1. In case of change of spouse one will be required to produce one or more of the following depending on each case-
-A sworn affidavit from the Magistrate or marriage certificate
-Copy of ID for both parties
-Death certificate for deceased spouse
-Coloured passport size photo(s)
2. For change of ID details, one will be required to produce a copy of the National ID.
3. For updating of dependant’s records (child), one will be required to produce birth notification / certificate/immunization (Child Health Card) and/also the necessary documents supporting adoption or fostering of a child and coloured passport size photo(s)
4. For updating of dependant’s records (spouse), one will be required to produce copy of ID, a sworn affidavit from the Magistrate or marriage certificate and coloured passport size photo(s)
In order for your claim to be processed, the following are required:-
1. Fill NHIF 3 (Claim form) correctly.
2. Original NHIF card and a clear photocopy.
3. Certificates of contribution paid (CCP), if applicable and MUST cover the period of hospitalization.
4. Original receipt and hospital FINAL INVOICE indicating date of admission and the date of discharge and both should bear hospital seal.
Note: For G.O.K hospitals without hospital seal, the receipt and invoice should bear hospital rubber stamp.
5. Attach clear photocopies of Identity document and that of spouse in case the spouse was the patient. The Identity document number quoted should be the one attached e.g. National ID, Passport or Aliens certificate.
6. In case 90 days have elapsed from the date the patient was discharged, one must write a letter explaining the reasons behind the delay in submitting the claim.
7. Attach clear copy of discharge summary/Doctor’s letter (sealed or stamped by hospital) as it applies.
8. In case ones medical bills were cleared by the employer or insurance company an authority letter is required to direct on who should be paid.
9. If the hospital bill was settled by credit card a receipt must be issued.
10. The claim covers contributors, their spouses and children as below:-
-Below 18 years of age
-Between 18-21 years are fully dependant on the contributor
-Over 18 years and attending full time course, evidence of attendance of school should be attached
-Over 18 years but mentally or physically sick and fully dependant on the contributor, a doctors’ letter to prove sickness or disability should be attached.
Note: A clear copy of birth certificate or birth notification should be attached for the above to prove age and relationship to the contributor. Letter of authority for use of card for dependants over 18 years must be given by the Branch Manager.
11. Alterations on hospital documents should be counter-signed by authorized hospital official and rubber-stamped by the hospital.
12. All cards for self-employed persons must be accompanied by a contributor’s payment receipt and must cover the month of hospitalization. In case of late contribution, the receipt for penalty should be attached.
13. The contributor must sign ALL the claim forms. 14. If original receipt and invoice are with the Employer, Advocate or Insurance firm, attach clear certified copies of originals, by whoever is holding them and should be sealed by the hospital.
15. If a contributor is deceased :-
-A death certificate or burial permit must be attached
-Payment will be through District Commissioner unless a letter of administration of the deceased estate is attached.
16. For foreign claims:
-Fill in NHIF 3b (claim form) correctly.
Attach a passport and visa, bearing dates of entry and exit from Kenya to the country of hospitalization and back.
-Attach referral letter from a resident doctor.
Note: All the above conditions for general claims apply.
17. Procedure for foreign claimsThe claim is then sent back to the office of origin for processing
18. Upon receiving, the claim should be stamped, perused and verified for proper documentation, captured and put under investigation.
19. The claim is then sent to the Manager claim who then forwards it to General Manager Operations for approval.
-All general claims including foreign claims are paid vide cheques except those amounting to Kshs. 2000 and below.
-General claims from hospitals under contract A and B i.e. comprehensive cover will be paid at rebate or at cost whichever is lower.
-General claims from hospitals that have signed maternity and C/S packages will be paid at rebate or at cost, whichever is lower.
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