The National Health Insurance Fund (NHIF) has been accused of colluding with commercial insurance providers to deliberately frustrate payment of millions of shillings in claims to police officers injured in the line of duty.
The unpaid claims relate to the Sh6.32 billion insurance cover for police and prison officers for two years - 2021 and 2022.
The revelations came after National Police Service Commission (NPSC) chairman Eliud Kinuthia, while appearing before the Senate's National Security, Defence and Foreign Affairs Committee, accused the NHIF, which is currently being transformed into the Social Health Insurance Fund (SHIF), of being hostile to the commission and police officers seeking their dues.
The claims relate to the Group Personal Accident (GPA) and Work Injury Benefits Act (Wiba) schemes under the police cover.
The committee was told that one of the reasons the NHIF has refused to pay the outstanding claims is the introduction of a second medical reassessment, which is not required under the contract signed between the NPSC and the NHIF.
The contract stipulates that the assessment by the Directorate of Occupational Safety and Health Services (Doshs) at the Ministry of Labour is final for the processing of claims.
On the second medical reassessment requirement, the committee accused Shif of siding with the co-insurers to frustrate the injured police officers, which Doshs and NPSC said was illegal.
Mr Augustine Wafula, the claims manager at SHA, had a tough time before the committee chaired by Baringo Senator William Cheptumo because a consortium of insurance service providers that NHIF contracted at Sh6.32 billion to cover the police officers is unable to settle the claims contrary to the contractual agreement between NPSC and NPSC.
This was revealed when Mr Cheptumo vowed that he would not relent until all the police officers' claims were settled.
"You will not get away with this," Mr Cheptumo said as he pointed an accusing finger at SHIF management.
NPSC CEO Peter Lelei accused NHIF of failing to meet its contractual obligation to settle assessed claims within 90 days as stipulated in the Work Injury Benefits Act.
Section 26 (4) of the Wiba Act states that an employer or insurer against whom a claim for compensation is lodged by the director shall settle the claim within 90 days of the lodging of the claim.
"One of the things that the insurance companies do is to reject the genuine claims that are lodged and the SHA is not firm as it allows the insurance companies to refuse to pay the claims despite the approval by the Doshs," said Mr Cheptumo.
The NPSC document presented to the committee shows that of the 2,162 claims submitted to NHIF, 937 worth Sh709.1 million were paid, while 240 GPA-related claims worth Sh289.44 million were rejected by the insurance companies as they disputed 158 other claims worth Sh264.7 million.
The committee was also told that 161 claims worth Sh108.01 million are in process, with 116 claims worth Sh110.2 million pending the submission of additional documentation by the claimants.
The 422 claims worth Sh444.52 million are under internal review by NHIF, 65 claims worth Sh81.3 million have been submitted after 24 months and 63 worth Sh69.02 million are awaiting the execution of discharge vouchers.
Mr Wafula's claims that the insurers refused to pay the claims because the police officers were injured while off duty were dismissed by NPSC chairperson Mr Kinuthia.
Mr Kinuthia reminded the SHA that police officers are on duty 24 hours a day, whether they are on leave or not, because they can be called upon whenever the need arises.
"The purpose of this cover was to recognise the vulnerability of police officers because of the nature of their work," said Mr Kinuthia.
"Police officers don't sleep, they just rest. When you are on duty 24 hours a day, where do you find time to sleep?" he posed.
This comes after Mr Wafula claimed that one of the police officers he is seeking compensation for was injured while sleeping in his house.
Mr Kinuthia claimed that the commission is unable to deal with the co-insurers because it has no contractual agreement with them, a move that has isolated it while exposing the "vulnerable" police officers who are not unionised and therefore cannot picket due to the sensitive nature of their work.
Before the NHIF was exempted from the provisions of Section 19 of the Insurance Act, allowing it to engage in the business of providing insurance without being registered with the Insurance Regulatory Authority (IRA), the NPSC contracted directly with commercial insurance providers.
"When we worked directly with the co-insurers, the experience was better than with NHIF. When we contracted with NHIF, things changed with the intention of delaying or disadvantaging a disadvantaged person," said Mr Kinuthia.
Dr Musa Nyandusi, the deputy director of Doshs, told the committee that the requirement for a second assessment report before claims could be processed was illegal, although he sympathised with the NPSC.
"We sympathise with the police. The claims remain unpaid even though the police are vulnerable because of the nature of their work," said Dr Nyandusi, adding, "we have lost sight of the police officers who are injured."
