Teachers will no longer be asked for copayment under their medical cover once they make hospital visits. According to Medical Administrator Kenya Limited (MAKL), no co-pay fee will be charged to any of its members with effect from June 1.

The letter signed by MAKL Chief Operating Officer, Parmanand Mishra stated that this is applicable for Teachers Service Commission (TSC) medical scheme. “This is to bring to your attention that no copayment fee will be charged to any of the MAKL members with effect from June 1” said Mishra. Similarly, Mishra said that no seven-day rule will be applicable.

“Please note that there is no seven days rule application. Ensure all our members are accorded with medical services as and when they require. Also remember to indicate physical discharge on Premium SMS (PSMS) to enable the claiming process,” Mishra said in the letter to medical service providers covering teachers among other schemes.

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The teachers also accuse the Teachers Service Commission (TSC) of allocating Sh60 million to a “ghost” company for actuarial services without advertising for competitive bidding.Of the total contractual amount of Sh53 billion signed between Minet and TSC, Sh51.4 billion has been allocated to the master capitator—Bliss Health Care Services.A tabulation of the three-year contract between TSC and Minet presented before Justice Bernard Odongo Manani Matanga by the teachers led by Mathai Boniface Ndirangu, shows how the Sh51 billion will be spent by Bliss.

The petitioners have named TSC and Minet Kenya as the respondents.As per the contract, which will run for three years, Bliss has allocated Sh32 billion for outpatient, Sh13.6 billion for in-patient, maternity (Sh2.07 billion), dental (Sh1.3 billion), optical (Sh2.2 million) and evacuation services Sh179 million.Minet has objected to the petition alleging there is no employer-employee relationship between the company and the teachers to warrant their being sued in the employment court.

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But the teachers argue that Minet signed a contract with their employer, TSC, so they have been properly sued. They have told Justice Matanga that the case is properly before him having been referred by the Constitutional Court, which handles rights issues.

“So there is no reason why teachers should be turned away or asked to top-up by a medical administrator brought on board by Bliss,” state the petitioners.Teachers are required to pay Sh100 (co-pay) before getting services yet they have unlimited in-patient and out-patient benefits.

Fake company?The court has been told that TSC is paying Sh20 million per year for actuarial services to a company they alleged is phoney.They add that the Sh60 million allocated for the services can be used to issue job and medical cards to teachers who will spend Sh3 billion of the contractual Sh53 billion for a system to identify them when they visit Bliss hospitals for treatment. Teachers do not have job identification cards.

Medical Administrators (K) Limited (MAKL), the aggrieved teachers say, was brought on board by Minet to ensure that they are not turned away from hospitals, yet Mr Mathai says he did not get treatment at Guru Nanak Hospital recently on grounds that he was not properly identified. The court has further been told that MAKL and Bliss are “one and the same in terms of ownership, and yet they are paid separately.

”Further teachers have faulted TSC for violating Article 277 (1) when it listed Star Discover Insurance Limited and Star Discover Life Insurance as part of the companies to bid for the Sh53 billion tender when they were just six months old and lacked the requisite capacity to bid for public tenders.

The petitioners say that from the contract documents, Star Discover Life Insurance, Star Discover Insurance Limited and MAKL share the same physical address—ARC Place Nyangumi Road—and postal address number 3421– Nyayo Stadium.“This means the three companies are run from the same office and place and are owned by the same person,” Mr Mathai says in an affidavit.Mr Mathai states that teachers are not asking the court to cancel the contract but to give directions to ease the authorisation process, which is frustrating.

There should be no limitation in the number of times a teacher accesses medical care in approved medical facilities, insurance firm managing the scheme has affirmed.

Minet Kenya chief executive Sammy Muthui said some service providers had misinterpreted the seven-day rule to frustrate teachers and then accuse the insurer of mishandling them.

“We like the truth and own up when there are problems and try to solve them. Under the seven-day rule, there is no limitation to treatment… There is no limit on the number of visits but providers, because they are motivated to make more money, misinterpret the rule and then distress our teachers,” he said at a media workshop.

Minet Kenya, Muthui said, had started taking disciplinary action against service providers who misinterpret the rule.

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He said if a member returns to the hospital within seven days for the same condition, the agreement states that the member should be attended to and the visit should not be charged to the members’ account.

This means the teacher should never be asked to pay out of pocket. “It is rogue service providers who want to charge capitation more times than they are allowed,” said Muthui.

“The seven-day rule should be for that incident that was treated. Even when someone is paying in cash, if you go for dressing, you do not get charged for consultation every time. We have not seen a situation where a dependent is locked out because of the seven-day rule and if there are such cases it should not happen.”

Muthui said that in 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.

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“Please note that 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.”

Minet Kenya was contracted by Teachers Service Commission (TSC) to manage teachers’ medical scheme since 2015.

To reach out to more teachers, Muthui said, they have been increasing the number of providers, including government hospitals, so that remote areas can be served well.

He said the insurer is in talks with Council of Governors to allow the insurer to accredit all government hospitals though the challenge at hand is that most do no have the administrative capability to do all the online transactions needed.

“There are cases of inadequate service providers in some areas and we have to work with what is on the ground but that does not mean we can just work with everyone. Sometimes we even blacklist some providers and have about 20 cases for service providers across the country,” he said.

Currently, Minet Kenya works with 34 public facilities which have been added to the service providers’ panel.

In all, there are 577 outpatient, 367 inpatient, 338 maternity, 95 optical and 154 dental service providers in all 47 counties.

Teachers previously earned a monthly medical allowance, which ranged from Sh954 to Sh4,412.

However, there was a policy shift to grant teachers a medical scheme to improve their welfare.

Owing to constraints in budgetary provisions, TSC settled for a hybrid insurance model namely capitation financing model and fully insured component.

“This scheme continues to cushion 341,760 teachers and 1.7 million households against the Covid-19 pandemic,” says the TSC.

A brief by Minet Kenya, the firm contracted by TSC to manage the scheme, revealed more than 10 ways that teachers, their dependents and hospitals use to fleece the scheme.

They include impersonation, billing for services not rendered, billing for conditions not covered under the scheme, double billing of medical expenses and falsification of the length of stay of patients in hospitals.

Incorrect reporting of diagnosis or procedures, false and unnecessary prescription of drugs, abnormal utilisation of services, bribery and unethical inducement are also ways used to cheat.

Mutheu cited impersonation as one of the most unethical ways both teachers and medical facilities exploit the scheme.

“We are talking about public funds and we have a duty to care. We have a legal and investigations department dealing with these. As we speak, many cases are under investigation and dozen others in court,” said Muthui.

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He explained that in most cases, hospitals collude with teachers to abet impersonation.

“As we speak we have about six IVF patients who are not scheme members. This is an expensive treatment and we are presently carrying out investigations,” said Muthui.

He said male teachers have been caught taking members of their second family to benefit from the scheme against the laid down rules.

Muthui said in most cases, teachers use their identity to help their relatives such as parents, siblings, or unregistered spouses.

“In our African setup and tradition, your cousin may have a similar name as yours. Your niece or nephew may have the same name as your children. So they use the same name to get treatment from hospitals,” said Muthui.

“When the preauthorisation team comes, they find a totally different person from the listed beneficiary on the hospital bed.”

Impersonation is also done by teachers to cheat maternity cover. “In most cases, you find the person who is on the bed is not the one on the scheme roll,” said Muthui.

“For teachers who are caught in this malpractice we pass them over to TSC for the disciplinary procedure,” he added.

It also emerged that some hospitals make huge claims based on false diagnoses while others presented bills for members who were never admitted.

In other cases, the health facilities demand payment for patients not even treated.

“Other facilities also cheat on the number of days patients were admitted,” said Muthui.

Some hospitals also make claims on services not covered under the medical scheme. “They (hospitals) manufacture bills and forward them for payments,” said Muthui.

He said in the past, the scheme administrator has had cases where some hospitals made claims for gynaecological and maternity services offered for male members of the scheme.

Cases of bribery have also been reported among teachers and hospitals.

“We have had cases where hospitals bribed scheme members or members’ representatives to cover up false claims and other corrupt practices,” said Muthui.

“In one such case, a patient confirmed that no breast ultrasound or excision was carried out, yet the two services were included in the final bills.”

Teachers service provide Aon Minet has introduced an app, deemed walimucare app to enhance better medical service among the teaching staff. The app was developed after there emerged several complaints among teachers. Some of the complaints included, among others; poor services, inadequate specialized medical personnel and lack of drugs in some hospitals. To visit your preffered healcare service, click here.

Walimucare app is projected to solve all these problems. Through the walimucare app, registered teachers will be able to access the following services;

• Order for medication
• Find a minet accredited hospital close to them
• Manage their dependents list by adding more dependents
• Give feedback on medical services for instant action
• Track hospital visits
• Get access to covid-19 health tips

Apart from the app, minet has also developed most of its healthcare service providers. For instance, it has broken its contract with some of the hospitals that were giving teachers a raw deal for dirty gains, and signed new contracts with more competent health facilities.

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Minet has also increased the number of health care providers, and tried to install facilities even in village market centres to save teachers the agony of spending too much money travelling to access services in towns. In case of any harrasment at any hospital, teachers are free to speak to the minet managers here.

To access walimucare app, all that teachers need is a smart phone. Walimucare app can be downloaded from google play store.

The Teachers Service Commission (TSC) has requested its employees who are aged 58 and above to stay at home and work from home. This comes after a realization that persons aged 58 and above have reduced immunity and are at a higher risk of succumbing to covid-19 and related infections in case infected.

In the new development, all Covid-19 ailments among teachers an their dependants will be fully covered by AON MINET, the teachers’ medical scheme.

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All teachers with pre-existing medical conditions like hypertension and diabetes were also directed by TSC to work from home.

“They can be utilized in offering critical duties such as preparing schemes of work, teaching aids and marking, among others. We assure them of the safety of their jobs,” said Dr. Nancy Macharia.

According the data revealed by Kenya National Union of Teachers (Knut), more than 50,000 teachers are aged 55 years and above

“Some of these teachers already have underlying conditions and the employer must conduct a serious audit to ascertain the exact number and how they can be helped,” said Wilson Sossion, the Knut secretary general.

According to Sossion, even younger teachers with pre-existing medical conditions should also work from home since they are at a higher risk of contracting Covid-19. An audit report is underway to identify these teachers and relieve them temporarily.

“These teachers are now in the frontline and must be protected fully by the employer,” the KNUT boss added.

Macharia assured teachers during the Tuesday brief that their medical needs would be taken care of.

“The commission has negotiated with the teachers’ medical provider, for teachers to be covered for all Covid-19 related illnesses,” said TSC boss told teachers.

AON Minet, through its CEO, pledged its commitment to cover teachers and their dependants even with the exponential rise in covid-19 cases.

“The main insurance practice in our market, however, is to have sub-limits for preexisting chronic conditions. The teachers’ scheme does not have such sub-limits,” said Minet CEO, Sammy Muthui.

Kenya Secondary School Heads Association (KESSHA) national chairman, Kahi Indimuli agreed with the proposal,  but challenged Minet Kenya to communicate the same to all AON MINET medical facilities.

“We hope that they have communicated that to the health facilities so that teachers do not get turned away,” Indimuli said.

Minet Kenya issued a Covid-19 Incidence Reporting USSD code, *202*07# that will assist teachers to report to Minet, any suspected or confirmed Covid-19 cases.

Teachers have yet another reason to be inspired as Rose Nyamunga, a nominated senator, has sworn not rest until teachers are freed from AON MINET or given improved health care by the latter. The Ruto allied senator empathized with teachers as she highlighted the frustrations teachers have experienced under the bogus health insurance provider. ‘Your employees are suffering seriously and you are seated watching. Rise from your comfort and give hope to the teachers,’ said rose Nyamunga to the Teachers Service Commission, TSC.

Senate Probe

Nyamunga’s plea forced the senate to open an investigation process, accusing AON MINET of acutely frustrating teachers in the name of offering health services.

The teachers service commission remitted ksh. 9B to AON MINET in the year 2020 and Ksh.12B this year, yet teachers receive low value health care under the service providers.

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Introduction of AON MINET as a health care service provider to teachers resulted to loss of medical allowance from teachers’ pay slips. The lowest paid teacher had a medical allowance of ksh. 3870 per month, an amount which unexpectedly shocked the entire senate.

Those set for interrogation by the Senate committee on Education include AON Minet management, TSC, and the Kenya National Union of Teachers (KNUT).Nyamunga questioned why teachers receive poor health services under AON MINET, that are not commensurate to the medical allowance that they lost. “How can teachers undergo double deductions on their pay slips both for National Hospital Insurance Fund (NHIF) and AON MINET yet there are no commensurate services?” Nyamunga questions AON management and TSC.

‘There is very low capitation on outpatient services with some teachers capped at as low as Sh900, which is inclusive of doctors’ consultations, tests and drugs. The teachers of this country are a frustrated lot and they feel their lives are potentially endangered by the poor services being offered under the AON MINET Kenya medical insurance cover,” says Nyamunga.

The Senate committee on education summoned KNUT Secretary-General Wilson Sossion to appear before it on 4^th November to respond to the allegations of Ms Nyamunga over gross mistreatment of teachers in the hands of AON MINET

Nyamunga insists that these concerns of below standard services by AON MINET are very serious and that TSC must fulfill the teachers’ need for quality healthcare.

“The decision to introduce a medical cover for teachers was very good because it was a step in the right direction. However, there appears to be glaring gaps and challenges that must be addressed by the employer immediately,” insists the furious Nyamunga.

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She quotes Article 43 (1) (a) of the Constitution which states,” Every person has a right to the highest attainable standard of health, which includes the right to healthcare services.”

Medical Allowance Back To Pay slips

If Nyamunga wins in her quest, then teachers will have medical allowance back to their pay slips, or TSC will contract a more competent health care provider to serve teachers.