Queries over new NHIF directive to cap medical claims

A new move by the National Hospital Insurance Fund to manage the caps of benefits enjoyed by members and their dependants has caused an uproar among Kenyans.

An internal memo from the Fund’s director of operations and quality assurance, Mr Ambrose Lugho, leaked on Facebook, informs staff that a client claim control system which will be used for pre-authorised surgeries and dialysis services is now ready for deployment.

The letter, dated July 14 and titled Deployment of LOU’s System Controls, advises that, moving forward, members — who pay monthly premiums of between Sh500 and Sh1,700 — will only enjoy limited access to the improved benefits introduced last year.

The affected benefits include surgery, specialised radiological and diagnostic services, as well as specialised laboratory tests like magnetic resonance imaging (MRI) and computed tomography scans (CT-Scans).


Beginning this month, Mr Lugho notes, each family will only be able to access one specialised surgery, two major surgeries, three minor surgeries, four cycles of “complex” chemotherapy, six cycles of basic chemotherapy, two MRI services, and two CT-Scans annually.

The Fund will also pay for 20 sessions of radiotherapy per member per year.

“The deployment is effective July 14 at 3pm,” adds the letter.

The limit controls will also affect dialysis, with notification of two sessions per family within seven days, directs Mr Lugho in the letter.


On Tuesday, however, some NHIF branches across the country said they were yet to get any communication from the head office on the matter.

We could also not confirm what informed the to drastically cap the national insurer’s claims.

The Fund last year announced new rebates and improved benefits for its members.

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Under the new scheme, NHIF, via a new category of specialised radiological and diagnostic services benefits, will pay Sh25,000 per session for cancer patients who access the services in any accredited hospital.


The national medical insurer will also pay Sh18,000 per session for those accessing radiotherapy, and foot up to Sh5,000 for clinical reviews monthly.

For those who need specialised laboratory tests like magnetic resonance imaging and computed tomography scans (CT-Scan), the insurer said it would offset a bill of up to Sh15,000 and Sh8,000, respectively.

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Eight months after announcing the new benefits, NHIF went on introduce a surgical benefit package which would deal with major, minor and specialised surgeries, including cancer surgeries, for its members to ease the burden of healthcare.

Major surgeries in levels 3 and 4 hospitals are currently upto a maximum of Sh80,000, and in levels 5 and 6 up to a maximum of Sh130,000, on pre-authorization basis. Specialised treatment is currently capped at a maximum of Sh500,000.

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