STAFF MEDICAL INSURANCE COVER

TERMS OF REFERENCE FOR STAFF MEDICAL INSURANCE COVER

1. Background

Islamic Relief Somalia (IRW-S) is an international Organisation contributing to the wellbeing of people in need in Somalia since 2006. We respond to the needs of conflict and drought-affected people through the provision of life-saving assistance. We work to provide immediate humanitarian relief and long-term sustainable development.

Our Somalia programme strategy, derived from Islamic Relief Worldwide’s Global Strategy, aims to reduce the suffering and losses resulting from conflict or natural disasters by providing timely, and relevant emergency assistance for people affected by conflict or natural disasters. We aim to empower communities to emerge from poverty and vulnerability by increasing assets, income, food security and access to employment opportunities for poor households.

Exemplifying our Islamic values, we will mobilize resources, build partnerships, and develop local capacity as we work to; Enable communities to mitigate the effect of disasters, prepare for their occurrence and respond by providing relief, protection and recovery; Promote integrated development and environmental custodianship with a focus on sustainable livelihoods; and Support the marginalized and vulnerable to voice their needs and address root causes of poverty.

1. The Need/Purpose

IRW-S is providing health insurance coverage for its approximately 270 employees and their dependents across the country. IRW-S is soliciting a detailed proposal from eligible insurance firms to provide Medical Insurance for its staff and dependents.

The staff number will be subject to change due to staff leaving and staff being hired.

Annual Premium: up to M+5

1. Medical Insurance

Description

Option 1

Option 2

Option 3

Outpatient Coverage

Member

Provide a suitable package you offer: M+1 M+2 M+3 M+4 M+4

Inpatient Cover

Members: up to M+5

Funeral / last expense per member

Funeral/ last expense per family

Maternity

Normal Delivery

Ceaserian section

Optical per family

Dental per family

1. Scope of Work

For this assignment and fair selection, the applicant companies should provide detailed quotations for the Insurance cover for the following categories of benefits at the minimum. Please note the list is not exhaustive.

Outpatient Services

• Routine outpatient consultation,
• Diagnostic Laboratory and Radiology services,
• Prescribed physiotherapy.
• Prescribed drugs and dressings.
• Vaccines: KEPI & Baby Friendly
• Private vaccines up to full outpatient limits.
• Chronic, Pre-existing conditions & and HIV/AIDS including the cost of ARVs covered up to the full out-patient cover limit per family per annum.
• Ambulance Services (for emergency treatment only)
• Congenital conditions up to the full outpatient cover
• Gynaecologic care
• Postnatal care up to six weeks post-delivery. Antenatal and postnatal. Covered within the outpatient up to the full limit
• Annual Check-up Options: up to $200 for the principal member and spouse once per year, for specific conditions

Inpatient Services

• Hospital Accommodation Charges
• Doctor’s (Physician, Surgeon & Anesthetist) fees.
• ICU/HDU and Theatre charges.
• Drugs/Medicines, Dressings and Internal Surgical appliances.
• Pathology, X-ray, Ultrasound, ECG and Computerized Tomography, MRI Scans.
• Radiotherapy and Chemotherapy.
• In-patient Physiotherapy.
• Emergency Road and Air Evacuation that is subject to the overall cover limit.
• Day care surgery
• Home nursing care
• Internal prosthesis

Bed Limit: Standard private room

Dental Benefits (Anaesthetist’s fees, hospital and operating theatre costs, fillings, extraction, root canal)

Optical Benefits – Eye Test, Frames, Contact & Optical Lenses

Maternity

• Caesarian Section to be covered on an emergency and not elective basis.
• Routine antenatal check-ups
• Postnatal care up to six weeks post-delivery

Psychiatric hospitalization Family per annum

Psychosocial support/Counselling (Employment Assistance Program)

Pre-existing chronic ailments and HIV/AIDS hospitalization covered up to per Family per annum

Congenital and neonatal conditions

Post-hospitalization Rehabilitation, Private Nursing & Hospice Services

Premature Deliveries

External Appliances and Internal Surgical Appliances and Prosthesis (wheelchair, crutches, lumbar corset etc.). per family limit

Non-motorized wheelchairs and cress covered for accidents on hire within Inpatient

Non-accidental inpatient ophthalmology cover

Non-accidental inpatient dental cover.

Accidental inpatient dental and optical will be covered up to the full Inpatient limit

Scheme members are covered for emergency air and road evacuation within East Africa/ Horn of Africa.

Days covered outside Somalia in any one visit.

Overseas referral for treatment not available in Somalia/ East Africa/ Horn of Africa

Lodger fees; Lodging facilities for parents accompanying a child below 6 years being admitted

Oncology, Organ Transplant, Acute Renal and Peritoneal Dialysis

Free Health Education webinars/workshops

Political Violence and terrorism cover up to full inpatient limit and outpatient limit.

Note to Quote

Please quote the rate applicable for:

• Short term Cover or pro-rata premium calculation
• Refund of premium when staff leave
• Refund policy of medical expenses incurred when staff use other medical providers
• Please quote any free rider on the cover
• A description of how the service will be administrated and the provider’s responsiveness should also be included in the offer.

1. The areas that shouldn’t be covered are:

• Family planning and fertility treatment i.e. costs of treatment related to infertility and impotence.
• Accidents caused by own intoxication or drunkenness or extreme sports
• Nutritional Supplements unless prescribed as part of treatment
• Cosmetic surgery unless caused by accident.
• Chiropractors, Acupuncturist, Herbalist
• Massage or beauty treatment

1. Option of voluntary adds -on by individual scheme members

Provide areas, where scheme members can individually or as a group, come together and decide on their own to add certain services to the cover without involving the IRW-S or affecting the premium paid by the IRW-S. This can for example include chiropractors or nutritional supplements not under prescription.

1. Duration of Cover

The successful Company will enter into a contract with Islamic Relief for a period of three (1) year, renewable. This contract will be reviewed annually based on performance and funding.

1. Territorial Limit

East Africa and Horn of Africa for local staff (Somalia, Kenya, Ethiopia). Global medical cover for at least 5 Expatriate staff.

1. Criteria for Proposal Evaluation

Technical Proposal

Each bidder shall submit a technical proposal addressing the services required and demonstrating how they will meet IRW-S needs. The proposal will be evaluated according to the following criteria:

1. Company and personnel qualifications
2. Benefit coverage
3. Provider network (Medical providers, Coverage Area)
4. Quality of service (Reservation, billing and reporting systems)

Financial Proposal

The financial proposal shall be evaluated according to the price structure proposed and will account for 30% of the total combined scoring.

1. Required Competencies/Skills

The successful bidder should have.

• Extensive experience and a proven track record in the health insurance business – A list of top 3 clients in the last 3 years is required
• Wide networks for national and international coverage – A full list of service providers is needed
• Reliable health coverage services
• Sound experience in servicing international organizations
• Able to provide particular and general statistical reports of the services rendered periodically and as per request from IRW-S
• Ability to provide 24-hour contact service and appoint a full-time relationship manager for IRW-S
• Real-time administrative support systems – Ability to assign a full-time account manager
• Ability to respond immediately to emergencies whilst maintaining high-quality standards of service delivery

1. GENERAL PROVISIONS

• This tender is open to qualified Health Insurance Company.
• Submit the health insurance proposal according to the health insurance benefit as requested which contains information on Inpatient benefits, Outpatient benefits, Provider coverage, Premium price,- General condition, General Exclusion etc.
• The technical proposal must be submitted as a separate document from the financial proposal.
• Only proposals that fully address the mandatory services listed in the bidding requirement will be evaluated.
• The proposal that comes after the closer of bid will not be accepted.
• Short-listed bidders may be invited to make presentations to the evaluation team.
• All pricing shall be guaranteed not to increase, based on an order placed within the proposal due date and intended for delivery following the specified delivery schedule.
• The performance of the successful bidder(s) who is contracted shall be monitored during the contract period. In the event of services not being under the specification or the conditions of the contract, IR reserves the right to cancel the contract.
• IRW-S reserves the right to reject any application(s) in whole or part without disclosing the reasons.
• The contracted firm should maintain high standards on ethical issues, respect and apply basic human and social rights, comply with labour standards to ensure non-exploitation of child labour, and give fair working
• IRS is serious about confidentiality. The contractors should maintain confidentiality and data protection principles. The contractor shall take all reasonable steps to ensure that its employees, agents and sub-contractors are bound by the same obligation.