Senators have issued an ultimatum to insurance companies involved in the Sh5.1 billion police cover to pay injured officers all outstanding claims or face sanctions.
The 11 insurance companies jointly contracted to provide the enhanced Group Life, Last Expense, Work Injury Benefits Act (WIBA) and Group Personal Accident (GPA) cover for the National Police Service and Kenya Prison Service have until mid-January 2025 to compensate officers injured in the line of duty.
Members of the Senate committee on Security, during a session yesterday, heard how the injured officers have been frustrated while pursuing their claims. The unpaid claims relate to GPA and WIBA schemes for two years— 2021 and 2022.
But even as the Senators issued the directive, it emerged that the government has not been releasing the insurance premiums to the insurance companies in time to enable them to pay the outstanding claims.
For instance, the government has not released Sh4.1 billion in insurance premium for the police cover for the current period despite the cover ending in March 2025. The amount is equivalent to nine months of unpaid premiums for a contract of 12 months. This means that the cover has only three months to expiry and therefore claims related to it are likely to be delayed for more than a year.
During the meeting, MPs heard that the insurance companies have been asking the injured police officers to undertake a second medical assessment through their privately contracted doctors, arguing that the Department of Occupational Safety and Health Services (DOSHS) was recommending rates that were too high and not consistent with the injuries.
Mr Augustine Wafula, the manager in charge of claims at the defunct National Hospital Insurance Fund (NHIF) and now at Social Health Authority (SHA) told the committee that the law does not provide for second assessment of the injured officers, effectively throwing the underwriters under the bus.
The revelations saw Senators Seki Lenku (Kajiado) and George Mbugua (nominated) accuse NHIF that has since transitioned to SHA of colluding with the insurance companies to frustrate the injured officers by making it so difficult to access the claims so that they can pocket millions in profits.
“Where are the insurance companies getting the powers to demand the second medical assessment report from the injured officers?” Mr Lenku demanded. “You make it become so difficult and ambiguous to frustrate the officers.”
“The contract does not provide for the second assessment report for the injured officers,” said Mr Wafula.
“This is not a contract but a deal. It is an injustice and there is no value for money,” said Mr Mbugua while accusing SHA of lacking the seriousness and competence to ensure the payment of claims to the officers in time.
“You are very casual in the manner you are responding to issues. Because of your laxity, the injured police officers have been subjected to torture in accessing their claims,” he said.
Section 26 (4) of WIBA Act states that an employer or insurer against whom a claim for compensation is lodged shall settle the same within 90 days.
A document submitted to the committee by the National Police Service Commission (NPSC) shows that of the 2,162 claims lodged with NHIF, 937 claims worth Sh709.1 million have been paid, with 240 GPA related claims worth Sh289.44 million rejected by the insurance companies, which also disputed 158 other claims worth at Sh264.7 million.
The committee was also told that 161 claims valued at Sh108.01 million are being processed and 116 claims worth Sh110.2 million are pending provision of additional documentation by claimants.
Some 422 claims valued at Sh444.52 million are under internal review, 65 claims valued at Sh81.3 million were submitted after 24 months and 63 worth Sh69.02 million are awaiting execution of discharge vouchers.
The insurers noted that the pending claims had been occasioned by failure to settle premiums by the NPSC in time, rejected claims that include those outside the WIBA Act, undocumented claims, those with inadequate documentation and those recommended for a second opinion.
Initially, the insurance companies had told the committee that the second medical assessment opinion is based on the contract, even as they noted that its specifications were not clear.
However, DOSHS told the committee that the second opinion was illegal and that all the insurers needed was to lodge an appeal to the directorate in case of dispute in the claims awarded.
A document in our possession shows that the NPS and Prisons Service have been pleading with the National Treasury to release Sh4.1 billion in premiums for the current cover, which is protecting the police officers in volatile areas and those in Haiti.
Assertions by Mr Wafula that the insurers declined to pay the claims because the police officers got injured while not on duty were dismissed by NPSC chairperson Eliud Kinuthia. He said that the police officers are on duty always, whether they are on leave or not, because they can be called in any time when need arises.
“The purpose of this cover was to recognise the vulnerability of the officers because of the nature of the job they do,” said Mr Kinuthia. “The police officers don’t sleep, they just rest. If you are on duty 24/7, where do you get time to sleep?” said Mr Kinuthia.
