Health Care

1. Waiting Period

• 21 days for outpatient illnesses
• 45 days for inpatient admission
• 90 days for surgical cases
• One year (12 months) for maternity
• One year for pre-existing, chronic and psychiatric condition
• 12 months for congenital conditions
• One year (12 months) waiting period for maternity, First emergency C/S and maternity related conditions.
• None for accident
• Two years (24 months) for cancer treatment
• One year (12 months) for removal of fibroids, uterus, adenoids, tonsils, lipomas and repair of hernias
• One year (12months) for optical laser treatment

2. Eligibility

• Adults - 19 years and above
• Children (38 weeks) full term and discharged from hospital to 18 years
• Maximum joining age 60 years, existing members covered for life.
• Eligible dependants include the spouse, own children and legally adopted children.
• Medical reports for new applicants over 57 years will be required.

3. Requirements

• Fully filled medical application form
• Certified copies of the national ID and birth certificate for children
• Full annual premium

4. Medical  Examination

• Persons over 57 years will be required to submit a medical report from our selected service providers at their own cost

5. Settlement of Service Provider Bill

• All inpatient bills will be paid net of NHIF rebate
• All outpatient bills will be paid net of co-pay
• There will be no refund for payment made directly by the insured to any service provider as Madison provides credit facilities through an approved panel of service provider
• Madison insurance is liable for all bills up to the selected cover limits only
• Any exceeded amount is payable by the insured member

6. Inpatient Management

Emergency Admission
       •   Each member is issued with a membership card for identification with the service provider
       •   Services are offered on presentation of the Madison Insurance Medical card and authentication of the member’s identity
       •   All members are required to produce their NHIF cards prior to discharge for purposes of NHIF rebate computation
       •   In the absence of the NHIF card, members will be required to pay the NHIF rebate in cash.

Scheduled Admissions
These refer to all non emergency admissions.

•  The patient will agree with the doctor on the date of admission
•  The doctor will then complete an inpatient pre-authorization form
•  The form should be presented to Madison in advance, but at least 48 hours prior to admission
•   Madison will evacuate the condition under the treatment and if covered, a letter of undertaking will be issued to the hospital with a copy to the patient
•   On the admission date the patient will be required to present a letter of undertaking to the hospital.
•   At discharge the patient is required to produce his/her NHIF card as above
•   Ensure to sign a claim form and the final invoice

7. Outpatient Management

 Co-payment of Kshs. 500 shall be applicable for outpatient visits to:

• The Aga Khan University Hospital
• Nairobi Hospital
• Karen Hospital
• Gertrude’s Garden Children’s Hospital

  Co-payment of Kshs. 200 shall be applicable in outpatient’s visits to all other service providers

• The outpatient cover excludes all dental and optical treatment and private vaccines
• Members should sign all outpatients’ bills before leaving the hospital

• Contact Madison insurance offices or your intermediary and complete an application form
• The application form is available on our website: www.madison.co.ke
• Members will be issued with a medical card and a policy document upon approval of the proposal

Exclusions

1. Illness occurring within the waiting period
2. Expenses incurred in connection with the venereal disease
3. Expenses incurred in relation to and or in connection with the ritual circumcision
4. Expenses incurred in relation to intentional self injury, attempted suicide, domestic violence, deliberate exposure to exceptional danger and hazardous sports.
5. Medical expenses incurred as a result of infertility, Impotence or in the course of treatment to correct the cause of infertility,family planning and hormonal replacement therapy.
6. Cosmetic treatment
7. Medical expenses incurred outside Madison Insurance panel of service providers
8. Expenses as a result of acts of terrorism and war
9. Expenses incurred where material information is withheld or misstated
10. Expenses incurred in connection with drunkenness, treatment of chronic alcoholism, intoxication, use of drugs not prescribed by a physician or drug addiction
11. Nutritional food supplements and weight management
12. Chiropractors, acupuncturists, and herbalists fee
13. Medical checkups
14. Private vaccines except KEPI recommended vaccine for children
15. Benefits not specified in the brochure or policy document
16. Outpatient ambulance services

NB: The policy document, application form and the policy schedule will be read as one document.