Medical cover guide
APA SME Cover — limits, benefits and options
APA SME Cover is a group medical scheme for businesses, with limits from KSh 500,000 per employee and optional outpatient cover.
Cover typeGroup and SME
Inpatient limitsKSh 250,000 to KSh 10,000,000
Plans available12
Medical examinationApplicants aged 60 and above
APA SME Cover — inpatient limits
| Inpatient limit | Bed entitlement | Plan |
|---|---|---|
| KSh 250,000 | General Ward · Max KSh 8,000/day net of SHIF | APA SME · KSh 250K |
| KSh 300,000 | General Ward · Max KSh 8,000/day net of SHIF | APA SME · KSh 300K |
| KSh 400,000 | General Ward · Max KSh 8,000/day net of SHIF | APA SME · KSh 400K |
| KSh 500,000 | General Ward · Max KSh 8,000/day net of SHIF | APA SME · KSh 500K |
| KSh 750,000 | Standard Private Room · Max KSh 17,000/day net of SHIF | APA SME · KSh 750K |
| KSh 1,000,000 | Standard Private Room · Max KSh 17,000/day net of SHIF | APA SME · KSh 1M |
| KSh 2,000,000 | Standard Private Room · Max KSh 17,000/day net of SHIF | APA SME · KSh 2M |
| KSh 3,000,000 | Standard Private Room · Max KSh 17,000/day net of SHIF | APA SME · KSh 3M |
| KSh 4,000,000 | Standard Private Room · Max KSh 17,000/day net of SHIF | APA SME · KSh 4M |
| KSh 5,000,000 | Standard Private Room · Max KSh 17,000/day net of SHIF | APA SME · KSh 5M |
| KSh 7,500,000 | Standard Private Room · Max KSh 17,000/day net of SHIF | APA SME · KSh 7.5M |
| KSh 10,000,000 | Standard Private Room · Max KSh 22,500/day net of SHIF | APA SME · KSh 10M |
Premiums depend on the members covered and their ages, so the price for a limit is confirmed in your quotation.
Optional benefits you can add
Depending on the plan you choose, the following can be added to the inpatient cover:
- Outpatient: KSh 30,000, KSh 40,000, KSh 50,000, KSh 75,000, KSh 100,000, KSh 150,000, KSh 200,000, KSh 250,000, KSh 300,000, KSh 500,000
- Maternity: KSh 50,000, KSh 60,000, KSh 75,000, KSh 80,000, KSh 100,000, KSh 120,000, KSh 150,000, KSh 175,000, KSh 200,000, KSh 250,000, KSh 300,000
- Dental: KSh 5,000, KSh 7,500, KSh 10,000, KSh 15,000, KSh 20,000, KSh 30,000, KSh 40,000, KSh 50,000
- Optical: KSh 5,000, KSh 7,500, KSh 10,000, KSh 15,000, KSh 20,000, KSh 30,000, KSh 40,000, KSh 50,000
What the cover includes
- Inpatient treatment for illness and accidents, including prescribed medicines, specialists, surgery, theatre, HDU/ICU and diagnostics
- Pre-existing, chronic, congenital and HIV/AIDS conditions after 12 months and full disclosure
- Newly diagnosed chronic conditions after 3 months
- Prematurity and neonatal conditions subject to the published waiting period and sub-limits
- Organ transplantation subject to a 2-year waiting period
- Psychiatry and psychotherapy within published sub-limits
- Post-hospitalisation treatment, home nursing, local ambulance and emergency air evacuation
- First emergency C-section / maternity complications within inpatient sub-limit after 10 months
- Inpatient accidental and non-accidental dental/ophthalmology benefits
- APA Femina Plus cancer diagnosis cash benefit
- Optional outpatient, maternity, dental and optical benefits
Benefit sub-limits (pre-existing conditions, chronic conditions, maternity, psychiatric care, last expense and so on) are printed on every quotation we issue and are listed in the insurer's brochure.
Waiting periods
- 30 days acute illness
- 90 days non-chronic surgical procedures
- 3 months newly diagnosed chronic conditions
- 10 months pregnancy/maternity
- 12 months pre-existing/chronic/congenital conditions and specified surgeries
- 2 years organ transplant
- No waiting period for accidental cases
Co-payment, where it applies
- KSh 1,500 at Aga Khan University Hospital, Nairobi Hospital, Premier Hospital, Nyali Children’s Hospital, Diani Beach Hospital, Maimooni Hospital, Mombasa Hospital, Mater Hospital and MP Shah Hospital
- KSh 500 at Gertrude’s Children’s Hospital, Avenue Hospital, Pandya Hospital, Eldoret Hospital, Nairobi West Hospital, Metropolitan Hospital, Oasis Doctors Plaza, Jocham Hospital, Palm Beach Hospital, Oasis Health Care Group and AAR Healthcare/Hospital
- All other providers: No Copayment
APA SME Cover — frequently asked questions
What inpatient limits are available on APA SME Cover?
The limits we quote are KSh 250,000 to KSh 10,000,000 per year. Each limit is a separate plan with its own benefits schedule, so the premium and the sub-limits change with the limit you pick.
Can I add outpatient, maternity, dental or optical cover?
Yes. Depending on the plan, optional benefits can be added at the amounts listed above. Outpatient cover is normally required before dental or optical benefits can be selected.
Who can be covered?
This product is a group scheme, so cover is arranged for a business with a minimum number of families or employees. The quote engine shows the family sizes and head count the insurer accepts.
How is the premium paid?
Premiums are paid directly to APA using the payment details printed on your quotation. Now Insurance Agency does not receive or handle client payments.
How long does cover take to start?
Cover is typically confirmed within 1 to 5 working days after payment or IPF settlement and receipt of complete documents, subject to the insurer's underwriting and acceptance.
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