The Claim Test
Why Most Health Insurance Policies Fail When You Need Them
None of what follows is accidental. It is what happens when a policy is sold instead of understood. Five failure modes — and what Amssurity does about each one before recommending a plan.
The gap
Hidden sublimits appear only after diagnosis
Your cancer sublimit is KES 300,000. Your oncologist's bill is KES 1,800,000. Your inpatient limit was KES 1,000,000 — but the sublimit applied. You pay KES 1,500,000. The policy worked exactly as written.
What Amssurity does
Every plan brief names the cancer sublimit, chronic conditions cap, maternity ceiling, and inpatient dental limit for every plan we recommend. The number is on paper before you sign — not when the bill arrives.
The gap
Waiting periods no one explained at purchase
You bought cover in February. The baby arrived in October. The maternity waiting period was 12 months. The claim was declined — not because you did anything wrong, but because no one told you the clock started at signing.
What Amssurity does
We map every waiting period per benefit, per plan. Maternity: 10 months (APA, CIC, Heritage) or 12 months (Old Mutual, Jubilee). Pre-existing: 12 months standard. Cancer: 24 months on most plans. If your timeline doesn't fit, we tell you before you buy.
The gap
"Covered" conditions that are quietly excluded
"Covered" is the most dangerous word in insurance. A condition can appear in a brochure and be excluded in the policy wording — due to an undisclosed history, a missed disclosure, or a clause the agent glossed over. Undisclosed pre-existing conditions are excluded for the lifetime of the policy on most plans.
What Amssurity does
We review your medical history in the application, flag conditions requiring full disclosure, and identify which underwriter handles each condition most favourably. The disclosure conversation happens before application — not after a declined claim.
The gap
Hospital panels that look wide — but exclude your hospital
One major underwriter's mid-tier plan explicitly excludes Nairobi Hospital, Aga Khan, MP Shah, Gertrude's, Mater, and AAR from outpatient access. This is stated in their benefit schedule. Their marketing material does not make it prominent.
What Amssurity does
We ask which hospital your family actually uses. Then we verify it against each insurer's actual benefit schedule — not the brochure. If your hospital is excluded at the plan level, you find out from us. Not from the hospital reception when you show your card.
The gap
Brokers who disappear when claims start
The policy was sold. The commission was paid. On the day of admission, the broker's phone goes to voicemail. The hospital needs pre-authorisation. You don't know who to call. The insurer is requesting documents you don't have ready.
What Amssurity does
Agnes opens your claim within 2 business hours of notification. A document checklist is sent immediately. The insurer is followed up every 48–72 hours until the claim is resolved. This is included in working with Amssurity — not an add-on. Agnes is on WhatsApp, not behind a call centre queue.
