FAMILY MEDICAL PLAN (JANUARY 2015)
TABLE OF BENEFITS
Benefit No.
A1
Benefit Description
Afya A
Afya AA
Afya AAA
Afya AAA+
Territory covered
INPATIENT (IP) BENEFITS:
Accident & Emergencies, Intensive Care, Intensive Coronary Care and
Theatre costs.
Hospital accommodation in General Wards
Hospital accommodation in Private Rooms
Nursing fees, medical expenses and ancillary charges
Surgeons', consultants', anaesthetists', medical practitioner's fees
Prescribed medicines and drugs
Reconstructive surgery following an accident or following surgery for an
eligible medical condition
Prostheses: artificial body parts designed to form permanet parts of an
insured person's body
MRI and CT scans
X-rays, pathology, diagnostic tests and procedures
Oncology tests, drugs and consultants' fees including cover for
chemotherapy and radiotherapy
Phsiotherapy by a registered physiotherapist, when referred by a
medicalpractitioner, consultant or specialist
Parent accommodation, insured parent with an insured child under 18
years of age in hospital
Maternity, Child birth and Ceaserian section up to a maximum of 10% of
the Family IP Limit.
Tanzania
Tanzania & India
East Africa & India
Africa & India
Covered
Covered
Covered
Covered
Covered
Not Covered
Covered
Covered
Covered
Covered
Not Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered after 18
months
Covered after 24
months
Covered
Covered after 18
months
Covered after 24
months
Covered
Covered after 24 months
Covered
Covered after 18
months
Covered after 24
months
Covered
Covered
Covered
Covered
Pre-existing conditions as on the day of inception of policy
A2
Post hospitalisation treatment received within 90 days of being
discharged from hospital
Covered
Covered
Accidental damage to natural teeth
Covered
Covered
EMERGENCY MEDICALLY EQUIPPED AMBULANCE (Coverage within IP Benefit Limit only within Tanzania)
Covered after 18 months
Costs of Knight Support road ambulance transport required due to an
emergency or medical necessity to the nearest available and
appropriate local hospital
Covered
Covered
Covered
Covered
Not Covered
Not Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered subject to a
maximum of TShs.
600,000/- per member
Covered subject to a
maximum of TShs.
1,000,000/- per
member
Covered subject to a
maximum of TShs.
2,000,000/- per member
Covered subject to a
maximum of TShs.
4,000,000/- per
member
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered after 12
months
Covered
Covered
Covered
Covered
Covered
Covered after 12
months
Covered
ORGAN TRANSPLANT (Coverage within IP Benefit Limit)
A3
Cost of the surgical procedures in performing an organ transplant of
either: kidney, liver, heart, lung, or heart and lung, in respect of the
insured person as recipient and not the organ donor
NURSING AT HOME (Coverage within IP Benefit Limit only within Tanzania)
A4
Primary care services of a reqistered nurse in the insured person's
home immediately after, or instead of, in-patient or daycare treatment
EMERGENCY EVACUATION (Coverage within IP Benefit Limit)
A5
B
The transportation costs, subject to limits mentioned, of an insured
person to the nearest centre where adequate medical facilities are
available. Payment of this benefit, including cost of treatment incurred,
will be subject to the insured person suffering from a medical condition;
(a) that necessitates the insured person being placed on a critical list,
and, (b) for which, in our opinion, adequate treatment is not available in
the place where the insured person is located.
OUT - PATIENT TREATMENT (coverage within Out-patient Benefit Limit only within Tanzania)
Primary consultations and treatment to include medical practitioners'
fees, prescribed medicines, drugs and dressings only for acute
conditions
Covered
X-rays, pathology, diagnostic tests and procedures
Covered
Specialists' and consultants' fees for consultations, prescribed
medicines,drugs and dressings
Covered
Physiotherapy by a registered physiotherapist, when referred by a
medical practitioner, consutant or specialist only on post trauma and
where trauma care was provided under this cover.
Covered
Oncology tests, drugs and consultants' fees including cover for
chemotherapy and radiotherapy
Covered
MRI and CT scans
Covered
Covered after 12
Medication, Diagnostic tests and consultaion for Chronic Conditions
months
Out-patient surgical operations
Covered
Covered after 12 months
Covered
Annual Family Benefit Limits
Inpatient
M Only
M+1
M+2
M+3
M+4
M+5
Outpatient
M Only
M+1
M+2
M+3
M+4
M+5
Afya A
TZS 10,000,000
TZS 12,500,000
TZS 15,000,000
TZS 17,500,000
TZS 20,000,000
TZS 20,000,000
Afya A
TZS 500,000
TZS 650,000
TZS 800,000
TZS 950,000
TZS 1,100,000
TZS 1,100,000
Afya AA
TZS 20,000,000
TZS 25,000,000
TZS 30,000,000
TZS 35,000,000
TZS 40,000,000
TZS 40,000,000
Afya AA
TZS 750,000
TZS 950,000
TZS 1,150,000
TZS 1,350,000
TZS 1,550,000
TZS 1,550,000
Afya AAA
TZS 30,000,000
TZS 37,500,000
TZS 45,000,000
TZS 52,500,000
TZS 60,000,000
TZS 60,000,000
Afya AAA
TZS 1,000,000
TZS 1,250,000
TZS 1,500,000
TZS 1,750,000
TZS 2,000,000
TZS 2,000,000
Afya AAA+
TZS 50,000,000
TZS 62,500,000
TZS 75,000,000
TZS 87,500,000
TZS 100,000,000
TZS 100,000,000
Afya AAA+
TZS 1,000,000
TZS 1,250,000
TZS 1,500,000
TZS 1,750,000
TZS 2,000,000
TZS 2,000,000
Waiting Periods:

Pre-existing conditions whether or not it was known to the member - 12 months

Maternity including Ceasarian Section and termination of pregnancy due to any cause - 9 months

Foreign Treatment other than for pre-existing conditions - 6onths

Foreign Treatment for pre-existing conditions - 12 months

Chronic Outpatient Benefits - 18 months

Inpatient treatment for Chronic Conditions that was pre-existing - 18 months.
Exclusions:

All claims within the respective Waiting Periods.

All claims for treatment outside the territorial limits of the policy.

All claims during the period when the payment of premium or deemed premium is outstanding for more than 15 days from intimation.

All claims for treatment received after the expiration of the policy unless the policy is renewed without break in coverage.

All claims for reimbursement of expenses where pre-authorisation was not sought and given by us.

All claims for reimbursement unless authorised in writing by us before incurring the expense.

All claims incurred at a Provider not associated with us on Credit Basis.

For other exclusions please refer the policy document.
Underwriting guidelines:

Policy will be effective from the 1st day of the month succeeding the month in which payment of premium in full has been made.

Proposers aged 50 years and over could be covered only if the family has atleast 2 other dependants below 50 years of age.

The maximum age limit for entry into the scheme would be 59 years (should not have completed 60 years).

The whole family consisting of proposer (principal member), legal spouse and all dependant children have to be covered under the plan.

Dependent children are those below the age of 18 years and unmarried and also those between 18 years and 25 years who are unmarried and continuing full time education.