Insurance firms contracted by the government in a Sh5.1 billion deal to provide insurance cover to police officers have until January 21, 2025, to present a report to the Senate detailing progress made in settling outstanding claims for the officers.
The directive by the Senate Committee on Security, Defence, and Foreign Relations came after the senators were left stunned as it emerged that contracted insurers are not paying claims to the officers injured while in the line of duty despite the claims being lodged.
This is despite the government having availed resources for the cover in what puts the Social Health Authority (SHA), transitioned from the National Health Insurance Fund (NHIF), and the National Police Service (NPS) in the spotlight.
At a previous meeting, Baringo Senator William Cheptumo, who chairs the committee, had vowed not to relent until all the claims due to police officers have been settled.
This as a member of the committee who did not want to go on record, said that the insurance service providers will be appearing before the committee to provide status update on the settlement of claims.
"The committee has summoned the insurance companies to provide details of compliance with its resolution of December 5, 2024, that directed them to pay the outstanding claims and report back," the committee member said on Sunday.
Section 26 (4) of the Work Injury Benefits Act states that an employer or insurer against whom a compensation claim is lodged shall settle the claim within 90 days of the claim.
“One of the things the insurance companies do is to reject the genuine claims lodged and SHA is not firm as it allows the insurance companies to refuse to pay the claims despite clearance by relevant government agencies,” said Mr Cheptumo.
NPS entered a contract with NHIF for the provision of comprehensive medical insurance cover for the 141,961 police officers and their families at Sh5.1 billion for the period January 1, 2023, to December 31, 2023.
However, a report by Auditor-General Nancy Gathungu on the accounts of the NPS for the financial year 2022/23, has flagged the unpaid police insurance claims despite the applications being made and the necessary paperwork done.
The unpaid claims relate to Group Life Benefits, Group Personal Accident (GPA) and Work Injury Benefits Act (Wiba) meant for the police- the principal members- and their dependents.
A National Police Service Commission (NPSC) document presented to the Senate committee shows that of the 2,162 claims lodged with NHIF, now SHA, 937 worth Sh709.1 million have been paid, with 240 GPA-related claims, worth Sh289.44 million, rejected by the insurance companies as they disputed 158 other claims valued at Sh264.7 million.
The committee was also told that 161 claims valued at Sh108.01 million are in the process while 116 claims worth Sh110.2 million are pending the provision of additional documentation by claimants.
Some 422 claims valued at Sh444.52 million are under internal review at SHA, and 65 claims valued at Sh81.3 million were submitted after 24 months, with 63 worth Sh69.02 million awaiting execution of discharge vouchers.
The contract provides that the assessment for the processing of the claims by the Directorate of Occupational Safety Health Services (DOSHS), domiciled at the Ministry of Labour, shall be final.
Wiba and GPA claims are paid through the Directorate of Occupational Safety and Health Services (Doshs), domiciled at the Ministry of Labour, in line with the law.
The insurance benefits in the cover are in line with the Public Service Superannuation Scheme (PSSS) Act and the human resource policies and procedures manual.
To process a claim, a claimant has to have healed before the extent of any disability can be determined by the Doshs.
However, the introduction of the second medical reassessment requirement has seen senators accuse SHA of siding with the insurance companies to frustrate the injured police officers.
Dr Musa Nyandusi, the Doshs deputy director, said that the requirement for a second assessment report before the claims are processed is illegal even as he felt sorry for police officers chasing their claims.
“We empathise with the police. Claims remain unpaid notwithstanding that the police are vulnerable due to the nature of their work,” said Dr Nyandusi adding; “we have lost the sight of the police officers who get injured.”
The contract between NPS and NHIF provides that upon the death of a member, the member’s declared next of kin shall be paid a lump sum compensation of five years’ annual basic salary.
Ms Gathungu notes that a review of insurance records revealed that at the time of the audit in November 2023, Britam had a backlog of 312 persons with unpaid injury GPA claims despite having been notified.
This is notwithstanding that the contract provides that where a member is out of work as a result of an injury arising out of an accident or as a result of illness such members shall be entitled to compensation for loss of gross salary up to a maximum period of two years.
The contract also provides that permanent total disability under Group Personal Accident (GPA) shall be compensated at a rate of five years’ basic salary multiplied by the percentage awarded.
However, during the period under review, the insurance company had not processed four claims worth Sh1.41 million under fatal GPA.
The cover also affords the police and their dependents compensation due to temporary disablement which shall be paid through a periodical payment equivalent to the member’s salary.
Periodical payments, the Auditor-General says, shall be made for as long as the temporary disablement continues but not for a period that exceeds 12 months.
However, the audit reveals that at the time of the audit, there were unpaid Wiba claims of 687.
The contract provides that death under Wiba or as a result of occupational accident shall be compensated at a rate of eight years’ gross salary of the beneficiary.
