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medical insurance in Kenya

Health and Medical Insurance Companies in Kenya

Medical insurance in Kenya is a great tool that can protect the insured from high costs arising out of an illness or an accident provided they are covered on a health policy. This way, it is a great tool for financial planning. The policy is divided into two main categories:

In-patient cover - Which is termed as treatment to a patient who is admitted to a hospital for treatment that requires at least one overnight stay.

Outpatient cover - Treatment to a patient who attends a hospital or clinic for treatment without staying there overnight. Under this section, the insured can also purchase additional cover specifically for optical and dental treatment.

The joining age for most medical insurance policies in Kenya new members is from new born babies at the time of Hospital discharge to 75 years old depending on the health insurance company one opts for. Eligible candidates have the freedom to choose the plan they want it can be Inpatient cover alone or Outpatient cover alone or even both.

There are factors to take into consideration when shopping for a medical cover, one should look for a cover that meets most if not all of his/her basic need when it comes to treatment for example if it will take care of day care treatment, Maternity, antenatal and post-natal care for young ladies who are looking forward to having a child, pre-existing and chronic conditions, dental and optical not forgetting laboratory test and prescribed drugs among others.

There are waiting periods on most medical policies and they vary with different health insurance companies, This is an initial period of membership during which no benefit is payable for a certain procedure or service. Waiting period can also apply to additional benefits when you upgrade from one package or provider to another.

The majority of medical insurance companies in Kenya have opted to partner with hospitals, clinics and specialist providers outside the country for their clients, it is reliable and affordable compared to the local hospitals, clinics and providers. This has in away changed the dynamics in the industry with every company running to that direction to ensure they are better placed and keep their current clients.

It is wise to spread the risks that we carry by having a cover with a reputable health insurance company in Kenya With this, one is better placed to handle any unexpected costs that may arise out of an illness or accident, these can otherwise wreck financial havoc and deplete any little savings and investments that one may have accumulated.

FAQ's

What will health insurance cover?
The main part of health insurance is the inpatient cover. All medical insurance plans in Kenya must have this option. This covers for all hospital charges when the insured is admitted to a medical facility or hospital. In addition to the inpatient cover, few common options can be added like outpatient, dental, optical and maternity covers.
Who is eligible?
All adults resident in Kenya of age 18-65 years may be admitted on cover. Some medical insurance companies may set the oldest joining age at 60 years of age and require a medical test to be taken for members above 55 years of age. Check your medical insurance quote carefully or ask a member of staff.
Can I use my insurance immediately?
Yes and No! There is a waiting period of 14 days before the medical insurance can be used for general illnesses. For medical procedures and surgeries, a sixty days waiting period exists. For accidents and emergencies, there is no waiting period. Note : Waiting periods of up to 3 years exist for pre-existing conditions, check your medical insurance quote and policy for details.
How can I save money and get the best medical insurace plan?
Compare and Compare! We compare all medical insurance providers in Kenya, products, limits, hospitals and prices.
Top tips :
  • Choose an economy health insurance package, these give you exactly the same type of cover as the premium packages but only work on a restricted list of hospitals excluding the leading hospitals in Kenya.
  • Secondly, mix and match the inpatient and outpatient limits, try to keep the inpatient limits no more than KSh 1 million and outpatient limits of KSh 50,000.
  • How can I make claims on my policy?
    All medical insurance providers issue a 'smartcard' to members. The smart card is to be presented at the medical facility/hospital before seeking treatment. If you seek treatment at a hospital outside of the panel of hospitals on the panel of your insurance company, then you may be forced to pay out of pocket then file for a refund. Note : Each insurer has set limits for refunds for different medical procedures. Confirm with your insurance before seeking treatment outside the prescribed list of medical facilities. For more details on how to raise a medical insurance claim, please check our claims page

    What is covered under inpatient?

    When getting health insurance in Kenya, it’s not only about going for the cheapest medical plan in the market, it is important to clearly understand what benefits can be provided on the medical plan: Here is a writeup of the most common sections of the cover.

    Bed

    Hospital accommodation charges are covered net of the NHIF rebate per day. This also depends on what your cover bed entitlement is i.e. Ensuite, standard private or general ward bed.

    Congenital

    Congenital is a state prevailing at or before birth regardless of cause. It is capped up to a particular limit depending on the inpatient limit you have taken. However it has a waiting period of one year or more depending on the Kenyan medical insurance company that offers your policy.

    Post Hospitalization

    This is the period when one has been declared fit to go home but a he or she needs to undergo tests to monitor recuperation. Medical Insurance covers up to 60 days from discharge. Coverage limits depends on the package one has.

    Medical Tests

    In medication process practitioners recommend various tests. Insurance cover extends coverage to these services but the laboratory must be in the approved panel of providers.

    Professional fees e.g. specialists

    These are the various consultation fee paid to specialists e.g Neurologists and cardiologists, gynecologists. They are covered fully depending on the coverage limit.

    What is covered under outpatient care

    These are various medical procedures or tests that can be done in a medical Centre without an overnight stay;

    • Outpatient consultations
    • X-rays, laboratory, scans and MRI
    • Laboratory
    • Antenatal & Postnatal care
    • Diagnostic examinations
    • Well baby check-ups inclusive of KEPI Immunization Programme at our selected well baby clinics only.
    • Injections and procedures performed at a primary care level in a doctor’s consultation room
    • Prescribed medicines
    • Minor trauma treatment
    • HIV services
    • Adherence and nutritional counselling
    • Follow-up every 3months
    • Prevention of mother to child Transmission (PMTCT)
    • ARV’s and Monitoring
    • Opportunistic infections
    • Baby friendly vaccines as a benefit to the member child up to a sublimit of KSh 20,000.

    What about optical & dental cover

    The Optical Plan extend to covers the following services;

    • Routine optical consultations
    • Prescribed lenses and replacement of lenses
    • Optical Prescriptions
    • Prescription of frames

    The Dental Plan extends to cover the following services;

    • Consultation
    • Crowning
    • Bridging
    • Braces
    • Extractions
    • Fillings (except precious metals)
    • Scaling
    • Dental X-Rays
    • Dental Prescriptions

    Maternity cover – in built or an extra add-on to the policy?

    This is often the most asked about section of any affordable health insurance plan. When a couple suddenly realizes they are expecting a child, they immediately want to inquire about maternity insurance in Kenya and it’s cost. This maternity cover may be bought as an outpatient add-on while some other providers offer it as part of the inpatient plan like Resolution health insurance and AAR medical insurance.

    This covers;

    • Inpatient cost incurred for normal and caesarean deliveries
    • Labor and recovery wards
    • Professional fees
    • Pregnancy & Maternity related hospitalization
    • Other related ailments and complications including ectopic pregnancies and miscarriages.
    • Home deliveries
    • Lamaze classes but this requires pre-authorization.

    Reimbursement

    One or two occasions one can be treated in a hospital outside the panel of providers, most providers reimburse 80% -20 % based on the approved rates in there panel of providers. i.e one can only compensated upto 80% of what they were to pay if one could have gone to the hospital approved by the insurer and accessible under your cover limits.

    This is to discourage people seeking medical attention from providers outside the panel provided by your insurer.

    The main exclusions

    The main exclusions are;

    • Illness claims incurred within the first 28 days of cover.
    • Surgical claims incurred within the first 60 days of cover.
    • Amounts recoverable from other insurances such as NHIF, GPA and WIBA.
    • Expenses where material information is withheld or misstated.
    • Benefits not specified in the brochure and policy.
    • Treatment by any other than a certified medical practitioner.
    • Expenses incurred in connection with active participation in riots and civil unrest
    • Self-inflicted injury and attempted suicide
    • Homeopathy, chiropractic treatment, acupuncture, herbal medicine and treatment
    • Medical costs due to experimental treatment.
    • Professional and hazardous sports activities.
    • Cosmetic Surgery i.e experimental surgery unless they
    • Infertility
    • Hospitalization Bills incurred by a member at a non-appointed provider.
    • Alcoholism & conditions related to alcohol intoxication
    • Any claim from a client who withheld information or misstatement when taking a cover.
    • Non KEPI Vaccines
    • Any cost incurred after the expiry of the cover.

    Waiting periods what are they and why exist? Can you get them waived

    Waiting period is a duration where a policy holder for the first time has to delay before starting to use a cover.

    Sometimes one can take a cover with higher limit and more benefits on renewal of existing policy, waiting period applies to the additional benefits.

    Health insurance provider may waive the waiting periods on certain benefits. In case of an accident, there is no waiting period.

    The following services quite often have waiting period;

    • Maternity and related conditions. Waiting period is from 10 to 12 months depending on the provider of insurance.
    • Pre-existing chronic conditions. The waiting is 1 year for most of the covers.
    • Also services like kidney transplant has a waiting period of 2 years.

    Different categories of hospitals from most expensive to gov’t hospitals.

    Hospitals have been clustered into dispensaries, referral hospitals, private hospitals, Nursing Homes County and sub county hospitals, and national hospitals.

    Dispensaries are government hospitals closest to the citizens. They offer simple outpatient services. Conditions which require more intensive observation, patients are often referred to more advanced hospitals in terms of services and specialists.

    The health centers are hospitals that not only offer simple services like common cold but also offer the prevention services. These hospitals also operate as a referral hospitals from the dispensaries.

    Nursing hospitals are hospital run by churches, organizations or individuals. They offer medical services that require more care and also the operational services.

    Private hospitals are hospitals that are more organized with more specialized personnel. They offer all services including the consultation services.

    We have another category of hospitals that is the sub county hospitals and county hospitals which act as the main referral centers for the small hospitals. The services here are more specialized and patients can get more comprehensive treatment while the county hospitals have extra services and resources i.e capacity to care intensive care services, they have life support machines and can carry more complex tests.

    National hospitals

    National hospitals provide all the health services which may not be available in these other hospitals.

    Copayment

    This is the cost one is supposed to cater for anytime he or she visits specific hospitals and the reason is to discourage people to visit hospitals for unnecessary attentions.

    Co-payment varies from on hospital to another and also depends on the health cover provider.

    Overseas treatment? On re-imbursement? Ticket included or not

    Overseas treatment is normally covered up to a certain limit normally it is on referral basis. The most common is South Africa and India. Most affordable Kenyan medical covers allow overseas treatment on referral. For many conditions, it may be cheaper and safer to have them treated overseas as the cost of medical treatment and hospitalization continues to increase here in Kenya. This is normally done on re-imbursement basis.

    NHIF SERVICES

    NHIF has empowered more citizens to access medical care. NHIF covers various services i.e.

    1. Bed entitlement.
    2. Artificial appliances like braces, thoracic collars and other orthopedic appliances.
    3. Eye and dental treatment.
    4. It also covers surgical services.
    5. Various tests including CT-Scan and MRI.
    6. Costs of medicine, registration and consultation are also covered by the NHIF.

    When a policy holder is an NHIF member, he or she has added advantage because it can be used when seeking attention of the above services. Also health cover pays bed entitlement net of NHIF rebates.

    Who are eligible?

    Children are covered to a maximum of 21 years any children above 21 years to a maximum of 25 years can be covered as long as the show proof schooling. The student ID should give information about when one will complete his or her studies.

    Last joining age vary from one provider to another. Members above 55 years are supposed to provide medical examination report before being given acceptance letter.

    Additional benefits

    Most covers have last expense limit as from 50,000 to 250,000. This is payable on death of any declared family member but has a maximum of 2 claims per a year.

    Insurance companies have 24 hour emergency lines.

    International medical covers? What are they and what’s the difference

    These are health covers created and controlled to offer international healthcare solutions for individuals who constantly move across the world i.e, employees of international organizations, multinationals, and small & medium enterprises. These international health insurance packages are much more expensive that ordinary Kenyan health insurance covers owing to the executive level services they offer.

    Some of the main providers in Kenya include AXA PPP, BUPA, AETNA, NowHealth, Allianz and many others.

    The main difference between the local covers and international covers is that the international covers’ scope of cover is internationally that means one can get services anywhere in the world without limited to which hospitals and panel of providers to visit.

    International health covers are often seek by individuals who work, live and do business outside their country of origin but time and again travel back to their mother country to either visit family, friends and even business. As well family members may visit. In this regard an individual may want to cover his or her family comprehensively against any risk while they are on the foreign land.

    Services in international and local covers can be the same.


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