By Roy Hezron
A total of 524,527 teachers and their dependants have benefited from optical consultations and given spectacles since inception of the medical scheme, a recent report by the teachers’ medical service provider, AON Minet, has shown.
The report shows that on average, 240 teachers and their dependants visit various accredited health facilities for optical consultation daily, which is the highest number of visits recorded across all in and outpatient, maternity and dental services.
It further shows that in a month there are 7,285 visits while in a year it comes to a total of 87,421 visits on average; with all the visits seeking optical services.
The 2015/2016 period recorded the highest number of hospital visits of teachers seeking optical services at 141,454 visits.
Optical consultations basically involve routine and annual eye examination, primary eye care, contact lens fittings and evaluation, prescription services and vision rehabilitation services for patients experiencing vision impairment.
In most cases, specialists normally prescribe for low vision, high power, pediatric, specialty lens, bi-optics, and special filters, among others.
The report shows further that approximately 12 million hospital services have been recorded since the inception of the cover. 10.5 million were outpatient visits, 342,000 were inpatient hospitalizations, 525,000 were optical consultations and issuance of spectacles, while dental services inched towards the 400,000 mark.
In addition, there were about 5,000 hospital visits per day ranging from outpatient, dental, optical, maternity and inpatient care, with outpatient leading at 88 per cent.
In a given year, the scheme pays death-in-service benefits to about 1,000 families that have been left behind by the passing on of a teacher, with funds being paid to aid in funeral expenses (Ksh200,000) and a lump sum (Ksh450,000 to Ksh1,050,000) to assist the family financially through the declared next of kin.
The teachers’ scheme will go down in the books of medical insurance history as one which was the first to accept to cater for Covid-19-related hospitalizations. About 1,000 members have benefited with costs approximated at Ksh300 million.
Over 80,000 babies have been born under the medical scheme since its inception with the report showing about 117,000 episodes, which translate to an estimated 70 per cent of the visits being recorded for the last 7 years.
In 2020/2021 alone, the total visits were 39,503; the highest number since inception of the scheme. The last time the scheme recorded the highest number of visits on maternity was in 2017/2018 period when a total of 24,186 was reported.
On average, the total number of visits by teachers and their dependents under maternity benefit per year is 19, 418, with a total of 1,618 visits being recorded as monthly average, or 53 per day.
The teachers’ medical scheme covers more than one million people, including the 339,369 registered teachers in various job groups and a total of 742,820 registered dependents. It is one of the largest insurance contracts in the history of medical insurance in the country, an agreement between Techers Service Commission (TSC) and AON-Minet.
The teachers’ scheme will go down in the books of medical insurance history as one which was the first to accept to cater for Covid-19-related hospitalizations. About 1,000 members have benefited with costs approximated at Ksh300 million.
The report further indicates that under the scheme, 1,900 families have benefited from a common pool that provides ‘excess-over-benefit’ as a cushion to teachers under Group Excess of Loss benefit.
7-day rule
Minet notes that there is misinterpretation of scheme rules by service providers such as the 7-day rule, adding that it has written circulars to them on interpretation and adherence to the policy.
Minet states that as per the capitation agreement between the payer and the service provider, the latter is required to provide quality services to all teachers without warranting a return to hospital for primary healthcare unless for a different diagnosis or a complication.
If a member returns to hospital within 7days for the same condition, the agreement states that the member should be attended to and the visit shall not be charged to the member’s account. The member should never be asked to pay out of pocket.
“There are no daily limits for outpatient services. Based on the capitation agreement with the service providers, the service provider is required to provide all the services required as per the diagnosis and the mode of treatment,” states Minet in the report.
Outside scope
According to Minet, scheme exclusions include massages (except where certified as medically necessary), cosmetic treatment (unless relating to an accident), and treatment other than that done by a registered medical practitioner.
Others are active participation in war, invasion, riots or terrorism, nutritional supplements unless prescribed by a doctor as part of the treatment of a deficiency, maternity cover for dependent children, medical expenses following attempted suicide, self-prescribed drugs, infertility investigations and family planning procedures and expenses.
Cosmetic dental care (cosmetic crowns, caps, bridges, orthodontics and dentures), self-prescribed teeth cleaning and whitening, and replacement and repair of old dentures, bridges and plates, are also excluded from the cover.
In addition, there can be no cover for replacement of spectacle frames within the same year of cover, unless necessitated by a medical condition. There is also no reimbursement of costs incurred outside the appointed panel of providers unless for emergency and accident cases, and only cases that have been pre-authorised by Minet.
Private vaccines and travel vaccines, alcohol-related rehabilitation, as well as photo chromatic and/or anti-glare lenses are excluded unless they form part of the prescription lenses, and treatment otherwise covered by the National Health Insurance Fund (NHIF).
