Taking the time to understand your health insurance plan can save you a lot of headache when you need medical attention. Insurance terminology is confusing to most people. Fortunately, understanding these terms isn’t too difficult. The following are five terms that are very important to understand your plan:

  1. Network
  2. Premium
  3. Co-pay and Co-insurance
  4. Waiting Period
  5. Sub-limits

Network

Your insurance company is not a hospital, therefore, to effectively provide medical services, they rely on a group of preferred providers. This is a network of physicians and hospitals. To access services within this network, the insurance company will issue you with some form of identification such as a smart card.

Premium

The premium is the amount of money you pay to your medical insurance company annually to keep your coverage active. It’s similar to the premium you pay to keep your motor insurance each year. The premium amount determines the scope of coverage. For example, a higher premium could mean higher inpatient coverage and/or additional optional coverage for maternity, dental and optical expenses.

Co-pay and Co-insurance

Co-Pay is sometimes confused with co-insurance, but they’re not similar. Co-pay is the fixed amount you pay the medical provider in advance each time you use a medical service. For example, your health insurance plan may come with a co-pay of Kshs 500. This would mean that each time you visit a preferred provider on their network for treatment, you would first need to pay Kshs 500.

Co-insurance is an amount you pay after meeting your deductible. A deductible is not a very common feature of Kenyan health insurance plans but it is the amount you would pay each year before your health plan starts to pay for a portion of your service. For example, if you have a Kshs 150, 000 bill for your medical expenses and your plan has a Kshs 50,000 deductible, the 1st Kshs 50, 000 paid towards the bill would be your responsibility. This Kshs 50, 000 payment meets your deductible and your insurance company would then pay their portion of the remaining Kshs 100, 000 balance. Where the policy has co-insurance, and after meeting your deductible, your insurance company would begin making a percentage of payment towards your medical expenses based on your plans co-insurance rate. Co-insurance rates typically range from 10 to 20 percent.

Waiting Period

A waiting period is a period following the inception of cover when all or some medical conditions are excluded (not covered). For example, most health insurance plans in Kenya have a 28 day waiting period for illness. Depending on the insurer, there are also waiting periods for up to two years for pre-existing conditions, chronic conditions, cancer, organ transplants and more. This means that after you have purchased the plan, you will not be able to make use of it in the event that you get sick until the waiting period lapses.

This feature is used to discourage fraud where people buy insurance after they find out that they are sick. However, waiting periods rarely ever apply in the event of treatment necessitated by accidental injury.

Sub-Limits

Sub-limits are policy conditions that limit that maximum amount of coverage for specified illnesses. For example, a policy may have an overall benefit limit of Kshs 1,000,000 but have a sub-limit of Kshs 300,000 for cancer treatment.

Working with an insurance agent will help you understand the terms and conditions contained in your health insurance plan. The last thing you want is drama at the hospital desk. If you would like to know more about health insurance or for a no-obligation quote, please contact one of our insurance gurus today.

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