (maximum of 2 ultrasounds)

Supplements Covered where they have

direct action in managing a diagnosed Covered subject to pre-authorization and medical necessity
condition.

Co-Pays:
Hospital Co-Pay

The Nairobi Hospital

Aga Khan University Hospital Nairobi

Pandya Hospital
2,000
The Karen Hospital

AAR Healthcare

MP Shah

All Others 500

Critical Illness cover

Benefit Waiting Period Cash Payout across all Categories

Critical Illness Lumpsum cash pay-out upon first diagnosis

of either cancer, stroke, heart attack, kidney failure or Lumpsum pay-out of KES 750,000 per year
28 days
paralysis. Cover ceases at 65 years. per family

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Premiums
Inpatient Rates
*The principal member
is the oldest insured
500,000 1,000,000 3,000,000 5,000,000 10,000,000

19 yrs. - 29 yrs.

Principal Member 32,257 34,284 49,172 53,025 60,535

Spouse 23,900 25,582 38,516 41,671 46,337

Child (0 -18 yrs.) 13,929 17,102 26,795 28,496 31,578

30 yrs. - 40 yrs.

Principal Member 33,863 35,223 52,342 56,437 64,692

Spouse 25,023 26,785 40,457 43,799 48,736

Child (0 -18 yrs.) 13,929 17,102 26,795 28,496 31,578

41 yrs. - 50 yrs.

Principal Member 38,059 39,385 62,185 62,634 68,870

Spouse 26,128 27,925 46,043 46,446 49,650

Child (0 -18 yrs.) 13,929 17,102 26,795 28,496 31,578

51 yrs. - 65 yrs.

Principal Member 55,550 56,704 76,889 82,030 91,449

Spouse 31,575 34,484 50,161 54,280 60,121

Child (0 -18 yrs.) 13,929 17,102 26,795 28,496 31,578

66 Years and Above

Principal Member 82,829 95,227 142,417 162,180 185,511

Spouse 64,526 78,683 115,311 131,186 145,655

Child (0 -18 yrs.) 13,929 17,102 26,795 28,496 31,578

Outpatient Rates

Limit 50,000 60,000 100,000 150,000 200,000

M (Also Per Person) 32,934 33,266 35,226 37,892 41,512

M+1 44,986 49,269 66,533 70,452 77,987

M+2 48,748 54,844 82,895 88,794 92,489

M+3 48,797 55,910 98,147 106,762 111,223

M+4 48,846 57,804 98,245 121,829 126,966

M+5 49,339 58,095 99,028 136,895 142,709

M+6 49,837 58,387 99,282 148,202 157,539

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Rules of Selection Cover;
a) Inpatient is the primary option and is purchased before purchasing outpatient.
b) Outpatient is limited to the amount of inpatient and is restricted as below;

Inpatient Limit Can Purchase Outpatient of:

500,000 60,000 and below

1,000,000 60,000 and below

3,000,000 100,000 and below

5,000,000 Any of the above

10,000,000 Any of the above

General Conditions

• Eligibility is all persons and their legal dependents from age of zero (0) months to sixty five (65)
years. Existing members can continue renewing in the scheme for life subject to renewal review
by Old Mutual General Insurance Company Ltd.
• Persons over 60 years will be required to submit a medical report in the prescribed manner for
eligibility.
Eligibility
• Eligible dependents include one spouse (age 18 to 65 years at joining) and own children from
birth to 18 years of age. Newborns will be added on cover from birth. Birth Notification must be
included in the application form and premium must be settled in full.
• Children above 19 years will be covered as principal persons.

NHIF NHIF shall apply where the principal already has an NHIF Cover.

• 28 days waiting period applies to illness claims and 60 days for surgical claims subject to
Waiting Periods
condition specific waiting period indicated in the benefit schedule.

• Cover cease age for this benefit is 65 years.

• Waiting period: 28 days waiting period for newly diagnosed chronic illnesses
Critical Illness cover
• For family cover, only one claim is paid in a single cover year
• Babies are covered from birth from 38 weeks and congenital conditions are excluded.

• Routine prescriptions and refill of prescriptions to be done using our ‘Meds on wheels’ platform
Tele-medicine and which can be accessed through our Chronic Disease Management Program.
drug delivery • We encourage members with chronic illnesses to have their treatment managed by specialists
on our panel of providers.

• Kenya, Uganda, Tanzania, Rwanda and South Sudan.

• In case of services sought outside the specified region, the insured member’s claims shall be
settled on re-imbursement.
Territorial Limit
• Reimbursement will be on Old Mutual General Insurance Company Ltd’s Reasonable and
customary rates.
• The cover on reimbursement basis is valid for the first 60 days outside the geographical scope.

• 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.
• The Company has credit facilities in India, and the referral must be approved by the company
Overseas referral
and respective government department.
• Air fare for patient and accompany person on economy class is payable from the overall cover
limit (inpatient), while accommodation costs are excluded.

• Cards
- Medical Cards shall be issued to all members of the scheme.
• Healthcare Providers:
i. Restricted to hospital network in the panel option chosen.
Administration ii. In case of genuine reasons for using a non-panel provider, reimbursement shall be allowed
subject to Old Mutual General Insurance Company Ltd’s customary and reasonable rates.
Consultation shall be reimbursed at Kes 2,000 for General Practitioners and Kes 3,000 for
Specialists.
iii. Inpatient total reimbursement shall be capped at 80% after application of the (i)above

• Only allowed for genuine medical emergencies and shall be reimbursed in accordance with the
Reimbursements
terms provided in the policy document.

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General Exclusions
• Expenses where material information is withheld or misstated
• Infertility treatment
• Cosmetic surgery unless caused by accident
• Weight management treatments and drugs.
• Participations in professional & hazardous sports e.g. bungee jumping,
paragliding
• Treatment other than by registered medical practitioner
• Self-referred or self-prescribed treatment.
• Drugs dispensed by the treating doctor.
• Nutritional supplements unless prescribed as part of medical treatment.
• Alternative treatment - Chiropractors, Acupuncturist, Herbalist
• Drunkenness, drug addiction
• Expenses incurred in connection with 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 cure clinics or health hydro’s
• Diagnostic equipment (e.g. Glucometers, BP machines,
• Pandemics and epidemics, unless where the Company has offered a buy-back
option, usually by way of a sub-limit within the main cover limit, for a specified
Pandemic or Epidemic).
• Experimental treatment.
• Contamination by radio activity from nuclear fuel, waste or fission
• Benefits not purchased or not indicated in the brochure.

*Refer to the policy document for detailed exclusions

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Old Mutual
Old Mutual Tower Upper Hill Road
P.O. Box 43013 - 00100
Nairobi Kenya
Call us on +254 711 065 100
Email us on [email protected]
Website: oldmutual.co.ke