Today, I attended a Question and answer session with a Minet County Manager. I have tried to piece together the queries and responses; here below:

Query: Under what circumstances does the approval team *refuse* to authorize a procedure that has been advised by *a specialist* yet they are not in a position to see the patient?

Response – We depend on diagnostic tests and medical reports from the specialists to determine whether or not an admission is justified. Whenever on is sick, the specialist will use these lab test results to determine plan of management. In most cases that are rejected, either the medical test results have not been shared or the medical reports and plan of management are unclear.

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Query: If my optical cover is 50000/- and I have not fully utilized it; why must I be confined to replace my glasses only once in a year?

Response – Replacement is spectacles once a year is common practice across the insurance industry to curb misuse. Our improvement of the benefit from 10K in the past to the current 60K is to make it possible for the entire family that is covered to be able to access service should they need. Also note – You are only restricted to one replacement per year for frames only. Incase it is changing lenses due to changed prescription, this will be approved.

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Query: Why should the cover be broken into small categories like dental, optical etc.

What is so different if all the amount is attached to my name say 2000000/- p.a.

Then whenever I visit the hospital for whatever reason, you just deduct the amount spent and I get to know my balance?

For instance, why give me a maternity cover of 300000/ and I have attained Menopause?

Response: I will respond to this with an example of simple analogy like motor insurance. Windscreen, car stereo etc. are covered separately from the rest of the car in comprehensive insurance. This is because these are high risk items that can lead to misuse of cover. Similarly, health insurance is categorized as such. While designing a product, all these are put into consideration and proper products are put in place with good options to manage such.

From a personal and knowledgeable point of view, I think it is important that I tell you that teachers have a good cover, compared to other corporate schemes we have in the industry. The challenges faced could be due to the model of administration chosen by TSC due to the numbers involved.

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Query: Upon retirement, how long does one still benefit from the cover?

Response: Currently, upon retirement, the member/dependants will cease to access cover immediately we receive exit instructions from TSC which is mostly within a month or two. In the past contract, we had a window for the member enjoying the cover until the end of that particular policy year in which they retired. TSC sends us update data (with entrants/exits) monthly.

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Query: Why do you sometimes unnecessarily take too long to approve admissions?

Response: Delays in approval for discharge are mainly due to back and forth on requested documentation and sometimes disagreements in cost between the insurer and hospitals. Ideally, standard TAT when all is well agreed is 15-30 minutes upon submission of all discharge documents.

 

It is also good to know that for the insurer, discharge time is when the hospital has shared with us a discharge request with all documentation. Some members complain of discharge delays from when the doctor has informed them that they are discharged, yet the same has not been communicated to the insurer.

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Query: Why is the capitation restrictions per visit still apply despite the 7-day wait being removed?. Was it a cosmetic language to massage members? You visit a hospital then you’re told they have approved drugs only for 3 days. That you are advised to come after 3 days to collect the remaining prescription. Reason – Minet approved a smaller amount. What is this animal of restricting drugs already approved by a specialist for a certain period?. Supposedly the distance from one residential point is challenged to access the said facility?.

Isn’t it making sense to understand that someone is incurring cost to collect drugs already approved?

Response: Coming From an opinion I gave above, I mentioned that the challenge with the cover could probably be the model administration chosen by the client (TSC). The model for this scheme is Capitation.

Capitation is a model whereby a fixed rate of reimbursement is agreed between the insurer and the hospital for all outpatient visits. The amount is reached at upon review of different cost items that inform what rate the hospital will be reimbursed.

That does not mean that the member should be restricted to services that amount to this rate. I will give an example. If I went to a hospital whose rate is 2k and I only have a scratch to be cleaned and dressed, the hospital will claim 2k even if the service was only 500 bob. Similarly, If I visit the same facility and I have need for services that eventually cost 3K, the hospital will still claim 2k. The idea is that the excesses paid for most primary outpatient services (which form 80% of hospital visits) should cushion the deficits by the few chronic cases (20%.

This is agreed with the hospitals at contracting and any hospital the sends you away due to exhaustion of capitation should be reported since this is contract malpractice, and we usually highlight specific scenarios with them with facts. We have channels to report either by contacting our call centre or via USSD *202*07#.

Again, please note that hospitals are in business and will want to make the most no matter what policies are in place. Should you be given insufficient medication on account of this, please reach out to us while still in hospital.

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Query: On the last expense cover.

My thought was that it is supposed to assist the family in planning for a descent send off to the teacher, unless that is not the case. We lost a colleague sometimes in March and it has taken forever for the same to be effected.

Response: True. However, the below contributes to this delay.

1. All next of kin who make death claims needs to be confirmed by TSC. Teachers ought to have a nominated next of kin while they are alive. This can be updated any time during the service of a teacher. Most times, the claimants we receive are different from what is in the teacher’s file.
2. Family disputes – Some disputes occur between family members on who should be paid, and this stops us from processing anything until everything is agreed upon to avoid litigation.
3. Documentation – sometimes, when on makes a claim for a fallen teacher and they are asked to provide certain documents for claim processing, they delay in providing the same.
4. Delay of funds – the TSC medical team is run by a consortium of 9 institutions. Death benefits are funded by Pioneer Assurance and Star Discovery General Insurance. Once everything is confirmed by TSC, Minet engages these companies to provide funds for settlement which sometime delay.

For your case, I request that you share with me the specific member number separately then I will check and give clear advise on where and why there is a delay if not fast track for speedy settlement.

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Question: kindly say something on rehabilitation cover. To which extent does Minet cover ?

Response: Thanks for asking about this. In the past, alcohol rehabilitation was an exclusion on the scheme. However, after presenting the feedback we received from teachers and other stakeholders to TSC on this, the same was accepted in this current contract.

The medical scheme will cover for a 3 month rehabilitation of a teacher or spouse in accredited facilities upon prescription by a qualified accredited facility and permission of leave to the teacher by the county TSC HR office.

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Question: Why is it that the maternity benefit is higher for senior teachers yet the majority of them no longer plan to have children?

Response: Kindly note that the medical benefits are pegged on Job Groups set out by the employer and therefore, when the Client places a tender, these are the specifics that we work with.

However, we have learnt that many young and productive teachers lie within job groups B5 to C5 and they maternity benefits are lower.  This is feedback we have received in different forums and escalated. The main request is that the benefits be inverted, and we await feedback from the client on this.

Question: In diagnostics especially radiology there has been a tendency by minet to ask teachers to seek help from NHIF first. Why is it the case?

Response: I believe you are talking about MRI and CT Scan. This is true. Common practice is that for anyone formally employed (like you and Me), they have an NHIF deduction and part of what this covers is these imaging diagnostic scans.

However, for the last few years, NHIF went from approving the total cost of the scans to approving half, a small amount of the cost and sometimes, they decline in totality. As a policy issue, we will request proof of approval or decline from NHIF for these services so that we can approve the difference or if declined, we can approve the total amount.

In insurance, there is a something called the Principle of Contribution where an insurer is not allowed to pay for a service which is also paid for by another insurer at the same time.

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Query:  kindly say something on the last respect cover. How long does it take the family of the deceased (God forbid)  to get the money? The procedure that should be followed?

Response

The claimant is requested to provide the following details:

• Original or a certified Copy of the Burial Permit
• ID copy of the Next of Kin (front and back page)
• ID copy or Surrender of ID form for the deceased (front and back page of ID)
• Relationship of claimant to the deceased
• Telephone number of the next of kin.
• A copy of the ATM card, deposit slip or bank statement of the Next of Kin indicating the account number, the account name, the bank and the branch where the account was opened (This is to confirm the account is active).
• Duly completed Minet Bank Details form
• Death certificate for claims reported 6 months after occurrence.