Definitions for your Medical Insurance Cover (Individuals)

Membership Eligibility

  • Age Definition:
    • Child: New Babies born after 38 weeks of gestation to full term to 18 years.
    • Adult: 19 years and above.
  • Joining Age is from birth (38 weeks of gestation to full term) up to 64 years of age.
  • In case of a child born prematurely, membership shall commence one month from the date the child ought to have been born full term.
  • Child applicants must join under a parent or adult guardian
  • Adult Dependant (except the spouse) are required to fill in their own application forms
  • All new applicants over 50 years will be required to undergo a Medical Examination at specific providers prior to being accepted as members. This will be at the applicant’s cost.
  • Members aged 65 years and above are only covered on renewal and are required to undergo a medical examination annually before each renewal. This will be at the applicant’s cost, however, members with Annual Well person Check Up Benefit can utilize this benefit before the cover end date.
  • At the time of application for membership, the applicant must have been discharged from hospital should there have been an admission.
  • Full disclosure of all medical information is mandatory. Failure to disclose means the member will be terminated with no option for a refund.

Medical Service Access

  • All In and Out-patient services can only be obtained from our appointed Medical Service Providers as per the plan purchased. These lists are subject to change from time to time. We currently have over 850 hospitals, clinics, doctors and other healthcare providers across East Africa.
  • Members have access to the Resolution Insurance Enhanced Medical Provider List or Standard Medical Provider List as per plan selected.
  • Frontline: Services can be accessed directly from these providers.
  • Referral: Services are on referral basis only by a Frontline provider or through Resolution Pre-authorization.
  • Members must present their Resolution Insurance Membership Card at the Medical Service Providers for identification.
  • Member validity will be verified by the Medical Service Provider representative prior to service delivery.
  • Members shall be required to sign the Resolution Insurance Claim Form at the Medical Service Provider.

Hospitalization Services

Includes the following while the member is hospitalized:

  • Surgical operations and procedures
  • Professional fees
  • Theatre fees
  • Anaesthetics for surgery
  • Assistants at operations
  • Ward accommodation
  • Intensive care and high care units
  • Visits and consultation by a GP and / or Specialist (while hospitalized)
  • X-ray and lab (while hospitalized)
  • Physiotherapy
  • Ultrasound scans (while hospitalized)
  • MRI and CT scan (while hospitalized)
  • Blood transfusion
  • Internal prostheses
  • Medicine dispensed and used in hospital
  • Medicine dispensed on discharge from hospital 100% of cost (maximum of 14 days’ supply)

Exceptional Customer Care Services

  1. Care management – We have a professional care management team that will provide guidance and facilitate access to best possible medical care wherever you may be.
  2. Chronic Disease Management Program – Through the program, Resolution Insurance facilitates management of chronic illness in conjunction with skilled medical professionals in various specialties.
  3. Medical Advisory services – Have difficulty in making healthy choices, options or adjustment to healthy lifestyle? Look no further. We would be glad to guide you.
  4. Wellness Programs – They empower you with knowledge and updates on medical advancements, so that you enjoy quality fulfilling life.

Hospital Admissions

  • All scheduled hospital admissions must be reported to Resolution Insurance at least 48 hours prior to admission, while emergency admissions must be reported within 24 hours of admission. Please seek written pre-authorization through the contacts at the back of your Resolution Insurance Membership Card.
  • Members are not required to pay any deposits; Resolution Insurance will co-ordinate admissions through our existing arrangements with hospitals and doctors on the medical service provider list.
  • Admission will strictly be by doctors on our select panel as per our Medical Service Providers list.
  • Resolution Insurance shall pay all approved bills less National Hospital Insurance Fund (NHIF) rebates.
  • Daily cash/Hospital cash is applicable after 3 days of admission up to a maximum of 180 days except in cases of maternity and pregnancy related admission where it is not applicable. Daily cash payable for admissions under the pre-existing sublimit will be paid from the same sublimit. This benefit is only eligible to working adults.
  • Home care services
  • This includes home based health and nursing services provided by visiting professionals such as a nurse, physiotherapist or home health agency. This benefit is provided post discharge where medically necessary. Access is subject to approval and is coordinated by Resolution Insurance Pre-authorization Team. The service is limited to a maximum of 90 days per membership year.

Lodger fee

Lodger fee is an accommodation charge for a parent or guardian accompanying a child up to 10 years of age during an admission.

Maternity Benefit

This includes:

  • In-patient cost incurred for normal and caesarean deliveries
  • Labour and recovery wards
  • Professional fees
  • Pregnancy & Maternity related hospitalization
  • Other related ailments and complications including ectopic pregnancies and miscarriages.
  • Home deliveries (pre-authorization required)
  • Lamaze classes (pre-authorization required)

Waiting periods

  • All membership benefits commence after the waiting period has been served except for hospitalization following an accident, which is covered from the date of commencement of cover.
  • 21 days waiting period for all Out-patient services.
  • 30 days waiting period for all illness admissions.
  • Chronic conditions diagnosed within 6 months of joining shall be covered under the pre-existing limit and are subject to applicable waiting period.
  • 10 months waiting period for all maternity services and pregnancy related conditions.
  • 10 months waiting period from the start date for cataract, lipoma and hernia surgeries; myomectomy; adenoidectomy; tonsillectomy; hysterectomy and any treatment for related conditions.
  • 12 months waiting period for chronic, declared pre-existing & congenital conditions and all related conditions.

Annual Well Person Check-up Benefits (For Principal & Spouse Only)

  • Annual Well person check up that includes the following:
    • Comprehensive History & physical exam
    • Random blood sugar
    • Urea, Electrolytes creatinine (kidney functions)
    • Liver function test
    • Stool for occult
    • ECG (Electrocardiogram)
  • Nutritional consultation: One consultation per year
  • Lipid profile: One test per year
  • Pap smear: One test per year for women
  • Mammogram: One test every two years for Women
  • Prostate Cancer (Prostate Specific Antigen, PSA) Screening: One test per year for men.

To access the services above, members are required to contact us through the contacts appearing at the back of your Resolution Insurance Membership card.

These services are only available at selected providers on the Resolution Medical Service Provider List.

International Emergency Cover

  • International emergency cover where applicable is limited to 60 days per membership year and caters for emergency admissions only.
  • All emergencies that arise out of any condition that is subject to a sublimit (stated as per cover plan) will be covered upto the applicable sublimit.

Overseas Evacuation Cover

Overseas evacuation cover only applies in cases where treatment is not available locally and the same must be authorized and arranged by Resolution Insurance.

Emergency Evacuation

Covers transportation of a member from a hospital in one geographical region where adequate medical facilities are not available to an appropriate medical facility as determined by Resolution Insurance. Evacuation shall be provided based on the member’s specified benefit limit.

Emergency Ambulance Service

Covers transportation of a seriously ill or injured person from the scene of an accident, or the scene of a medical event, to the nearest hospital or health facility, in order to, receive urgently needed treatment. It does not include transportation to hospital for the routine management of an ongoing medical condition or transportation between Hospitals.

Travel Cover

MEMBERS INTERNATIONAL AND INCOUNTRY TRAVEL INSURANCE
BENEFITS INCLUDED IN MEDICAL PROGRAMMESWorldwideExcess
Assistance Services  
24 hour Assistance HelplineServicesN/A
Emergency Cash Advance$2,000N/A
Consular ReferralServiceN/A
Emergency Travel and Accommodation ArrangementsServiceN/A
Replacement of lost travel documentsServiceN/A
Message RelayServiceN/A
Section B –Emergency Medical and other expenses  
Emergency Medical Expenses (In-patient & Out-patient)$100,000$100
Accident Only when travelling by Road – In country (Personal Accident)$10,000Nil
Evacuation and repatriation of mortal remains or funeral  expenses$5,000Nil
Coffin Expenses whilst travelling In country$500Nil
Emergency Dental treatment$2,000Nil
Overseas hospital confinementYes Nil
Additional travel and accommodation expenses due to illness$2,000Nil
Compassionate visit overseasEconomy class flight for one family memberNil
Annual Accumulation Limit $100,000$100

Note: In country travel – A single trip that is more than 300 kilometres.

  • One must notify Resolution Insurance and get a written approval of cover before the travel benefit can kick in
  • The travel benefit is applicable for travel periods not more than 60 days (cumulative)
  • Terms & Exclusions of Travel Cover available on our website or on request
  • For members with Value Plans, International Emergency Cover and any other medical expenses arising from a trip will be covered under Travel Cover.

Changes To & Cancellation of Membership

  • Any changes to membership can only be made within the first 30 days from the date of commencement of cover as communicated by Resolution Insurance. This is provided that no claims have been incurred.
  • Premium is non-refundable after 30 days of commencement of cover.
  • 80% of premium is refundable in case of cancellation within 30 days of cover commencement date if no claims have been incurred.

Misrepresentation and Fraud

It is a term and condition of membership that at the time of application, the member discloses all medical information whether material or not that is within the member’s knowledge. This includes:

  • Non-disclosure of any material information will render the membership null and void.
  • Membership terminated as a result of misrepresentation or none disclosure, may result in legal proceedings being instituted to recover monies paid on any claim, under the said membership.
  • The decision to institute such proceedings shall be made by Resolution at is sole discretion.
  • All premiums paid for membership terminated as provided shall be forfeited.
  • The agreement adopts the terms and conditions as provided in the member application form duly completed and signed by the member.
  • It is understood that a breach of any of those terms, conditions and undertaking by the member is automatic breach thereof.

Notes

  • All members of a family will be required to take up the same product line. Dependants are not allowed to have higher benefits than the principal member. Our products lines are Value plans and Harmony plans.
  • Resolution Insurance shall pay all approved claims less applicable NHIF rebates.
  • For In-patient Bed allowance, if your entitlement is not available, you should access a bed not exceeding their entitlement as stated under the cover plan.
  • New Born Baby Illness Cover is a benefit under the mother’s annual limit if the mother is eligible for maternity benefit. It covers care for babies born prematurely, illness after birth and before discharge.
  • Personal Accident cover provides accidental death, permanent total disability (PTD) or critical illness benefit. Child guard is a Personal Accident cover for children. These vary as per plan selected.
  • The Personal Accident claim on Death, PTD and Critical Illness, is payable only on one of the benefits and is limited to once in a lifetime.
  • Recovery of over utilization amounts: Member / applicants undertake to repay the scheme any amounts paid under circumstances where no benefits were payable under the terms and conditions of the scheme. Acknowledgment should be on the form.
  • Rehabilitation benefit includes aiding a member, following an admission due to illness or accident using medically necessary practices to manage their current medical status. A consultant has to confirm in writing that rehabilitation is required.
    • Services offered are Physiotherapy services, Hydrotherapy and Post Admission Consultation Reviews.
    • Rehabilitation is subject to a specific number of days, or a sub-limit whichever occurs earlier.
  • External Prosthesis as an in-patient benefit covered up to Kshs.100,000
  • Third party recovery: Where costs incurred are recoverable from a third party, the Member shall facilitate Resolution Insurance involvement to ensure it recovers such costs from and through all relevant parties.
  • Continuous Resolution membership means having been on cover with Resolution insurance for more than one 12-month cycle with no lapses in between the cycles. Once a member lapses, they will reapply as new members.
  • A Pre-existing condition refers to a medical condition (whether declared or not) of which a member was aware, or in the company’s opinion, ought to have known existed prior to becoming member.
  • A congenital condition is a genetic, physical or (bio) chemical defect, disease or malformation which may be either hereditary/familial or due to an influence during intra uterine development of the foetus and which may or may not be obvious at birth.
  • A chronic condition is defined as an illness that has no known cure; likely to recur; needs prolonged monitoring and treatment by a specialist; is permanent; or is caused by changes in the body that cannot be reversed. Such conditions include but not limited to: Arthritis, Hypertension, Diabetes, Asthma, HIV/AIDS and Cancer etc.
  • A dependant is defined as:
    • A legally married spouse as evidenced by a marriage certificate or affidavit.
    • A child under the age of 18 as evidenced with birth certificates.

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