Medical Insurance

Medical Insurance

Medical insurance is one of the most popular classes of insurance in Kenya. This is because of the historical problems that relate to affordability, accessibility, sustainability, and quality of public health insurance programs.

Medical insurance plans in Kenya are available for both individuals and companies. Insurance companies usually deliver services via provider networks. These are national networks of hospitals, clinics, doctors and other medical professionals who have been vetted by the insurance companies. Policyholders usually identify themselves and access services at these establishments using smart cards issued by the insurance companies.

Types of Medical Insurance

There are two main types of medical insurance in Kenya:

  • Inpatient
  • Outpatient

Inpatient Medical Insurance

Inpatient medical insurance is the core benefit providing by the majority of insurance companies in Kenya. It typically covers all types of treatment and surgery while the patient has been admitted in a hospital with the exception of certain exclusions. The following are some of the most common exclusions:

  • Maternity.
  • Dental treatment as a result of an illness.
  • Optical treatment as a result of an illness.
  • Most insurance companies have a general waiting period of 30 days for new entrants on illness claims.
  • Pre-existing, Chronic, Psychiatric, Congenital, Organ Transplant, HIV/Aids and related treatment usually have a waiting period of between 6 months and 2 years. This varies with each company.
  • The age limit on entry is usually 1 month to 60 years.
  • All hospital bills are paid net of what the National Hospital Insurance Fund (NHIF) would contribute. Every Kenyan is expected to have signed up with NHIF.
  • Cosmetic or plastic surgery unless necessitated by an accidental injury.
  • Sexually transmitted diseases.
  • Peri-Menopause, Menopause, andropause, hormone replacement therapy, age, and puberty related treatment.
  • Genetic disorders and related conditions.
  • Riding or driving in any kind of race.
  • Beauty treatment or massage.
  • Naval, military and air force operations.
  • Stays at sanatoria, old age homes, places of rest, etc.
  • Medical check-ups, general health examinations, prophylactic treatment, vaccinations except for KEPI vaccinations.
  • Transportation other than on a licensed ambulance.
  • Hearing tests or cost of hearing aids unless resulting from an accidental injury.
  • Nutritional food supplements or replacements.
  • Injury or illness resulting from insurrection or war, civil commotion or an act of terrorism, whether declared or undeclared.
  • Injury as a result of participating in a riot or strike.
  • Alternative treatment such as herbal treatment, acupuncture treatment, chiropractors, etc.
  • Expenses resulting from the insured participating in extreme/hazardous sports and activities.
  • Pain management.
  • Treatment required as a result of noncompliance, failure or refusal to comply with medical advice.
  • Contraceptive services and supplies, family planning and fertility treatment.
  • Services primarily for weight reduction or treatment of obesity and slimming preparations or any care which involves weight reduction as the main method of treatment.
  • Epidemics, pandemics or unknown diseases

However, some of the exclusions above can be covered by purchasing optional coverage. For example, most insurance companies offer Maternity, Dental and Optical coverage at an extra cost.

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Outpatient Medical Insurance

Outpatient insurance covers all treatment where the insured does not need to be admitted to a hospital. For the majority of insurance companies, this is a supplementary cover. You must first purchase the core inpatient benefit. Most of the exclusions noted above also apply to outpatient treatment.

Optional Covers

As mentioned above, optional medical insurance plans that can be purchased together with an outpatient cover include:

  • Maternity cover – this will usually come with a one-year waiting period and will typically cover Pre-natal & Ante-natal outpatient treatment, KEPI Vaccinations, normal and C-Section delivery, labour/recovery ward, professional fees, pregnancy/maternity related hospitalisation, and, other related ailments & complications.
  • Dental Cover – this will typically cover dental consultations, extractions, fillings, dental X-rays and prescriptions.
  • Optical Cover – eye examinations, prescriptions and the cost of spectacles.

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The above is the basic design of medical insurance policies in Kenya. However, companies can differ greatly in the following areas:

  • The actual scope of coverage.
  • The premiums charged.
  • Customer service and responsiveness when you need treatment.
  • The quality of the provider network.
  • Overseas treatment.
  • Free-extras.

If you are looking for a medical insurance plan, contact us today or request a quote and one of our insurance gurus will get in touch with you. You can also read about critical illness insurance in Kenya.

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