Health Medical Insurance in Kenya

Health Medical insurance coverage is a very important insurance that one should have. In the modern world today, the cost of healthcare has shot up, and footing a hospital bill drains a family financially. This can be addressed by having Health Medical insurance coverage. As the saying goes, “health is wealth”, one should always strive to guard their health and well-being. In addition to taking preventive measures such as eating healthy and keeping fit, it is vital to also have medical insurance as a cover that will relieve you financially in case unwell or sick.

In this Article we explore and dive into medical health insurance in Kenya, in brief, the Article looks at:

1. What is Health Medical Insurance
2. Terminologies Used in Medical Health Insurance
3. What Does Health Medical Insurance Cover
4. What to look at when sourcing for Medical Health Insurance
5. Corporate and SME Medical Insurance Schemes
6. Benefits of Having a Medical Insurance Cover
7. How Medical Insurance Premium is Determined
8. Common Health Medical Insurance FAQs

What is Health Medical Insurance

Medical health insurance is an insurance cover that pays for the hospital bills of an insured person. This includes hospitalisation, consultation, and medicine bills.

The insurance is offered by Medical Insurance companies that underwrite the cover based on a number of factors such as age as shall be discussed in a later section of this article.

Medical insurance is an essential cover that one should take up, in addition to the social medical insurance provided by the government (e.g. NHIF /SHF) and by an employer.

In addition to having your employer insurance, it is important to have your own private medical insurance especially when working and you have cashflow to afford one. Why this is advisable because often, the job may not be guaranteed, and in case of job loss you seize being a member of the insurance scheme. On the other hand, the scheme may have limits or not cover all medical conditions.

Terminologies Used in Medical Health Insurance

You may come across the following terminologies within medical insurance which are new terms or jargon that you don’t know what they mean.

1. Inpatient: This refers to admission cases where one is administered to a hospital and is only discharged to go home after recuperation and feeling better. It often applies to critical health conditions such as when one is admitted to a general ward, ICU (Intensive Care Unit), or HDU (High Dependency Unit).
2. Outpatient: This refers to hospital visits that do not require admissions and one is allowed to go back home after visiting a hospital.
3. Waiting Period: This is the minimum number of days that must lapse before the medical insurance can cover some medical bills.
   • The timeframe often varies from one insurer to the other with common ones being 10 -12 Months for Maternity to take effect unless it is a case of renewal where there is no waiting period.
   • Waiting periods are set by insurance companies to give time for the onboarding to take effect for short time frame , while waiting periods with the long timeframe waiting to protect insurance from risks of being defrauded as people take the insurance knowing they have a condition that they do not disclose to the insurance company.
4. Onboarding: The process taken by an insurance company to have an insured person listed on their insurance scheme and details populated, saved, and broadcasted on their systems.
5. Panel of Providers: This is a list of hospitals, health centers, specialists, and pharmacies provided by an insurance company where their customers can get medical services using their insurance scheme.
6. Exclusions: These are conditions that medical health insurance does not cover and does not pay for. An example is cosmetic surgery which is not a health illness or condition. However, some exclusions are covered by an insurance company if purchased at an additional premium.
7. Copay: This is an amount of money that an insured person is expected to pay out of pocket when they visit a hospital despite having insurance coverage that is required to pay for the bills. It is often levied on the tier one hospitals which are relatively expensive to discourage them from visiting them over minor health conditions that can be addressed in other levels of hospitals.
8. Ridder: This is an additional insurance cover that is sold together with the main insurance. E.g. most health insurance is sold as Inpatient, and outpatient stand-alone but can also be sold with ridders such as Dental, Optical, and Maternity.
9. Pre–authorisations: For health insurance, there are treatments that require prior approval by the insurance companies before you can get the services at the hospital. This is where the hospital has to contact your insurer to ask if they will cover the bill for the treatment.
   • Pre-authorization is often sought on conditions such as admissions, surgery cases or treatment that are expensive. This is determined by the agreement and, terms and conditions set by the insurance.
   • Pre-authorization often slows access to health as patient have to wait for their insurer to confirm if they are committing to settle bills that relate to a certain health condition that requires pre-authorization.
10. Limit: This is the maximum amount that an insurance company can pay on the bills of an insured person.

What Health Medical Insurance Covers

This often varies from one insurance company to the other. However, most insurance companies will cover the following to certain limits;

• Outpatient Services
• Inpatient Services
• Dental Services
• Optical Services
• Consultation Fees
• Specialist fees. e.g. Gynecologist
• Cost of Medicine
• Operational fees
• Ward bed charges
• The last expense in the unfortunate demise and Life has been endorsed as a ridder.

What to look at when sourcing for Medical Health Insurance

As it is now clear on what medical insurance can cover it is undoubtful it is an essential insurance cover. The question then one may ask is What do I need before purchasing medical insurance? What do I need to look at from the different insurance providers? Is it ok buying through an intermediary? and so on.

There are a number of factors to consider when purchasing an insurance cover. These are summarized as follows:

1. Do not look at the cost, look at the benefits.- Often people get quotes from different providers and choose the cheaper one. You should compare based on the benefits being provided by the different insurance companies, go for one that gives more cover benefits.
2. Pay attention to Exclusions: An insurance will give a list of what is covered and what is not covered. Pay attention to the exclusion list to see what they will not cover that you would want covered and negotiate for its inclusion even if it means paying an extra premium.
3. Note the Waiting Periods: you should look at the waiting period to ensure you are not rushing to the hospital just after buying the insurance. Until the waiting period lapses, that is when some covers can take effect. e.g. Maternity is covered after 10-12 months, don’t purchase insurance when you are pregnant, buy before for it to cover the fees related to delivery.
4. Limits of the Insurance Cover: you should look at the different limits the insurance cover has to ensure it is sufficient to cater to anticipated bills. For example with a limit of 1 million for Inpatient means, in the case of Admission it can only cover up to 1 million.
   • The Limit gets depleted as it is utilized, this means, for instance, an Outpatient limit of Ksh 75,000 in AAR Bronze Medical Insurance Cover. When you visit the hospital and your bill is Ksh 12,000 your resulting Outpatient balance is now KSh 63,000.
5. Consult an Insurance Expert: Consult an insurance expert such as an Insurance Agent to guide you on sourcing and selecting the most appropriate insurer that matches your risk and budget.

Corporate and SME Medical Insurance Schemes

A company or an SME business can take up a Medical Insurance cover for their employees. A corporate medical cover scheme is ideal for any SME with a minimum of 3 employees and can be customized to have different limits for the different employee job groups.

As an SME or company having medical cover for your employees as an additional benefit gives your business a better rating and commitment of employees since their welfare is considered. On the other hand payment of insurance premiums is a tax-deductible expense for the business.

Looking for a corporate SME Medical Insurance? Our team can help you with sourcing the best cover, get in touch for a quote.

Benefits of Having a Medical Insurance Cover

It is not debatable what are the benefits of not having medical insurance, medical insurance is important due to the following:

1. Access to better healthcare
2. Financial Protection in Health Crisis
3. Access to a wide panel of hospitals where you can access medical care
4. Offers Annual Medical Checkups
5. For a family medical cover, beneficiaries are well covered.
6. Rescue and ambulance services

How Medical Insurance Premium is determined

The cost of medical insurance varies depending on a number of factors. When you quest for a quote on medical insurance, the underwriter considers the following:

1. Age of the person; elderly persons are prone to lifestyle diseases and often the premium applied is higher. Most insurance providers also require medical tests done on Seniors above 65 years before they can cover them.
2. Number of Lives: for insurance policies that cover more than one person e.g. Family and SME/Corporate insurance, the number of members will influence the premiums charged.
3. Gender: for instance, maternity cover only applies to female
4. Pre-Existing Conditions: on taking up medical insurance, one is required to disclose their health conditions while filing the insurance proposal form. Those with preexisting conditions may get relatively higher premiums as they are prone to other illnesses.
5. Cover Limits: An insurance cover with a higher limit cover will attract a higher premium.

Health Medical Insurance FAQs

Some of the frequently asked questions in regard to medical health insurance include the following:

1. What is the validity of Medical Insurance? often medical insurance is valid for one year, after which the policy cover expires and has to be renewed.

2. Can I Purchase a Medical insurance cover for my Children only?

Yes, there are underwriters that offer medical insurance to children alone without requiring them to be covered under a principal member who is the guardian.

3. Can I Purchase Medical insurance cover for my Elderly  Parents?

You can purchase for your parents a medical insurance cover to cover their bills in their retirement. In as much as most underwriters require them to go for medical tests for those above 65 years, there are some insurance providers that do not require the mandatory medical test.

On the other hand, it is better to take up medical insurance for your parents enough before they hit retirement age so that there is a good relationship with an insurance company. This is because often mist underwriters are hesitant to cover elderly persons because they are susceptible to weak immune systems.

4. Can I cover my boyfriend/girlfriend under my Medical Insurance?

Well, you can only add your Spouse to your Medical Insurance. However, you can be kind enough to purchase for your boyfriend/girlfriend a separate independent medical insurance cover.

5. Can I cover for my adopted children under my Medical Insurance?

Yes, provided you have the appropriate adoption documentation to be the Guardian.

6. Does insurance refund unutilized funds before expiry?

Medical insurance is an insurance policy taken to cover the risk of an illness happening but is not a fund. In case you do not utilize the amount, the unutilized funds are not refunded by the insurance company.

7. My Employer has covered me do I need another medical insurance?

Often, when as an agency we approach and pitch to potential clients this question arises as an objection since one is covered by their employer’s medical scheme.

However, its is important to have your own private medical insurance especially when you have the financial capability of buying one. Remember your employer may terminate the insurance cover, job position or even there are set limits on the employer medical scheme.

With private medical cover, you can get customized medical insurance to cover what is not covered by your employer scheme e.g. a medical scheme that also has international cover benefits such as Cigna.

8. What happens if my medical coverage is exhausted?

When you utilize your medical cover to the limit,  you can negotiate with your insurer to issue an extension cover that can be prorated to the expiry of your existing cover. Otherwise, you have to wait until renewal with no medical cover.  

9. Can I have more than one medical insurance?

Yes, you can take up insurance from more than one insurance company. This would often work where you buy a stand-alone cover e.g. You buy an Inpatient only from Insurer A and an Outpatient from Insurer B . This trick can work where you want to get maximum benefit from different insurers.

Contact our team to learn how you can use this trick to strike two birds with one stone where you will have relatively affordable medical insurance with maximum benefit limits for both outpatient and inpatient services

10. What is the impact of social medical insurance i.e. NHIF /SHIF?

As there is a mandatory statutory requirement for employers to deduct and remit NHIF/SHIF. The money remitted may not necessarily cover medical illness as is the case with private medical insurance,  however, it often settles bed charges and in some cases for public servants, it has settled significant bills for critical illness patients.

Conclusion

Medical insurance is a vital insurance cover that you should take up as an individual for your family, parents, and even for your employees. Medical insurance helps in settling hospitalization bills and other bills such as medication and bad charges in case one is admitted to a hospital.

With medical insurance, you are covered by financial shocks and crises, especially in cases of inpatient admission where bills escalate overnight.

You can contact our team to get a custom quote for your health medical insurance today. You can also initiate a Whats app chatbot and get instant responses.