How to submit a claim

How to submit claims

Please ensure that your original hard copy claims are submitted to our administration office by your healthcare provider, or through the relevant medical scheme administrator or intermediary, i.e., your human resource manager (employer), insurance agent or insurance broker. The original hard copy claims should be sent to the address below.

Your claims will be processed based on receipt of the original documents accompanied by the Heritage Claims Form, completed by your healthcare provider. We cannot process claims that are photocopied or scanned and or forwarded by email, as they do not qualify as originals.

Physical and postal address for original, hard copy claims

The Heritage Insurance Co. (Kenya) Ltd
Liberty House, Processional Way
PO Box 30390-0100
Nairobi
Kenya

We will process, and pay valid claims

We will process original claims received according to your benefits and policy conditions. Payment is subject to the correct information being supplied, including the tariff codes and submission of claims within 90 days.

There is a weekly payment cycle for members, which may only reflect in your account within 10 working days, depending on which bank you use.

Statements

Once we process a claim, a claims statement will be distributed to the healthcare provider or member (claim for reimbursement) on the day the payment is released. We also send monthly statements to our members if a claim has been processed for them in the course of the month.

Claims process

We have made the claims process as simple as possible for you and your treating provider. The list below provides all the details required when submitting a claim to us either by you or your treating provider.

Information that must be on the claim:

• Membership/policy number
• Patient’s name and surname
• Patient’s date of birth
• Principal member’s name and surname
• Employer/scheme name
• Diagnosis
• Date of service (include admission & discharge dates for hospitalisation)
• A detailed description, per item, of the treatment or service received/provided (i.e. name of medicine, ward level)
• Quantity (i.e. 30 Disprin, 3 days in General Ward)
• Tariff code (if available)
• Amount charged per service or treatment (as per the contracted Tariff price list)
• Name of the treating healthcare professional
• Facility name (i.e. General Hospital, Africa Medical Clinic)
• Total charged (the sum of the individual amounts charged on the claim)
• Proof of payment (receipt and proof of electronic (EFT) payment), in the case of a refund request for the principal member. The only document we will accept as proof of payment is a receipt or proof of electronic (EFT) payment. If the correct proof of payment is not attached, the account will be rejected.
• Signature of the insured person or principal member if the insured person is a minor
• Signature of the provider
• Invoice (for credit claims)
• Provider stamp
• Insured’s cell phone number