OBLIGATIONS

The scheme has three parties the member, NHIF and the Health Care Facility, whose roles are outlined below;-

 

• Obligations of the Member The member shall:

1. Register with NHIF and declare all eligible dependants;
2. Provide necessary and correct documentation & information of

themselves and dependants;

• Update all beneficiaries in a timely manner;

1. Not engage in fraudulent activities in order to unlawfully obtain

benefits; and

1. Abide by the provision of the Contract on benefit package and

selection of health care providers.

1. Where a member is not able to access services as stipulated, they are encouraged to call or visit the nearest NHIF office for further

 

• Obligations of the Health Care Providers The health care provider shall:

1. Render the agreed range of health services to bonafide Scheme members and their beneficiaries;
2. Maintain high standards of quality healthcare services;

• Not engage in any fraudulent activities in order to unlawfully obtain

payments or any other benefits.

1. Fully abide by the provision of the contracts signed between the facility and NHIF.

 

• Obligations of NHIF

The obligation of the Fund in relation to the Member and Health Care providers shall be as follows:

1. Accredit and contract healthcare providers;
2. Provide a list of accredited and contracted healthcare facilities;

• Register and issue members with membership cards;

1. Receive premiums;
2. Ensure adherence to the terms of agreement by all parties;
3. Pay the service providers in a timely manner; and

• Sensitize all stakeholders on the

 

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9.0 EXCLUSIONS

Exclusions are those services which are not covered in the benefit package. They may include but not limited to expenses incurred by a beneficiary as a result of:

1. Cosmetic or beauty treatment and/or surgery;
2. Massage (except where certified as a necessary part of physiotherapy

following an accident or illness);

• Treatments arising from non-accredited health facilities and/or un- authorized referrals;

1. Expenses recoverable under any other insurance;
2. Treatment by chiropractors, acupuncturists and herbalists or stays and /or maintenance or treatment received in nature cure clinics or similar establishments or private beds registered within a healthcare provider, convalescent and /or rest homes with ‘cures’ attached to such establishments;
3. Vaccines except KEPI vaccines, Rota virus vaccine, Anti – rabies, Anti

–Snake venom, Yellow Fever (NHIF to liaise with the Ministry of Health

and County Governments in the provision of the Vaccines);

• Investigations, treatment, surgery for obesity or its sequel, cosmetic or

beauty treatment and or surgery;

• Claims expenses for Members who are outside the country on official

duty for a period exceeding more than six weeks at any one visit.

1. Charges recoverable under any Work Injury Benefits Act (WIBA) or

any other medical plan; and

1. Any other restrictions as provided for in the negotiated