Thousands of teachers’ children to miss on insurance as scheme limits cover to 4
Teachers with more than four children will be forced to leave some of their children uncovered in the insurance scheme for teachers employed by the Teachers Service Commission (TSC).
The scheme by Minet Kenya Insurance dictates that a principal member can only add up a maximum of five dependants, comprising one legal spouse and four children. This could see thousands of children in teachers' families go uninsured, in case the teacher has more than four children.
Minet Kenya Insurance, Sammy Muthui explained that in instances where teachers are married to each other, the limit of coverage in the family increases to eight children.
“For instance, I am dependent on her benefits and she is dependent on my benefits. Say for example we have four children and are dependents on my benefits and also on her benefits, that is double coverage. If we have four children we can divide under whose benefit they will go,” Muthui explained, in a media forum held in Nairobi.
“For teachers who are married, they can have up to eight children in the scheme because four can go one side (husband) and others to the other side (wife),” he added.
He said that teachers who have more than four children have to make tough choices by selecting the four who will be in the medical scheme.
At least 80,000 births have been recorded under the teachers’ medical scheme, now in its seventh year.
TSC, which has now employed close to 400,000 tutors, transited to a cover, replacing the medical allowance, which it says was barely enough for their expenses.
Explaining this situation, Muthui said the benchmark is the Salaries and Remuneration Commission (SRC) requirements for public sector employment, which provides for one spouse and four children.
He explained that Minet covers children from 0 – 18 years old, the age bracket still under parental care.
Documents required in this case include a birth notification for 0-6 months and a birth certificate or proof of guardianship or legal adoption papers for children aged 7 months to 18 years.
The scheme also allows children aged 19 -25, noting that this age bracket is assumed to be in school and documentary evidence is provided in case they want to access the benefits.
“No maximum age limit shall apply to child dependents with a disability. For children with disability above 18 years, documents needed are a birth certificate and a disability card from the Association for the Physically Disabled of Kenya (APDK),” he explained.
Treatments excluded in teachers' cover
Although Muthui said a lot is covered under this scheme, it excludes cosmetic treatments, self-prescribed treatment, experimental treatment, costs already catered for by another insurance company, reimbursement costs unless in cases of an emergency and notified to the insurance within 24 hours of admission as well as maternity for child dependants.
Muthui also explained that previous medical scheme policies have had a requirement that medical service providers should not charge a member if they require medical attention for the same ailment as had been treated within a timeline of seven days.
However, the rule had been misinterpreted by some medical service providers and caused challenges despite continued communication to clarify its application.
“This has since been removed and therefore members seeking services are not subject to daily limits for outpatient services. The service providers have been informed to provide all the services required as per the diagnosis and the mode of treatment. This has been reinforced and there is no clause limiting the number of visits to be made by patients seeking medical care,” he explained.
On pre-authorization, he said that it is a process to determine that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary.
For the teachers' medical scheme, he said it is crucial to safeguard member benefits which are public funds by guarding against fraudulent activities, adding that preauthorization is important in costly medical procedures to ensure that the patient is not overcharged for medical services and that the member has an available limit.
“For enhanced administration, preauthorization for the teachers' medical scheme is not required for regular outpatient visits. Target turnaround time for preauthorization has been revised to 10 minutes,” he affirmed.
Similarly, he said no copay is currently applicable for any of the visits under the teachers’ medical scheme.
Muthui explained that a co-pay is a fixed amount for a covered service paid by a patient to the service provider before receiving the service, which is a standard practice in the insurance industry.
Minet provides medical cover on behalf of TSC.
