Here is all you need to know about Jubilee Insurance Medical cover:
ABOUT JUBILEE
Jubilee Insurance was incorporated on 3rd August 1937, in a small office in Mombasa and is one of the pioneers in the establishment of a local composite insurance company.
In keeping with our mission of contributing to the economic growth of the region, Jubilee Insurance took the bold step of converting itself into a public Company in 1984, to broaden its ownership base locally which now consists of over 5,000 shareholders. Today more than seventy five years since inception Jubilee Insurance is a leading insurance company in East Africa with the largest shareholders’ funds and solid emphasis on security for policyholders, information technology, committed, knowledgeable & professional staff, and a reputation for superior customer service.
Currently, the Jubilee Insurance group is the largest medical insurance underwriter in East Africa.
KEY BENEFITS
- 5 Levels of Comprehensive cover with optional benefits (Maternity, Outpatient, Dental and Optical). Select the plan and options to suit your medical insurance needs and budget
- Cover for Pre-Existing, Chronic, Psychiatric , congenital and HIV/AIDS including related conditions
- Country wide Provider Network
- Overseas inpatient referrals covered on credit under listed hospitals
- Cover for inpatient dental and optical treatment
- Post hospitalisation benefit
- Funeral expenses benefit
- Free Personal Accident benefit for Principle member
- Direct access to treatment within East Africa
PLAN SUMMARY
J-CARE
INDIVIDUAL/FAMILY MEDICAL INSURANCE
INPATIENT BENEFITS (CORE PRODUCT – COMPULSORY)
All inpatient treatment is subject to pre authorisation
All benefits are subject to overall annual benefit unless specified otherwise
| PLANS | CLASSIC | PREMIER | ADVANCED | EXECUTIVE | ROYAL | ||||||||
| Overall benefit limits in KShs. per insured family per | 500,000 | 1,000,000 | 2,000,000 | 3,000,000 | 5,000,000 | ||||||||
| annum | |||||||||||||
| Pre -existing, Chronic, Congenital Conditions, HIV/ | |||||||||||||
| AIDS and related conditions existing/not existing and/ | |||||||||||||
| or not diagnosed at the time of joining. Subject to full | 250,000 | 300,000 | 400,000 | 500,000 | 1,000,000 | ||||||||
| disclosure at the time of joining (1 year waiting period) | |||||||||||||
| Cancer treatment | (2 years waiting period) | ||||||||||||
| Organ Transplant | (1 year waiting period) | ||||||||||||
| Psychiatric conditions (1 year waiting period) | 100,000 | 200,000 | 250,000 | 300,000 | 500,000 | ||||||||
| Standard Private | Standard Private | ||||||||||||
| Bed limits per day net of NHIF | General Ward | General Ward | General Ward | room up to | room up to | ||||||||
| Bed | Bed | Bed | KShs.12,500 | KShs.18,000 | |||||||||
| Net of NHIF | Net of NHIF | ||||||||||||
| Covered for | Covered for | Covered for | Covered for | Covered for | |||||||||
| Lodger Fees for parent accompanying sick child member | Child under 8 | Child under 8 | Child under 8 | Child under 8 | Child under 8 | ||||||||
| years | years | years | years | years | |||||||||
| 1. | |||||||||||||
| Physicians, specialists, surgical fees including anaesthetist | ||||||
| fees, theatre charges, HDU, CCU & ICU, Diagnostic Tests, | Paid in Full | Paid in Full | Paid in Full | Paid in Full | Paid in Full | |
| physiotherapy as part of inpatient treatment | ||||||
| Inpatient MRI/CT Scans and PET Scans (authorisation | Paid in Full | Paid in Full | Paid in Full | Paid in Full | Paid in Full | |
| required) | ||||||
| Surgical appliances/internal prosthesis | Paid in Full | Paid in Full | Paid in Full | Paid in Full | Paid in Full | |
| Reconstructive surgery following an accident | Paid in Full | Paid in Full | Paid in Full | Paid in Full | Paid in Full | |
| Inpatient non accident related dental surgery/treatment | 100,000 | 100,000 | 100,000 | 100,000 | 100,000 | |
| (1 year waiting period) | ||||||
| Inpatient dental surgery from an accident | Paid in Full | Paid in Full | Paid in Full | Paid in Full | Paid in Full | |
| Inpatient opthalmology surgery as a result of an | Paid in Full | Paid in Full | Paid in Full | Paid in Full | Paid in Full | |
| accident | ||||||
| Inpatient non accident related eye treatment (excluding | 100,000 | 100,000 | 100,000 | 100,000 | 100,000 | |
| correction of refractive errors and laser treatment) (1 | ||||||
| year waiting period) | ||||||
| Day case surgery under general anaesthesia | Paid in Full | Paid in Full | Paid in Full | Paid in Full | Paid in Full | |
| Medically necessary home nursing on doctor’s | 90 days | 90 days | 90 days | 90 days | 90 days | |
| recommendation after discharge from hospital | ||||||
| up to 3 weeks | up to 3 weeks | up to 3 weeks | up to 3 weeks | up to 3 weeks | ||
| Post hospitalisation treatment | after discharge | after discharge | after discharge | after discharge | after discharge | |
| Max 10,000 | Max 15,000 | Max 20,000 | Max 25,000 | Max 30,000 | ||
| Discharge take home medication | up to 30 days | up to 30 days | up to 30 days | up to 30 days | up to 30 days | |
| after discharge | after discharge | after discharge | after discharge | after discharge | ||
| OTHER BENEFITS INCLUDED WITHIN INPATIENT COVER | ||||||
| Local road ambulance to hospital for emergency cases | Covered | Covered | Covered | Covered | Covered | |
| Commercial Air Evacuation out of Kenya (must be pre | Economy return | Economy return | Economy return | |||
| fare only within | fare only within | fare only within | ||||
| authorised) for treatment not available or not safe to | Not applicable | Not applicable | ||||
| Africa, India and | Africa, India and | Africa, India and | ||||
| undertake locally | ||||||
| Pakistan | Pakistan | Pakistan | ||||
| Funeral expenses – (free for principal member. Optional | 50,000 | 50,000 | 75,000 | 100,000 | 100,000 | |
| for dependant over 18 yrs.) | ||||||
| Personal Accident (Free for Principal Member. Optional | 500,000 | 500,000 | 500,000 | 500,000 | 500,000 | |
| for dependents over 18 yrs.) | ||||||
| OUTPATIENT BENEFITS (OPTIONAL) | ||||||
| Annual limits | 50,000 | 50,000 | 80,000 | 100,000 | 150,000 | |
| Consultation fees (doctors on panel) | Paid in Full | Paid in Full | Paid in Full | Paid in Full | Paid in Full | |
| Pathology, Xrays, MRI, CT Scan and other necessary | Paid in Full | Paid in Full | Paid in Full | Paid in Full | Paid in Full | |
| diagnostic tests *1 | ||||||
| Prescription drugs and dressings upto a maximum of 30 | Paid in Full | Paid in Full | Paid in Full | Paid in Full | Paid in Full | |
| days dosage | ||||||
| Gynacological illness and treatment*2 | Paid in Full | Paid in Full | Paid in Full | Paid in Full | Paid in Full | |
| Pre-existing, chronic cover, Psychiatric, Congenital | ||||||
| conditions and HIV/AIDS and related treatment ( 1 year | Paid in Full | Paid in Full | Paid in Full | Paid in Full | Paid in Full | |
| waiting period) | ||||||
| Cancer treatment (2 year waiting period) | Paid in Full | Paid in Full | Paid in Full | Paid in Full | Paid in Full | |
| Physiotherapy (pre authorisation required) | Paid in Full | Paid in Full | Paid in Full | Paid in Full | Paid in Full | |
| ROUTINE MATERNITY BENEFITS (OPTIONAL) | ||||||
| Annual limit per member/spouse | 80,000 | 100,000 | 120,000 | 120,000 | 150,000 | |
| KEPI Vaccinations (within maternity limit and subject to | up to 5,000 | up to 5,000 | up to 5,000 | up to 5,000 | up to 5,000 | |
| pre-authorisation) | ||||||
| Pre-natal & Ante-natal outpatient treatment ( 1 year | Covered under maternity limit | |||||
| waiting period) | ||||||
| Benefits covered under maternity limit | Normal and C-Section delivery. Labour/recovery ward, professional fees, pregnancy/ | |||||
| maternity related hospitalisation, other related ailments & complications including etopic | ||||||
| (1 year waiting period) | ||||||
| pregnancy and miscarriage | ||||||
| ROUTINE DENTAL BENEFITS (OPTIONAL)* | ||||||
| Annual Limit per person | 5,000 | 10,000 | 20,000 | 30,000 | 40,000 | |
| Dental | Dental | Dental | Dental | Dental | ||
| Consultations, | Consultations, | Consultations, | Consultations, | Consultations, | ||
| Benefits covered (pre-authorisation required) | Extractions, | Extractions, | Extractions, | Extractions, | Extractions, | |
| Fillings, Dental | Fillings, Dental | Fillings, Dental | Fillings, Dental | Fillings, Dental | ||
| Xrays and | Xrays and | Xrays and | Xrays and | Xrays and | ||
| Prescriptions | Prescriptions | Prescriptions | Prescriptions | Prescriptions | ||
| ROUTINE OPTICAL BENEFITS (OPTIONAL)* | ||||||
| Annual Limit per person | 5,000 | 10,000 | 20,000 | 30,000 | 40,000 | |
| 1 eye test per | 1 eye test per | 1 eye test per | ||||
| 1 eye test per | 1 eye test per | person per | person per | person per | ||
| person per | person per | annum. Frames | annum. Frames | annum. Frames | ||
| Benefits covered (pre-authorisation required) | annum. Frames | annum. Frames | and prescription | and prescription | and prescription | |
| and prescription | and prescription | lenses. Frames | lenses. Frames | lenses. Frames | ||
| lenses every 2 | lenses every 2 | limit – KShs. | limit – KShs. | limit – KShs. | ||
| years | years | 10,000/- every | 10,000/- every | 10,000/- every | ||
| 2 years | 2 years | 2 years | ||||
This is only a summary of the benefits for more details refer to the policy document *Dental and Optical options are available only with Outpatient plans.
GENERAL CONDITIONS
- General waiting period of 30 days for new entrants on illness claims. No waiting period for accident related treatment.
- *(1) MRI, CT scan on pre authorisation.
- *(2) Fibroids, Adenoidectomy, Haemorrhoidectomy and Tonsillectomy procedures shall have a waiting period of 1 year.
- Cancer treatment will be subject to 2 years waiting period.
- Pre-existing, Chronic, Psychiatric, Congenital, Organ Transplant, HIV/Aids and related treatment, Maternity and related complications, inpatient non accident related ophthalmology and dental surgery shall be subject to 1 year waiting period.
- Eligible for the main member and his/her legal dependents from the age of 1 month to 60 years. Existing members can continue on cover up to age of 65 years. Children above 18 years will enjoy their own cover as principle members.
- New applicants aged 50 years and over will be required to undergo a medical examination at specific providers, before membership and eligibility of cover can be confirmed. Please note that this will be at applicants cost.
- Cover must be confirmed in writing and premiums paid to Jubilee Insurance for the benefits to be effective.
- All scheduled admissions must be pre authorised at least 48 hours prior to admission.
- For emergency admission the hospital will contact Jubilee Insurance within 48 hours of admission.
- All inpatient hospital bills shall be paid net of National Hospital Insurance Fund (NHIF)
- Medical cards must be presented at the accredited panel of providers for access to service. Each member will also be required to complete and sign a claim form.
- A member travelling outside the country will be eligible for emergency medical benefits up to a period of six (6) weeks in any one visit. All medical expenses will be on reimbursement basis and will be within the acceptable guidelines of the Kenyan Medical Practitioners and Dentists Board and as per the policy terms and conditions.
4.
EXCLUSIONS
- Treatment for pre-existing chronic conditions, congenital and psychiatric conditions (within the first year)
- Treatment for HIV/AIDS and related ailments (within the first year)
- Treatment of Cancer (within the first two years)
- Sexually transmitted diseases except HIV/AIDS
- Peri-Menopause, Menopause, andro-pause ,hormone replacement therapy, age and puberty related treatment Organ transplant (within the first year)
- Treatment of Haemorrhoids, Fibroids, Hernia (except congenital), Adenoidectomy (within the first year).
- Genetic disorders and related conditions.
- Cosmetic or plastic surgery unless necessitated by an accidental injury that occurs while the insured is covered under this contract;
- Riding or driving in any kind of race
- Beauty treatment or massage
- Naval, military and air force operations
- Stays at sanatoria, old age homes, places of rest etc.
- Medical check-up, general health examinations, prophylactic treatment, vaccinations except for KEPI vaccinations.
- Transportation other than a licensed ambulance, as provided for under the in-patient coverage of this contract
- Hearing tests or cost of hearing aids unless resulting from an accidental injury
- Nutritional food supplements or replacements.
- Injury or illness resulting from insurrection or war, civil commotion or an act of terrorism, whether declared or undeclared
- Injury as a result of participating in riot, strike
- Alternative treatment such as herbal treatment, acupuncture treatment, chiropractors etc.
- Expenses resulting from the insured participating in extreme/hazardous sports and activities
- Pain management
- Dental treatment including teeth extractions, fillings, teeth scaling, etc. unless the dental cover has been purchased.
- Optical treatment relating to correction of eyesight e.g. eye glasses, contact lenses, laser eye treatment unless the optical cover has been purchased.
- ntentional self-injury while sane or insane, suicide or attempted suicide, treatment of acute or chronic alcoholism and drug addiction
- Expenses recoverable under any other insurance e.g. NHIF
- Treatment required as a result of noncompliance, failure or refusal to comply with medical advice
- Pregnancy, childbirth, maternity benefits, medically necessary abortion, miscarriage, antenatal or postnatal care, caesarean operation except where purchased and subject to twelve months waiting period
- Contraceptive services and supplies, family planning and fertility treatment e.g. costs of treatment related to infertility and impotence, any injury, illness or disease specified as exclusion and complications caused by a condition that is excluded.
- Services primarily for weight reduction or treatment of obesity and slimming preparations or any care which involves weight reduction as a main method of treatment.
- Epidemics, pandemics or unknown diseases
PROVIDER PANEL
Jubilee Insurance’s provider panel allows members access to the medical care they require. The panel is on credit basis, which means that provided the treatment is covered and has been pre authorised where necessary, the bill will be settled directly with the service provider. This allows members to get quality care when required.
The provider panel will be in the membership pack upon purchase of the policy and the same can also be accessed via the Jubilee Insurance website www.jubileeinsurance.com
APPLYING FOR COVER
To apply for cover, complete and sign the member application form. Submit it together with the required supporting documents. Jubilee Insurance shall revert within 3 working days of receipt of your application and confirm the terms and conditions applicable.
5.
The policy will be effective from the date the premium is paid. Waiting periods where applicable will start from the date the policy is effective.
POLICY DOCUMENTS
Once the policy commences, you will receive a membership pack within 30 days which will include:-
- Membership Card (s)
- Welcome Letter confirming the plan and benefits purchased
- Policy document
- List of providers
FREQUENTLY ASKED QUESTIONS
When does my cover commence?
The cover commences once Jubilee Insurance provides you with an acceptance letter and once premium is fully paid.
To whom should premiums be paid to once I have received confirmation that my application has been accepted?
Payment should be made directly to Jubilee Insurance by the following means:
- Cheque
- MPESA Number – 328102
- Cash payment to our Head office or any of our branches
What am I covered for?
The benefit options are provided in this brochure and the further details will also be provided in the policy document
Which hospitals can I go to?
A list of providers and specialists will be provided in your membership pack. The same can be accessed on the Jubilee Insurance website. You can also call our offices directly for further assistance.
What do I need in order to access a credit facility?
Remember to always carry your Jubilee Insurance medical card and your national ID/ Passport in case further verification is required.
What is the procedure of enrolling a new born child?
Inform Jubilee Insurance immediately the child is born and provide all documentation (application form and passport size photo) as soon as possible. Cover commences once Jubilee Insurance confirms acceptance and full premium is paid.
What does the policy say about treatment abroad?
A member is covered whilst 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 and will be covered on reimbursement. Travel and accommodation costs are not covered.
How do I change my policy if I am covered with another Insurer?
Provided there is no break in cover, and subject to the underwriting procedures some of the waiting periods may be waived allowing for a seamless transition.
Once I have the initial medical examination having joined after the age of 50 years, will I need to go for an examination at each renewal?
Jubilee Insurance may require medical examination when necessary. Communication will be provided in writing at the policy renewal.
