KCB Simba Health write up 2022.

Inpatient Cover

Inpatient benefit Per family Per family Per family Per family Per family
access
Overall Cover Limit 1M 2M 3M 5M 10M
Bed limit (net of NHIF General Std. Std. Ensuite Ensuite
rebate) Ward Private Private
Bed Rate Maximum 10,000 20,000 20,000 25,000 30,000
limit
Emergency Evacuation Road & Road & Road & Road & Road &
Within East Africa (No Air Air Air Air Air
waiting period Africa) Ambulance Ambulance Ambulance Ambulance Ambulance
Hospitalization Fully Fully Fully Fully Fully
expenses including covered covered covered covered covered
surgeon, physician, within within within within within
theater, ICU &HDU inpatient inpatient inpatient inpatient inpatient
fees
Diagnostics and Fully Fully Fully Fully Fully
physiotherapists fee, covered covered covered covered covered
prescribed drugs, within within within within within
dressing, surgical inpatient inpatient inpatient inpatient inpatient
appliance
Accommodation costs Fully Fully Fully Fully Fully
for parent/guardian covered covered covered covered covered
accompanying child of within within within within within
Ten (10) years and inpatient inpatient inpatient inpatient inpatient
below
Funeral expenses per 100,000 120,000 150,000 200,000 250,000
person per annum
Pre-existing chronic 300,000 500,000 750,000 1,200,000 2,000,000
conditions, HIV AIDS
on full disclosure at the
time of joining (six
months waiting period)
Cancer and Dialysis (12
months waiting period)
Maternity and 75,000 100,000 150,000 200,000 250,000
related
complications

First Ever Emergency 100,000 125,000 175,000 200,000 250,000

caesarean Section&

KCB Bancassurance Intermediary Limited

Directors: Mrs. A. Kirenge (Chairman); Mrs. M. Kositany ; P. Russo; S. Makome; A. Mulumbi
www.kcbgroup.com
 related
complications

(Maternity & First

Ever Emergency
caesarean section
one year waiting
period)
Prematurity/ Neonatal 250,000 350,000 400,000 500,000 500,000
complications after
birth
Psychiatric & 150,000 200,000 300,000 350,000 400,000
Psychological
conditions

Newly diagnosed 300,000 750,000 1,000,000 1,500,000 3,000,000

chronic condition
subsequent year under
chronic sub limit (after
six months waiting
period)
Post-Hospitalization / 25,000 30,000 40,000 50,000 60,000
Rehabilitative
treatment related to
cause of pre-authorized
admission. Subject to
maximum of three
weeks
Inpatient accident Fully Fully Fully Fully Fully
related Dental and covered covered covered covered covered
Optical within within within within within
inpatient inpatient inpatient inpatient inpatient
Inpatient non- 100,000 150,000 200,000 250,000 300,000
accident-related
Optical treatment
Inpatient non-accident 100,000 150,000 200,000 250,000 300,000
related Dental
Gynecological surgery 250,000 300,000 350,000 400,000 500,000
(After six months
waiting period)
Congenital defects and 250,000 300,000 300,000 400,000 750,000
genetic disorders (after
six months waiting
period)
Internal and external 250,000 300,000 400,00 500,000 750,000
surgical implants,
appliances, joint
replacements, and
prostheses (excluding
dental fixtures)

KCB Bancassurance Intermediary Limited

Directors: Mrs. A. Kirenge (Chairman); Mrs. M. Kositany ; P. Russo; S. Makome; A. Mulumbi
www.kcbgroup.com
 Organ transplant after 250,000 300,000 400,000 500,000 750,000
two years of cover (cost
of donor or securing
the organ is excluded)
COVID19 and Related 300,000 500,000 500,000 500,000 500,000
complications
(Moderate/ Severe
cases)
Accidental death or 500,000 1,000,000 1,500,000 2,500,000 5,000,000
permanent total
disability for principal
and Spouse

Outpatient Cover Benefits (Kshs.):

Outpatient Per Per family Per family Per family Per family Per family
benefit family
access
Outpatient 50,000 100,000 150,000 200,000 250,000 300,000
Overall
cover Limit
Emergency No Road & Road & Road & Road & Road &
Evacuation waiting Air Air Air Air Air
Within East period Ambulanc Ambulanc Ambulanc Ambulanc Ambulanc
Africa e e e e e
Outpatient 5,000 10,000 20,000 25,000 30,000 35,000
Dental
Optical 5,000 10,000 20,000 25,000 30,000 35,000
(Frame
replacement
after 2 years
from date of
issue)
Vaccines KEPI KEPI KEPI KEPI KEPI KEPI
Baby Baby Baby Baby Baby Baby
Friendly Friendly Friendly Friendly Friendly Friendly
and and and and and and
private private private private private private
vaccines vaccines vaccines vaccines vaccines vaccines
(Chicken (Chicken (Chicken (Chicken (Chicken (Chicken
pox & pox & pox & pox & pox & pox &
MMR) MMR) MMR) MMR) MMR) MMR)
Outpatient Covered Covered Covered Covered Covered Covered
Chronic within the within the within the within the within the within the
conditions outpatien outpatient outpatient outpatient outpatient outpatient
(Six months t up to up to the up to the up to the up to the up to the
waiting the full full limit full limit full limit full limit full limit
period) limit

KCB Bancassurance Intermediary Limited

Directors: Mrs. A. Kirenge (Chairman); Mrs. M. Kositany ; P. Russo; S. Makome; A. Mulumbi
www.kcbgroup.com
 Outpatient Covered Covered Covered Covered Covered Covered
Cancer, within the within the within the within the within the within the
HIV/AIDS, outpatien outpatient outpatient outpatient outpatient outpatient
and related t up to up to the up to the up to the up to the up to the
conditions the full full limit full limit full limit full limit full limit
(Six months limit
waiting
period)
Congenital Covered Covered Covered Covered Covered Covered
defect and within the within the within the within the within the within the
genetic outpatien outpatient outpatient outpatient outpatient outpatient
disorders t up to up to the up to the up to the up to the up to the
(Six months the full full limit full limit full limit full limit full limit
waiting limit
period)
Out Patient
Health check
ups for
principal 0 20,000/= 20,000/= 40,000/= 40,000/= 60,000/=
member and
spouse once
a year
Outpatient
Infertility
treatment
(Six months 5,000/= 10,000/= 10,000/= 15,000/= 15,000/= 20,000/=
waiting
period)
Outpatient 5,000 5,000 5,000 5,000 10,000 10,000
Family
planning(Si
x months
waiting
period)

Stand-alone Covid-19 cover limits (can be bought as a separate cover):

NB: All benefits are subject to the overall cover limits per annum (Inpatient &
Outpatient)

INPATIENT COVER (subject to policy terms and conditions).

Summary of benefits
The policy provides comprehensive and flexible hospitalization (inpatient) cover, which includes
the following services:
• Hospital Accommodation Charges
• Doctor’s (Physician, Surgeon & Anesthetist) fees.
• ICU/HDU and Theatre charges.
• Drugs/Medicines, Dressings and Internal Surgical appliances.
KCB Bancassurance Intermediary Limited
Directors: Mrs. A. Kirenge (Chairman); Mrs. M. Kositany ; P. Russo; S. Makome; A. Mulumbi
www.kcbgroup.com
 • Pathology, X-ray, Ultrasound, ECG and Computerized Tomography, MRI Scans
• Chronic, Pre-existing conditions, Cancer, & HIV/AIDS including cost of ARVs
• Radiotherapy and Chemotherapy.
• In-patient Physiotherapy.
• Ambulance Services (Must lead to admission).
• Emergency Road and Air Evacuation subject to overall cover limit relating to inpatient or
daycare treatment only
• Day care surgery
• Home nursing care for critical illness
• Disease management program with specified providers / specialist
• Overseas treatment to India & South Africa on reimbursement and on credit in India only
with accredited providers. Air ticket for patient and accompanying person or guardian

The outpatient services (subject to policy terms and conditions).

These include:
• Outpatient benefit access
• Consultation to general practitioner
• Direct access to specialist consultation
• Diagnostic Laboratory and Radiology services.
• Prescribed physiotherapy.
• Medical checkup to include BMI, Blood Pressure, Blood Sugar and HIV test. (Principal
and spouse only)
• Cervical and PSA once per year
• Prescribed drugs and dressings.
• Chronic conditions up to outpatient limit.
• Vaccines: KEPI and or baby Friendly.
• Counselling
• X –rays, Electrodiaogram, Encephalogram and Audiogram,
• Chronic, Pre-existing conditions, Cancer, & HIV/AIDS including cost of ARVs covered
up to the full out-patient cover limit per family per annum.
• Travel Vaccines (Yellow Fever and Oral Polio)
• Routine Antenatal and Postnatal services

Note: Outpatient benefits will be up to a maximum of 15% of the Inpatient benefits but
within the provided options

Dental services (subject to Dental limit)

• Dental consultation.
• Dental treatment expenses (anaesthetists’ fees, operating theatre).

Dental exclusions shall include:

• Expenses arising from replacement or repairs of old dentures, bridges and plates unless
directly caused by accidental injury.

KCB Bancassurance Intermediary Limited

Directors: Mrs. A. Kirenge (Chairman); Mrs. M. Kositany ; P. Russo; S. Makome; A. Mulumbi
www.kcbgroup.com
 • Expenses relating to orthodontic treatment of a cosmetic nature unless directly caused by
a disease or accident.

Optical services (subject to Optical limit)

• Eye consultation - including refraction and eye examination.
• Check-up of glasses
• Post-surgical follow up reviews.
• Prescribed glasses (frames and contact lenses) subject to the optical sublimit.
Optical exclusions shall include:
• Replacement of optical frames in a period of less than 2 years from the date of issue.
• Replacement of lenses unless prescribed by a qualified Ophthalmologist, as necessary.
• Laser eye surgery for correction of sight

Additional Benefits

Additional benefits include:

• Accidental death or Permanent total disability of the principal member & spouse, 50% of
inpatient overall cover limit
• Last expense cover per person with a limit from Kshs, 100,000 to Kshs. 250,000 (The last
expense cover is payable on death of any of the declared family members subject to a
maximum of two claims per year).
• 24-hour emergency/ help lines

General Condition

Eligibility

• Own and legally adopted children are covered from birth to the age of 21 years
• Eligibility is all persons and their legal dependents from age of zero (0) months to
seventy-five (75) years. Existing members can continue renewing in the scheme for life
subject to renewal review by the underwriter
• The maximum joining age is 75 years
• All new entrants above the age of 55 years will be required to submit a medical report
from our selected service provider at their own cost.

Subject to the following conditions:

• The child must have been medically discharged from the hospital after birth at term (38
weeks).
• KCB Insurance Agency must be notified by a duly filled Application form to include the
child on cover within seven days from birth.
• Children above 21 years of age but below 25 years will continue to be covered under
their families if proof is provided to show that they are full time students at university or
regular college. (Student ID with Validity Period or Letter from Learning Institution will
suffice)

KCB Bancassurance Intermediary Limited

Directors: Mrs. A. Kirenge (Chairman); Mrs. M. Kositany ; P. Russo; S. Makome; A. Mulumbi
www.kcbgroup.com
Outpatient Co-payment

Provider Co-pay Applicable

The Aga Khan Hospital and satellite clinics Kes. 500/= per visit
The Nairobi Hospital and satellite clinics Kes. 500/= per visit
The Karen Hospital and satellite clinics Kes. 500/= per visit
Gertrude’s Children Hospital and satellite Kes. 500/= per visit
clinics
MP Shah Hospital and satellite clinics Kes. 300/= per visit
Mater Hospital and satellite clinics Kes. 300/= per visit
Other providers No Co-pay

Commencement of Cover
• Cover commences on every 1st and 15th day of the month.

Reimbursement
• Services received outside the provider panel will be reimbursed on 80-20% based on
APA’s approved rates.

Waiting Periods
• The standard waiting period is 15 days for all claims (including outpatient), except accidents
and medical emergencies.
• 60 days for surgical cases except accidental injuries incurred within the period cover
• 12 months for maternity and related conditions
• Inpatient & Outpatient six months for pre-existing and newly diagnosed, chronic,
congenital, HIV/AID related conditions, Gynaecological surgeries and internal /external
implants.
• 12 months for Cancer Inpatient treatment.
• 12 months for dialysis Inpatient treatment.
• Two years for organ transplant, optical frames.

Territorial Limit:

Republic of Kenya

TREATMENT OUTSIDE KENYA FOR CRITICAL ILLNESS

Members going outside the country for treatment

• If treatment is not available in Kenya the member is free to seek treatment outside
Kenya within the accredited providers and payment will be made up to the policy limit.
The underwriter will also arrange for treatment in India and pay the hospital directly up
to the maximum applicable limit. Cover will cater for Air ticket on Economy class for
patient and one accompanying person or guardian

• If treatment is available in Kenya but member prefer to go outside the country,

Member to inform KCB Insurance Agency or the underwriter and the claim will be
reimbursed at the same rates that would apply here in Kenya or at a rate agreed with the

KCB Bancassurance Intermediary Limited

Directors: Mrs. A. Kirenge (Chairman); Mrs. M. Kositany ; P. Russo; S. Makome; A. Mulumbi
www.kcbgroup.com
 underwriter but up to the maximum applicable limits. The policy will however not pay
for the air fares, accommodation outside the hospital and for the accompanying family.

Exclusions:

• Cosmetic surgery unless caused by accident

• General Health checkups except for principal and spouse
• Weight management treatments and drugs.
• Participations in professional & hazardous sports e.g., bungee jumping, paragliding
• Family planning/infertility related treatment i.e., cost of treatment related to infertility
and impotence
• Treatment other than by registered medical practitioner
• Self-referred or self-prescribed treatment.
• Nutritional supplements unless prescribed as part of medical treatment
• Costs of donating an organ or incurred while locating a replacement organ including
transport and administrative costs.
• Alternative treatment - Chiropractors, Acupuncturist, Herbalist and Ayurveda treatment
unless prescribed by a medical practitioner license by the Kenya Medical & Dentist
Board
• Drunkenness, drug addiction, Intentional self-injury, attempted suicide.
• War and Kindred risks (whether war be declared or not)
• Participation in Riot, Strike and Civil commotion
• Naval, Military or Air force operations
• Expenses recoverable under any other insurance e.g. NHIF, GPA, WIBA
• Beauty treatment in nature cure clinics or health hydro’s
• Diagnostic equipment (e.g. Glucometers, BP machines etc.) and hearing aids.
• Experimental treatment.
• Contamination by radio activity from nuclear fuel, waste, or fission
• Laser correction of eyesight
• Plano lenses and photochromatic lenses
• Stay at sanatoria, old age homes, place of rest
• Claims and costs for treatment in respect of medical expenses incurred after the expiry
date of the policy period arising from accidental bodily injury and/or illness occurring
during the policy period unless the policy has been renewed
• Any claim from a member whose application for medical insurance shall contain any
willful misstatements or misrepresentation or who shall have willfully withheld any
material information (including information withheld on the member’s behalf)

KCB Bancassurance Intermediary Limited

Directors: Mrs. A. Kirenge (Chairman); Mrs. M. Kositany ; P. Russo; S. Makome; A. Mulumbi
www.kcbgroup.com
KCB Bancassurance Intermediary Limited
Directors: Mrs. A. Kirenge (Chairman); Mrs. M. Kositany ; P. Russo; S. Makome; A. Mulumbi
www.kcbgroup.com