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CoopCare

A Health Insurance solution built for Cooperative Members

We do health insurance differently - with more coverage,
less hassle, and perks that give you the most out of your premium.

What is CoopCare?

This is a medical product tailormade for Cooperative members and affiliates with a minimum membership of 4 principal members. The product allows members for a cooperative to enjoy a group cover on fairly priced group terms. The product covers Inpatient, Outpatient, Maternity, Dental, Optical and Last Expense benefits. One may choose to purchase Inpatient only or both Inpatient and Outpatient benefits.

Affordability is at the center of this product with a carefully selected low-cost provider panel mainly encompassing mission hospitals and low-cost private hospitals.

Members can take up the product as a family package allowing up to six dependents  or as a member only. Any family beyond the member and six dependents category will attract a minimal additional premium to cover the extra dependents.

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How it Works

  • Product type: micro health insurance
  • The product allows members of a cooperative to enjoy a group cover on fairly priced group terms.
  • This is a medical product tailor-made for registered Cooperative members with a minimum membership of 4 principal members.
  • Once a Cooperative hit the threshold count of 4 principal members or more, the relevant Cooperative administrator verifies the details and submits to CIC for policy creation.
  • Once the registered members are verified and premium settled by the Cooperative, the member policies are activated and begin running at the start of the following month.
  • CoopCare Health insurance photo cards will be issued within 5 workings days on submission of full documentation from the Cooperative.
  • Where the threshold of the minimum number of 4 verified members isn’t met or payment from the Cooperative isn’t received, the members are pushed to the next month for verification and activation of their policies.

Benefits Summary

CoopCare Benefit

BenefitInpatientOutpatientMaternityDentalOpticalLast ExpenseAccomodation (Net of NHIF)
Family/ PersonFamilyFamilyFamilyFamilyFamilyFamilyBed Type
Option 1100,00030,00015,0005,0005,00050,000Ward Bed
Option 2200,00040,00020,0005,0005,00050,000Ward Bed
Option 3300,00050,00025,0007,5007,50050,000Ward Bed

CoopCare Benefit Summary

Benefits Cover SummaryLimit of CoverSublimit/ Stand Alone
Inpatient maternity complicationsMaternity and 1st ever emergency caesarian section are mutually exclusive and cannot both be accessed in the same policy year.
1st Ever Emergency CaesarianUp to Kes. 30,000Sublimit of inpatient
Antenatal and postnatalCovered within the outpatient up to the full limitSub limit of inpatient
Inpatient pre-existing Conditions/pre-existing Chronic conditionsUp to 50% of the Inpatient cover limit Newly diagnosed to be covered up to the full limit.Sub limit of inpatient
Congenital and prematurity conditionsUp to Kes. 50,000 per familySub limit of inpatient
Accommodation/Bed CapacityAs per table above net of NHIF Where a member does does not have NHIF, the member shall be required to copay Kes 500 for every day of admission.Sub limit of inpatient
Last ExpenseAs per table aboveStand alone
Inpatient psychiatryKes. 20% of overall inpatient cover Sublimit of inpatient
Inpatient Non-accidental Dental SurgeryKes. 30,000 of overall inpatient coverSublimit of inpatient
Inpatient Non-accidental Opthalmological SurgeryKes. 30,000 of overall inpatient coverSublimit of inpatient
PosthospitalizationCovered up to Kes 20,000 within Inpatient on reimbursement basis up to 4 weeks post discharge.Sublimit of inpatient
Terrorism, Political war and ViolenceCovered up to the full limit subject to the claimant not being an active participant.Sublimit of both inpatient and outpatient.
VaccinesKEPI vaccines.Sub limit of outpatient
Outpatient Chronic conditionsCovered within the outpatient up to the full limit.Sublimit of outpatient
Outpatient congenital conditionsCovered within the outpatient up to the full limit.Sublimit of outpatient
Outpatient HIV/AIDS and related conditionsCovered within the outpatient up to the full limit.Sublimit of outpatient
Lodger feesPayable up to 12 yearsInpatient
ICU and HDU coverCovered within the applicable benefit limitSublimit of inpatient
External aids including corsets, walking frames, wheelchairsCovered within Inpatient up to Kes 30,000Sublimit of inpatient
Air evacuationNot coveredN/A
Outpatient Ambulance servicesNot coveredN/A
Health Check-upNot coveredN/A
Joining age37 weeks subject to dischargeN/A
Overseas referralNot coveredN/A
Covid - 19Covered up to full Inpatient for Option 1, Covered up to Kes 150,000 for Option 2, within Inpatient Covered up to Kes 200,000 for Option 3, within Inpatient. Outpatient treatment is covered up to full Outpatient limit. Outpatient tests are capped at Kes 6,000 per test within Outpatient. The test must be prescribed by a doctor. Covid testing for purposes of travel is excluded. Inpatient and Outpatient as applicable

Special Terms

  1. Waiting periods
    • No waiting period for accident related admissions
    • 1 year for pre existing & chronic conditions treatment.
    • 1 year waiting period for maternity related treatment.
  2. Eligible age for Children from birth (born at full term of 37 weeks) to 18 years; 21 years up to 25 years subject to proof of full time learning with proof from the learning institution.
  3. Eligible age for Principle member and spouse – up to 70 years.
  4. Geographical limit is Kenya only.
  5. Lodging facilities for parent accompanying a child below 12 years being admitted
  6. Copay of Kes 100 applies to every outpatient visit.
  7. Members without NHIF shall be required to copay Kes 500 for every day of admission
  8. Access is strictly within the designated panel provided.
  9. Members will access services through Photo cards. Cost of card replacement for lost or damaged card is Kes 300 per card.
10. Dental benefits which covers;

  • Cost of fillings
  • Root canal
  • X-rays
  • Polishing and scaling necessitated by a prevailing medical conditions and authorized by a doctor.
  • Tooth extractions including surgical extraction together with anesthetics fees
  • Decay
  • Accidental dental injury.
  •  Consultation

11. Optical benefits which covers;

  • Expenses relating to eye treatment
  • Accidental eye injury.
  • Consultation.
  • Eye testing
  • Treatment arising from injury to the eyes caused solely and directly by accident external and visible means or arising from a disease affecting the eye or optical nerve.
  • The supply of Lenses
  • The prescribed spectacles will be acquired from an approved optician limited to one pair every two years.

Exclusions

  1. Cosmetic surgery unless caused by accident
  2. Weight management treatments and drugs.
  3. Hazardous sports e.g., bungee jumping, paragliding
  4. Family planning/infertility related treatment
  5. Treatment other than by registered medical practitioner
  6. Self-referred or self-prescribed treatment.
  7. Scaling, crowns, bridges, orthodontics, and dentures.
  8. Nutritional supplements unless prescribed as part of medical treatment.
  9. Specialists Fees.
  10. Alternative treatment – Chiropractors, Acupuncturist, Herbalist.
  11. Drunkenness, drug addiction, Intentional self-injury, attempted suicide.
  12. War and Kindred risks (whether war be declared or not).
  13. Participation in Riot, Strike and Civil commotion.
  14. Naval, Military or Air force operations.
  15. Expenses recoverable under any other insurance e.g. NHIF, GPA, WIBA.
  16. Beauty treatment in nature cures clinics or health hydro’s.
17. External surgical appliances – unless benefit has been provided for.
18. Diagnostic equipment (e.g. Glucometers, BP machines etc.) and hearing aids.
19. Experimental treatment.
20. Contamination by radio activity from nuclear fuel, waste or fission.
21. Laser correction of eye sight
22. Pregnancy related treatment for dependants other than the spouse if covered on the benefit schedule.
23. Optical exclusions – Plano prescriptions, +/-0.25 prescriptions, photo chromatic lenses, antiglare coatings.
24. Bills incurred by doctors/hospitals outside the CIC designated panel.
25. Pandemic & Epidemic occurrence.

  • Expenses relating to eye treatment
  • Accidental eye injury.
  • Consultation.
  • Eye testing
  •  Treatment arising from injury to the eyes caused solely and directly by accident external and visible means or arising from a disease affecting the eye or optical nerve.
  •  The supply of Lenses The prescribed spectacles will be acquired from an approved optician limited to one pair every two years.

Frequently Asked Question on CIC Coop Care

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