Blow to Teachers As Hospitals Turn Away AoN Beneficiaries

Blow to Teachers As Hospitals Turn Away AoN Beneficiaries

Blow to Teachers As Hospitals Turn Away AoN Beneficiaries

Teachers, police, and prison guards face a  health care crisis as hospitals refuse to  provide medical care because they are not  paid for unpaid capitation claims.

Hospitals contend that their inability to continue providing treatment is due to the  significant sum of Sh5 billion in unpaid capitation claims.

Teachers are not the only government employees who are struggling financially—police and prison officials are also affected since the government withholds money  from their paychecks.

Hospitals are having trouble receiving payments on time even though the  government gave Sh13.6 billion to the National Police Service Commission  (NPSC) and Sh17.6 billion to the Teachers Service Commission (TSC) for medical  insurance in the current fiscal year.

Police and prison staff are covered by a comprehensive program that includes  medical cover, last expense, group life, Group Personal Accident (GPA), Work Injury  Benefits Act (Wiba), and last expense.

The situation has prompted investigations by both the Senate and the National Assembly, particularly focusing on the legal status of Medical Administrators Kenya Limited (MAKL). This private company’s delay in processing capitation claims has raised concerns and drawn the ire of hospitals.

Nominated Senator Raphael Chimera has called for the Health Committee of the Senate to summon key stakeholders, including Minet Kenya and MAKL, to provide explanations.

Chimera also questions the legality of capitation as practiced in Kenya, suggesting the possibility of a forensic audit by Auditor-General Nancy Gathungu. The audit would seek clarity on the administration of schemes for teachers, police, and prison officers, demanding transparency from insurance companies regarding owed amounts, services rendered, and the current status of payments to hospitals.

Several hospitals , such as Nairobi West Hospital owed Sh576.79 million in outstanding medical claims, have issued ultimatums to MAKL, threatening to suspend medical services unless payments are made promptly.

This financial strain has severe implications, impacting hospital operations, including the ability to pay doctors, service providers, and suppliers, as well as procure essential medical supplies.

The core issue revolves around the role of MAKL as a private company in administering capitation claims for insurance schemes. Both the National Assembly and the Senate express concern over the disguised nature of this arrangement, highlighting that the procurement of insurance for TSC and police is presented as an insurance scheme. Minet Kenya and a consortium of insurance companies, led by CIC General Insurance Limited, act as intermediaries, channeling premiums provided by the government to MAKL for capitation purposes.

However, the intricate dynamics of this system result in hospitals negotiating with MAKL for low capitation fees, aiming to maximize profits. This, in turn, leads to frustrations for insured individuals, with hospitals either denying services outright or causing delays, forcing patients to seek alternative financing or facing severe health consequences.

The goal of the Senate’s inquiry is to address the core problems with the  management of these healthcare programs and provide clarification on the reason  behind the  delayed claim processing. Important parties, such as TSC, NPSC, and the Insurance Regulatory Authority (IRA),  are anticipated to give an explanation of the steps they have taken to address the  issues raised by MAKL’s capitation claim handling.

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