DEFMIS

DEFMIS Patient and Hospital Guidelines

WELCOME TO DEFMIS
Dear Esteemed Member, Welcome to the Kenya Defence Forces medical Insurance Scheme (DEFMIS). The card that you have been issued with certiﬁes that you are a fully paid-up member and you may now start accessing medicare as stipulated in our Trust Deed. You will be required to carry it with you whenever you seek treatment and produce it at the receptions of the scheme's accredited hospitals. Unless otherwise directed, you will seek treatment as a hospital patient and not directly from a specialist. Visit our website defmis.org for a list of accredited hospitals. At the hospital's reception/accident and emergency centre you will be required to duly ﬁll Part I of the DEFMIS claim form and be sure to sign in order to facilitate payment for the services rendered to the institution promptly. Each dependant has his/her own card and are the only persons authorized to receive treatment. Ensure they fully understand this obligation. Failure to observe these provisions may render you liable to meet your treatment expenses. The medical cover takes care of you and your spouse for life. Your children, who must be single are covered up to their 21st birthday after which they cease to be members, regardless of their marital status or whether or not they are still school-going. For in-patient health care, the scheme shall pay 100% of the legitimate bills incurred by you during your hospitalization provided that the total payment with respect to you and your dependants in one calendar year shall be subject to a maximum of Kenya Shillings Two Million (Shs 2,000,000/=). The scheme pays for general ward bed only. You will be required to pay for any extra costs for a suite, private wing or other preferential treatment. During admission the hospital must inform the scheme for pre-authorisation. During the same time you are expected to know your limits because any extra bill beyond limits must be paid to the hospital by the members. All inpatient cases must be with approval of DEFMIS through pre-authorization letters which the hospital will seek (Except in cases of accident or acute medical emergency). In cases of accidents or acute medical emergency, the hospital will inform the Trust within 24 hours. Thereafter, the hospital will send a report on the third and seventh day then weekly if hospitalization continues. For out-patient healthcare, the scheme shall pay 75% of legitimate bills incurred by you or your dependant while you shall be responsible for 25% of the total bill provided that the total payment with respect to you and your dependants in any given calendar year shall be subject to a maximum of Kenya Shillings Four Hundred Thousand (Shs 400,000/=). Should you fall sick at an area where there are no accredited hospitals, you may seek treatment at any healthcare facility available, provided that you have contacted the MD or any member of the Management Team. It is mandatory that when you fall sick, you be seen by a General Practitioner (GP) doctor who will in turn recommend you for further treatment. Kindly note that a member who becomes aware of the death of any other member has a responsibility of reporting such death to the Scheme.

WELCOME TO DEFMIS

Dear Esteemed Member,

Welcome to the Kenya Defence Forces medical Insurance Scheme (DEFMIS). The card that you have been issued with certiﬁes that you are a fully paid-up member and you may now start accessing medicare as stipulated in our Trust Deed. You will be required to carry it with you whenever you seek treatment and produce it at the receptions of the scheme's accredited hospitals. Unless otherwise directed, you will seek treatment as a hospital patient and not directly from a specialist. Visit our website defmis.org for a list of accredited hospitals.

At the hospital's reception/accident and emergency centre you will be required to duly ﬁll Part I of the DEFMIS claim form and be sure to sign in order to facilitate payment for the services rendered to the institution promptly. Each dependant has his/her own card and are the only persons authorized to receive treatment. Ensure they fully understand this obligation. Failure to observe these provisions may render you liable to meet your treatment expenses.

The medical cover takes care of you and your spouse for life. Your children, who must be single are covered up to their 21st birthday after which they cease to be members, regardless of their marital status or whether or not they are still school-going.

For in-patient health care, the scheme shall pay 100% of the legitimate bills incurred by you during your hospitalization provided that the total payment with respect to you and your dependants in one calendar year shall be subject to a maximum of Kenya Shillings Two Million (Shs 2,000,000/=). The scheme pays for general ward bed only. You will be required to pay for any extra costs for a suite, private wing or other preferential treatment. During admission the hospital must inform the scheme for pre-authorisation. During the same time you are expected to know your limits because any extra bill beyond limits must be paid to the hospital by the members.

All inpatient cases must be with approval of DEFMIS through pre-authorization letters which the hospital will seek (Except in cases of accident or acute medical emergency). In cases of accidents or acute medical emergency, the hospital will inform the Trust within 24 hours. Thereafter, the hospital will send a report on the third and seventh day then weekly if hospitalization continues.

For out-patient healthcare, the scheme shall pay 75% of legitimate bills incurred by you or your dependant while you shall be responsible for 25% of the total bill provided that the total payment with respect to you and your dependants in any given calendar year shall be subject to a maximum of Kenya Shillings Four Hundred Thousand (Shs 400,000/=).

Should you fall sick at an area where there are no accredited hospitals, you may seek treatment at any healthcare facility available, provided that you have contacted the MD or any member of the Management Team. It is mandatory that when you fall sick, you be seen by a General Practitioner (GP) doctor who will in turn recommend you for further treatment.

Kindly note that a member who becomes aware of the death of any other member has a responsibility of reporting such death to the Scheme.

PROCEDURES FOR ATTENDING TO DEFMIS PATIENTS
1	Members will be seen as hospital patients and will be required to carry their membership cards and National ID Cards for identification purposes. Each dependant has his/her own card with the owner’s picture, ID card/birth certificate number and expiry dates on the children's cards.
2	Verification is done using fingerprint biometrics captured during the initial hospital visit or via OTP in exceptional cases using the Smart Access system. Members can monitor their coverage through the Smart Access App (available on Google Play and Apple App Store) or by dialing 891#. Smart Access App Steps:* Self Registration - Register with phone/email - Receive OTP - Enter OTP - Set password and complete setup Insurer Initiated - Receive Member Code - Enter Member Code - Receive OTP - Enter OTP - Set password (auto-fill details) Link Cover - Use Member Code or Self-Registered flow - Enter Service Number to generate cover Hospital Visit - Tap "Initiate Visit" to get Visit Code - Hospital uses code to retrieve details - Register two fingerprints (for new members) - Billing follows; end visit with biometric Children under age 6 are linked to parent/guardian. For help: Call Smart Access (0203206000/0709326000) or DEFMIS ICT (0793531197 / 0793666333).
3	All patients are required to pay 25% of the total outpatient bill, reflected on both invoice and receipt. Some facilities (e.g., military, faith-based) may be exempt — refer to defmis.org.
4	For all inpatients and day-case procedures under general anaesthesia, the Scheme pays 100% of the bill.
5	Day-case procedures under local anaesthesia require the patient to pay 25% of the total bill.
6	After receiving medical services, the client must sign the invoice to confirm accuracy.
7	Admissions must be reported within 24 hours. A pre-authorization form must be filled and sent to DEFMIS for a letter of undertaking.
8	If a patient must be moved to another facility, the Trust must be informed. Note: Ambulance costs are NOT covered unless it is an emergency and prior approval is obtained from DEFMIS.

EXCLUSIONS
(a)	Treatment abroad unless sanctioned by the Board of Trustees.
(b)	Services rendered in facilities not accredited except in emergencies.
(c)	Self-induced or inflicted conditions or injuries.
(d)	Cosmetic/plastic surgery unless medically beneficial and approved.
(e)	Routine check-ups not necessary for diagnosis.
(f)	Funeral and testamentary expenses.
(g)	Injuries sustained while committing a crime.
(h)	Use of facilities as hospices, old-age homes, or residences for comfort.
(i)	Refunds of contributions unless expressly authorized.
(j)	Loans to members.
(k)	Sunglasses.
(l)	Contraceptives.
(m)	Slimming tablets.
(n)	Travel expenses.
(o)	Sexual performance enhancement drugs.
(p)	Willful non-compliance to prescribed treatment.
(q)	Caesarean section unless recommended by a doctor.
(r)	Dental cosmetics and dentures.

PROCEDURE FOR OVERSEAS TREATMENT
The following guidelines stipulate the requirements to be met when seeking/processing request for overseas treatment.
1	A member shall forward a letter of request to DEFMIS addressed to the Trustees and attach the following documents: 1st opinion letter of case introduction from primary doctor or hospital. 2nd opinion expert advice from relevant consultant. 3rd opinion comment from admitting overseas hospital, with cost implications.
2	DEFMIS will prepare a brief for the Assistant Chief of Defence Forces in-charge of Personnel and Logistics (ACDF P & L) for convening the Medical Advisory Committee (MAC) meeting. The Membership of MAC is stipulated in the Trust Deed. The outcome of the MAC meeting is forwarded to DEFMIS for communication to member. Accepted cases are forwarded to the Trustees for funding approval. Members will be informed on cases that have not been approved. Funds are prepared and forwarded to the relevant hospital, member will be informed accordingly. Member departs for treatment.
3	Time factor should be considered when applying for authorization.
4	Stable cases will be processed within one month. Urgent cases are forwarded to the Trustees promptly.
5	The Trust Deed does not provide for post facto (refunds after treatment/management) refunds.
NB: Kindly note that Overseas Capping is under the Inpatient Cover.

WITHDRAWAL OF BENEFITS
If a spouse remarries following the death of the contributor. Through divorce. If a child gets married or attains the age of 21 years. If a beneficiary is found guilty of gross misconduct and expelled by the Board of Trustees. If a beneficiary is convicted in court for any offence against DEFMIS. NB: Withdrawal of benefits for a specific beneficiary shall be without prejudice to other beneficiaries not involved in the case.

WITHDRAWAL OF BENEFITS

If a spouse remarries following the death of the contributor.
Through divorce.
If a child gets married or attains the age of 21 years.
If a beneficiary is found guilty of gross misconduct and expelled by the Board of Trustees.
If a beneficiary is convicted in court for any offence against DEFMIS.

NB: Withdrawal of benefits for a specific beneficiary shall be without prejudice to other beneficiaries not involved in the case.

Your Health care Partner in Retirement

DEFENCE FORCES MEDICAL INSURANCE SCHEME

DEFMIS Patient and Hospital Guidelines