Good news for teachers over medical cover benefits

As published on on Feb 29th 2024

Teachers may now enrol up to eight children in the multi-billion medical scheme that has so far given birth to 80,000 children.
Details of the enhanced medical scheme revealed that if two teachers are married, each will be considered a principal member and, hence will be able to separately enrol up to four children in the scheme. This means that each couple will have a maximum of four slots for their children to benefit from the scheme and thus can insure up to eight children in total. Presently, teachers married to non-tutors can only enrol a maximum of four children.
“So, in the case where both spouses are teachers and have more than four children, they can agree among themselves which kids they want to insure up to a maximum of eight,” Sammy Muthui, Minet’s managing director said. The cover takes care of 360,000 teachers out of the 406,000 teachers on the Teachers Service Commission (TSC) payroll. “Currently we take care of about 360,000 teachers who have about 230,000 spouses, and 677,000 children. So, in total, we cover about 1.3 million lives,’’ said Muthui.
Muthui said that the new development is part of a raft of changes the medical scheme provider has instituted to cushion teachers. Muthui said that the changes under the scheme are necessary to ensure proper utilization of public funds. Top among them is the removal of the contentious requirement for teachers to co-pay for each of their hospital visits. Teachers were previously required to top-up Sh50 for outpatient visits. Muthui said this has so far been eliminated from the requirement following public feedback. He said the idea of co-pay is adopted by insurers to reduce the risk of overuse in a medical cover. This means that the amount charged for outpatient consultancy is partly charged to the member of the scheme while the balance is covered by the scheme.
This, Muthui said, is meant to ensure that those covered only go to the hospital when they are sick. “There is so much confusion and pain around this, so we decided to remove it so that the pain is no longer felt,” said Muthui. Muthui also said that the scheme has reduced the turnaround time for pre-authorisation of in-patient cases. The requirement for pre-authorisation has been another contentious issue in the scheme that involves the insurer verifying an in-patient request before treatment.
Muthui said that they have since reduced the turnaround time to 10 minutes to reduce the delays from previous incidents. However, he noted that this step is important as it helps deal with cases of fraud. To curb fraud, pre-authorisation is a meticulous process of authenticating the claims launched. “The reason this scheme has been sustainable, both financially and infrastructure-wise, is because of our diligence in our duty of care,” Muthui said. According to Muthui, health insurance is highly exposed to fraud with the Insurance Regulatory Authority (IRA) indicating that up to 30 per cent of the claims in medical insurances are fraudulent. He said the scheme records an average of 7,000 daily outpatient visits, while another 300 people are hospitalized.
However, Muthui credits that the scheme for recording improved mortality rates; explaining that they have witnessed a major decline in mortality among teachers and their dependents under the scheme. He noted that in the earlier years of the scheme, they witnessed about 2,000 deaths within the teaching fraternity. “Nowadays even with the number that has gone up to 360,000 teachers, we are unfortunately losing about 1000 a year. When we look at our calculation, we are of the opinion that the scheme has reduced the mortality rate by 50 per cent,’’ Muthui said.
The other enhanced benefit of maternity targets lower job groups. The cover has now been reviewed from Sh100,000 to Sh120,000. The insurer said that teachers are experiencing a baby boom with an average of 175 births recorded daily under the scheme. The maternity cover is limited to only two members of the family, the teacher, and the spouse. This means if a child dependent gets pregnant, the cover does not consider them.
In the nine years it has been in operation, the scheme has recorded 80,000 births. Dental cover has also been reviewed from Sh35,000 to Sh45,000. Optical has also been enhanced from Sh45,000 to Sh60,000. According to the insurer, they attend to about 400 optical cases and an equivalent number of dental cases daily. The in-patient cover now ranges from Sh1 million and Sh3 million. Previously, it ranged between Sh750,000 to Sh2.5 million. And outpatient, teachers’ cover has also been enhanced from Sh150,000 to Sh450,000. Previously the scheme ranged between Sh100,000 and Sh375,000.
Muthui said that the teachers’ cover now also covers fertility treatments such as in vitro fertilization (IVF). This is a type of fertility treatment where conception is done outside of the human body. The procedure can be used to prevent passing on genetic problems to a child. “One of the joys we have as the schemes administrators is when children are born out of the IVF process and we manage to be part of the journey from beginning to when the mother gets the child,” Muthui said.
Other enhanced benefits of the scheme include the provision of prosthetics which include artificial body parts within the inpatient function. The cover also provides baby-friendly vaccines, travel vaccines such as yellow fever and polio, diagnostic equipment such as blood pressure machines and glucometers, and family planning and fertility tests. The teachers’ scheme also covers alternative treatments such as acupuncture and chiropractor, rehabilitation of substance abuse and alcoholism within outpatient and inpatient for the principal member and their spouse.
It also emerged that plans are underway to roll out a separate cover that will cushion teachers in the event of death. The life cover– previously under Minet– will now be separated from the medical cover. Previously, the group life cover under Minet provided a minimum of Sh450,000 and a maximum of Sh1,050,000 as compensation for the death of a principal member. Currently, teachers only get funeral cover at a flat rate of Sh300,000 from their medical insurance scheme. The scheme is also currently providing medical treatment to seven overseas referrals in India. For International treatment, teachers get Sh2 million for international medical and Sh200,000 for international travel for the patient and one person.