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KCB Insurance will assist the Client set up the scheme: determine benefit limits, what to cover, exclusions and general scheme rules. Other additional benefits provided by KCB Insurance include:

  • Staff presentations of scheme benefits and rules.
  • Prepare medical cards for all staff members (which will also be used for In Patient treatment).
  • Set up the Service Provider network.
  • Cost negotiations with the service providers on, say, the consultation fees to charge, doctors’ fees, bed charges, cost of drugs and other cost control measures.
  • Full administration of the credit facilities with service providers – vetting, processing and settling of bills at the agreed credit period of 30 days with the credit facility and account reconciliation on the same.
  • Vetting, processing and reimbursement of all claims incurred by the members.
  • Maintenance of the membership registers with the hospitals.
  • Provide all stationary required to manage the scheme – application forms, claim forms, pre-authorization forms among others.
  • Preparation of various management & expenditure reports and member statements. Our computer software system is able to generate expenditure reports that gives analysis on the following:

REPORTS AVAILABLE

  • Member utilization statements
  • Over utilization reports
  • Breakdown of payments per Service provider
  • Diagnostics expenditure (ailment analysis)
  • Treatments statistics –e.g. average cost per ailment per employee

SCOPE OF INPATIENT COVER

Payment of medical expenses incurred as a result of admission to recognized hospitals.

SCOPE:

  • Hospital Accommodation charges (bed limit)
  • Doctor’s fees (physician, surgeon & anesthetist)
  • ICU/ HDU and Theatre charges
  • Drugs/ Medicine, dressing & Internal Surgical Appliances
  • Pathology, X-ray, Ultrasound, ECG, MRI Scans
  • Physiotherapy, Radiotherapy and Chemotherapy
  • Emergency road evacuation leading to hospitalization
  • Approved day care Surgery
  • First non-elective and emergency caesarean

RIDERS:

Cover includes HIV, Pre-existing diseases & chronic illnesses

Medical (Outpatient) Insurance

Payment of medical expenses incurred as a result of admission to recognized hospitals.

SCOPE:

  • Doctor’s fees (physician, surgeon & anesthetist)
  • ICU/ HDU and Theatre charges
  • Drugs/ Medicine, dressing & Internal Surgical Appliances
  • Pathology, X-ray, Ultrasound, ECG, MRI Scans
  • Radiotherapy and Chemotherapy
  • Physiotherapy
  • Emergency road evacuation leading to hospitalization
  • Approved day care Surgery

RIDERS:

Cover includes HIV, Pre-existing diseases & chronic illnesses

ADVANTAGES OF A SELF FUNDED SCHEME

Flexibility of scheme rules

  • Client can opt to have a fully self-funded scheme to include the Outpatient benefits.
  • Client will also determine which medical facilities would be appropriate for their needs.
  • Wide scope of cover to include what would be excluded under the insured scheme.

Possible Cost Savings

  • In a period of favourable claims experience and prudent cost control initiatives, client may make cost saving relative to the insurance premium that would otherwise have been paid.

DISADVANTAGES OF A SELF FUNDED SCHEME

The Risk

  • Client is the Risk Carrier and, in a period of adverse claims experience could overshoot the budget allocation.
  • The scheme costs will depend on the actual claims incurred by scheme members. 

Possible Higher Costs

  • Since claim payments are at the prerogative of management, there may result higher costs due to compassionate or ex-gratia considerations.
  • Thus the need for Third Party administration of a Self-Funded scheme to ensure strict adherence to scheme rules, over and above implementation of cost control management.
  • The client will spend the actual cost incurred by its members.

Scheme Information required

Population

  • Number of parishes and number of members in each parish.
  • Number of presbyteries and number of members each.
  • members in head office
  • Total population based on above data
  • Insured Premium if the scheme was insured

FUNCTIONS AND RESPONSIBILITIES OF KCB INSURANCE AGENCY

KCB Insurance Agency will take over the management of the clients cover for the membership noted above as scheme managers/administrators and will be responsible for the following functions and responsibilities.

  • Scheme management

The client will benefit from our expertise and wide experience in handling service providers and medical claims management.

Cases of fraud, misuse, over-utilization and overcharging are reduced to a minimum through our claims vetting and medical audit processes.

Negotiate on discounted rates/terms with medical providers under the panel to ensure the scheme is run cost effectively.

  • Service Providers

We have a panel of service providers which are customized to meet the client’s requirements. Members will be restricted to the appointed service providers. In emergency cases where no appointed service provider is available, members can use the nearest service provider and claim reimbursement with approval from KCB Insurance Agency.

A wide panel of medical providers to cater for all areas in the country will be put in place even in areas where we do not have adequate representation in the panel.

  • Reports

We will provide quarterly utilization reports of the fund to allow the client monitor utilization. Management reports will be provided to help in decision making and future planning/allocation.

  • Scheme Funding

Any unutilized balance will be rolled over to the next quarter/year. However in case the fund is exhausted before expiry of cover period an additional fund will be required.

An interest accruing account will be opened where the client will deposit towards the funding of the scheme. Funds paying the claims will also be made from the account and KCB will always provide monthly statements.

  • Smart Card Option

We are able to manage the outpatient scheme through Smart Cards. Each member will be issued with a smart card for identification in hospitals and all our appointed clinics/hospitals.

The advantages of using smart card system are:-

  • It bears all details of the member, including medical history.
  • The card maintains a record of the amount claimed for each individual on a daily basis.
  • Enhanced control of benefit utilization (Fraud and misuse) and costs.

KCB Insurance Agency Value Added

  • Advisory Role

Insurance is complex and KIA will advise the client on the changing medical industry trends and the best cost effective way of running the staff medical scheme.

  • Sourcing

Source the most cost effective cover and comprehensive cover to meet the clients’ requirements/needs.

  • Service Providers/Credit Facilities administration

KIA will be responsible for running of the credit facilities and will act as the liaison between the providers and the client. The staffs never get to see the bills and as bills are not sent to the client but KIA or underwriter depending on the scheme taken.

  • Admission Facilitation

KIA will arrange admission with admitting providers and facilitate discharge and the client will not be directly involved in the process which at times can be very involving especially during non-working hours.

  • Customer Service

A team under an account manager will be responsible for day to day running of the scheme by liaising with HR and appointed medical providers.

  • Care Management

Through our care managers KIA will ensure medical services are delivered in the most cost effective way to be within set budgets

To ensure quality services are provided to the members and this is done conveniently.

  • Claims Management

An IT system is in place for claims administration to ensure accurate claims records and utilization

  • 24/7 assistance

A 24/7 help line will be available to offer assistance to scheme members at any time of the day. Scheme members will get prompt assistance from care management on call to serve the members.

  • Professional health talks to staff

Will facilitate free health talks to staff in important topics that help the staff in healthy living.

  • Management reports

To provide management reports on agreed periods of time to help in making informed decision and control of expenditure. The reports also help in planning and setting aside the required funds.

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