Event Details:

Terms of Reference for the recruitment of the Medical Insurers for WaterAid-Rwanda

Company Background

WaterAid Rwanda developed and approved its new Country Program (CP) strategy in 2023, with two aims (Programmes): 1) Bugesera Universal, safe and sustainable WASH programme and 2) WASH for health programme. Aim one will be implemented in Bugesera District to provide a proof of concept of Universal and sustainable WASH achievement for the rest of districts while Aim two will be implemented across the country. The overall objective is to contribute towards the achievement of universal, sustainable, and safe WASH services in Bugesera District through systems strengthening thereby creating a model to influence wider change.

Overview

WaterAid-Rwanda in collaboration with our broker – Alliance Insurance Brokers Ltd is seeking a qualified and experienced medical insurers to provide comprehensive insurance services to cover our employees and their dependents. The provider will be responsible for offering a range of health, and medical insurance products, ensuring the well-being of our team members while also providing value-driven insurance solutions that align with our organizational goals.

The insurer will be expected to provide excellent customer service, efficient claims processing, and continuous support for the full duration of the contract.

Objective

The objective of this contract is to engage a medical insurance provider who can deliver tailored insurance packages, offer competitive rates, and ensure smooth service delivery for our employees. The provider will be expected to uphold the highest standards of service in health insurance, ensuring employees have access to critical care, medical treatments, and coverage whenever required.

Scope of service

The Medical insurer will be responsible for providing a comprehensive range of services, including but not limited to:

Medical Insurance:

Offer a group health insurance package covering employees and their eligible dependents.

Provide a range of coverage options that meet the diverse needs of employees, including outpatient, inpatient, maternity, dental, and optical care.

Coverage should be inclusive of preventive care, emergency medical evacuation, and hospitalization.

Access to a wide network of health care providers, including hospitals, clinics, and specialists.

Claims Management:

Provide a clear and efficient claims management process.

Offer 24/7 claims support and a user-friendly portal or mobile app for employees to submit and track claims.

Ensure timely payment of claims and transparent communication throughout the process.

Choosing Doctor on reimbursement basis, (where no partnership in place with insurer) based on cover limits

Claims incurred outside the geographical scope of the policy (Rwanda/East Africa/ India) either during holiday or business trip shall be covered on reimbursement basis within the contract limits.

Prorated reimbursement for leaving staff with not more than 20% claims experience

Consultancy and Reporting:

Offer consultation and advice on structuring the most cost-effective insurance plans.

Provide annual reviews, reports, and performance evaluations of the insurance policies.

Regularly update WaterAid Team on consumption level, any changes in policy terms, regulations and any change that might affect the organization or its employees.

Employee Support:

Provide regular information sessions and materials to educate employees about their insurance benefits.

Set up a dedicated helpline or customer service contact for employees’ queries and assistance.

Compliance and Regulations:

Ensure that all insurance plans comply with relevant laws and regulations, including those pertaining to employee benefits and health care.

Provide WaterAid Rwanda with all necessary documentation for audits and compliance checks.

Scheme Management

Automatic addition of new born and spouse at no extra premium

Automatic addition of new staff subject to prorated premium

Automatic deletion of member leaving the scheme upon receipt of letter from the HR with no requirement for returning the medical card

Fraud Management in liaison with the Broker, client and insurer

New members and dependants will be issued with new cards at no cost

Provision of scheme utilization report on a quarterly basis

Member education of scheme benefits

Overseas medical cover during travel or holiday maximum 6 weeks per year per staff will be covered on reimbursement basis based on reasonable and customary prevailing rates in East Africa.

Treatments in East Africa countries without referral. The patient will go to an appropriate facility in the country of choice within area of cover as per insurer’s partnership. In India the transfer or presentation of medical report with prior approval of the insurer with WATERAID management.

Provision of Utilization report on monthly basis

Care Management

Proper and timely managing of pre-authorization for treatment (indicate turnaround time)

Coordinating hospitalization of beneficiaries.

Undertaking clinical follow ups

Carrying out patient visits

Outpatient treatment follow up especially following admission (post hospitalization)

Ensure all facilities are aware of exclusions

Known or pre-existing Chronic conditions covered within the overall inpatient limit. Newly diagnosed chronic conditions during cover period to be covered at 100%

The medical cover exclusions, where applicable, MUST be clearly stated on a separate cover giving specific details of each excluded condition.

Network coverage

          The tenderer is required to provide the following: -

Full details of towns where the insurance underwriting company is represented.

The appointed Hospitals (Rwanda, EAC hospitals & India), Clinics, pharmacies, laboratories and Doctors all over the country that can be accessed by WATERAID employees and their dependants.

Full details of the medical cover outside Rwanda and all exclusions that are applicable. This is taking into consideration that WATERAID employees move across the country.

Deliverables

The following deliverables are expected from the medical insurer:

A comprehensive medical insurance cover within 5 days from the contract signing include medical insurance cards and all other related system registrations.

Monthly performance reports covering claims, utilization, and feedback from employees.

A bio-annual membership education and a dedicated support team for claims and policy administration.

Regular employee communication and educational materials about their benefits.

K.ey Qualifications and Experience

The life and or medical insurance provider must meet the following minimum qualifications:

Experience:

Minimum of 5 years of experience providing medical insurance solutions.

Proven track record of managing insurance plans for corporate organizations of similar size and scope.

Demonstrated experience in offering flexible and scalable insurance solutions that meet the needs of diverse employee populations.

Licensing and Accreditation:

The provider must be licensed and regulated by the relevant local regulatory bodies.

The insurer should be compliant with all applicable insurance laws, regulations, and industry standards.

Reputation:

Strong reputation in the market, demonstrated by positive client reviews and references.

Proven ability to deliver high-quality customer service and claims management.

Customer Support:

Demonstrated ability to provide 24/7 support for the organization’s employees.

Access to digital platforms for claims submission and tracking.

Financial Stability:

The insurer must be financially stable, with clear evidence of their ability to cover the claims of all employees and dependents.

Proposals submission

Interested insurers are invited to submit a proposal that includes:

Company profile, including relevant experience and qualifications.

A detailed technical proposal of the insurance coverage options.

A financial proposal with a clear breakdown of premiums, deductibles, and any other fees associated with the insurance packages.

Details of customer service, claims processing, and employee support mechanisms.

At least three client references from similar organizations (preferably with NGOs).

Selection criteria

Proposals will be evaluated based on the following criteria:

Comprehensiveness and quality of the insurance coverages provided.

Competitive pricing and value for money.

Reputation and experience of the insurer in providing life and or medical insurance services.

Customer service and claims management processes.

Usage of Technology & Tools for Service Delivery.

Flexibility and customization of coverage options.

Partnership level (Number of Hospitals, clinics, Pharmacies, and others)

Contractual Term

Term: The contract will initially be for One year with the possibility of extension based on performance and satisfaction level of WaterAid-Rwanda staff members.

Payment Terms: Payment will be based on the agreed terms to be outlined in the contract.

Confidentiality: The insurer must maintain confidentiality of all information relating to WaterAid-Rwanda and its employees, including personal and medical data.

Termination Clause: The contract may be terminated with a 30 days’ notice for failure to meet service standards or other breaches of contract otherwise it will be terminated in accordance with its duration.

Scope of Cover

Maternity and Childbirth Benefits:

Coverage for pre-natal treatments and examinations, post-natal treatments and care (up to 6 weeks post-delivery), premature delivery (including ectopic pregnancies), and new-born accommodation.

Eligibility:

Children covered from birth (irrespective of gestation) to 21 years, or up to 25 years with evidence of schooling.

Employees and spouses, up to a maximum age of 70 years.

New-born Abnormality and Treatment: Coverage for abnormalities, constitutional disabilities, and malformations in new-born babies.

Reconstructive Surgery: Coverage following an accident or surgery for an eligible medical condition.

Physiotherapy: Specify if there is a cap on the number of sessions.

Pre-Existing and Chronic Conditions: Coverage for pre-existing conditions, chronic ailments, and HIV opportunistic infections.

Dental Treatment:

Benefit of Rwf 500,000 per person.

Optical Treatment:

Coverage of Rwf 500,000 per person, including frames (50% of the optical limit).

Inpatient & Outpatient Cover (Combined):

Limit of Rwf 15,000,000 per family.

Maternity Benefit: Limit of Rwf 1,050,000

Hospital Accommodation:

Standard private room charges of up to Rwf 56,000 per night in Rwanda and USD 150 outside Rwanda.

Individual private rooms covered; VIP rooms excluded unless beneficiary’s top up the difference.

Diagnostics and Imaging: Coverage for pathology, x-rays, ultrasounds, ECGs, CT, and MRI scans.

COVID-19 Coverage: Expenses within inpatient and outpatient limits, including doctor-recommended quarantine and isolation.

Immunizations: Coverage for both children and adults, including Hepatitis B vaccinations. A detailed list of covered vaccinations must be provided.

Family Planning: Rwf 30,000 per visit, including drugs and devices.

Critical Care: ICU/HDU and theatre charges covered.

Congenital Malformations: Covered under the overall limit.

Psychiatric Cases: Coverage provided.

Hospital Accommodation for Guardians: Lodger fees for a parent or guardian accompanying children under 16 years of age.

Automatic Enrollment: Addition of new-borns and spouses without additional premiums.

Automatic Addition of Staff: New staff added on a pro-rata premium basis.

Pro-Rated Refunds for Resigned Staff: Refunds provided for resigned staff who have not made claims.

Card Return Requirement: Departing beneficiaries are removed with no requirement to return medical cards.

Place of Treatment: A list of partner facilities must be provided.

Flexible Provider Selection: Members may choose any doctor, pharmacy, or health facility on a reimbursement basis if not covered by the insurer’s network. Specify reimbursement timelines.

Network Flexibility: Staff-preferred centres not on the insurer’s list must be added. Indicate processing timelines for new facilities.

Fraud Management: Insurer must collaborate with the employer on fraud prevention measures.

Funeral Benefit: Rwf 1,000,000 per beneficiary as a standalone benefit.

General Medical Check-Ups (All Members): Principle allowed twice annually and dependents are allowed once annually.

Circumcision: Covered for both children and adults.

Overseas Medical Cover: Coverage for travel or holiday medical expenses for up to 6 weeks annually, on a reimbursement basis.

Non-EAC Medical Claims: Claims incurred outside Rwanda and the EAC region reimbursed up to full cover limits.

Counselling Services: Coverage for counselling consultations. Specify session limits or benefit caps.

Optical Services: Lenses and frames covered; consultations and optical prescription drugs covered under outpatient benefits.

Dependent Coverage: Extension for staff dependents living in East African countries and beyond.

Emergency Ambulance Services: Road ambulance within Rwanda and air ambulance for life-threatening cases covered on a reimbursement basis.

Card Issuance: New cards for members and dependents issued at no cost.

Utilization Reports: Quarterly and on-demand utilization reports to be provided.

Card Replacement: Cost of medical card replacement to be specified.

Member Education: Education on scheme benefits for members.

Overseas Treatment: Coverage for treatments within East Africa without referrals and limited overseas treatments in India with prior insurer approval.

Premium Basis: Premiums quoted on a per-staff basis, not per family size.

External Appliances: within overall limit upon pre-authorization

Cover for artificial limbs

Infertility treatment and investigation – Rwf. 500,000

Other concessions/Wider Coverage, e.g. better Extensions, limits and sub-Limits not requested in the tender that will be offered for FREE if any

Submission deadlines and contact information

All proposals must be submitted by 18th March 2025. Proposals should be sent electronically to or delivered to [email protected] , [email protected] , [email protected] , [email protected]

For further inquiries, please contact +250 781 074 204 and or +250788318824.