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Top 5 Essential Components of Health Insurance


Health Insurance in Kenya components

Health insurance also commonly known as medical insurance in Kenya is one of the most sought-after insurance products by individuals and businesses. As per the IRA report of 2020, Medical insurance formed about 34.4% of the gross premium underwritten in non-life insurance premiums. This just goes to show you how much Kenyans value health insurance. This could also be attributed to the high cost of healthcare in Kenya.

Types of Health Insurance in Kenya

Medical insurance is composed of 5 major types in the health insurance marketplace:

  1. Inpatient cover.
  2. Outpatient cover
  3. Dental cover
  4. Optical cover
  5. Maternity cover

Inpatient Health Insurance Covers

Inpatient Health Insurance

Just like the name suggests, it caters to all medical costs related to your hospital stay. Any health insurance company will specify what is covered, what is not covered, and to what limit. The various limits of coverage and illnesses and conditions are usually considered when calculating the premium or amount charged on an inpatient health insurance cover

What is Covered Under Inpatient Health Insurance Cover

As insurance agents, we have come across this question several times. We shall look at the details of what is covered under inpatient cover.

  • Inpatient Limit

You have probably talked to an insurance agent and they have mentioned something like an inpatient limit of 500,000. This means that you are covered up to 500,000 for the various illnesses as defined in your policy in that insurance year.

  • Accidents.

This is one of the areas that inpatient health insurance covers. An accident as per insurance is defined as an unanticipated event requiring medical attention. This has to result in an injury that is evidenced externally, violent and visible as advised by a medical doctor. As per one of our previous articles on medical insurance terms explained, this particular kind of treatment has no waiting period meaning that you are covered upon being placed on the cover.

  • Pre-existing/Chronic/Congenital conditions/HIV-AIDS/Psychiatric/Psychological Treatment

These conditions are subject to the term defined as sub-limits and waiting period. Sub-limits are usually expressed as a percentage of the inpatient limit. What this means is that for any of the above conditions you will not be covered to the full inpatient limit as taken but rather ass per a sub-limit indicated in the policy schedule.

What this means is that you will need to have a candid conversation with us or your agent about your current health status so that we can be able to get the best limits for you. This might mean getting a bigger inpatient limit for you be able to get more comprehensive coverage.

Chronic conditions have several characteristics:

  • Has no known cure
  • Is likely to recur
  • Requires palliative treatment
  • Needs prolonged monitoring/treatment
  • Requires specialist training/rehabilitation
  • Is caused by changes to the body that cannot be reversed

A congenital condition is a medical condition that is present at birth or before birth or believed to have been present since birth.  The condition could be inherited or caused by an environmental factor

Pre-Existing Condition has at least one of the following  characteristics: 

  • A medical condition which a member had, knew, or ought reasonably to have known and can be medically proven they had before, either for the first time, before renewal, before reinstatement or before upgrading cover. 
  • Any ailment/condition diagnosed within the first 90 days of taking corporate/SME or an individual cover unless specified otherwise in the policy schedule. 
  • Any ailment/condition diagnosed within the first 180 days-1 year of joining individual cover unless specified otherwise in the policy schedule. 
  • Any known chronic ailment/condition that existed in any previous year of cover. 

Psychiatric/Psychological Treatment focuses on your mental health and it will deal with matters such as anxiety, depression, and any other mental health treatments that your policy will define. Coverage of such will vary from one insurance company to another. However, treatment for alcoholism and other substance abuse is NOT covered.

  • Inpatient Dental and Optical Non-accidental Treatment

There are some dental and optical conditions such as cataract removal that are usually provided under this option. This coverage means that there is a sub-limit attached to it and therefore, means it is subject to the sub-limit as specified in.

  • Covid-19 Coverage

One of the biggest considerations right now from the discussions we have had with clients is if they are covered for Covid-19. Yes, our partners are covering it subject to the specified sub-limit as per the policy picked by the client. There are several conditions that will be imposed in regard to testing and treatment and this varies from company to company. It is therefore important to ask the terms and conditions regarding this.

  • Evacuation Services

In the event you need air evacuation or ambulance services in the event of an emergency leading to admission, your inpatient cover facilitates the cost associated with that. This will be covered up to your inpatient limit or sub-limit as specified in your policy.

  • Overseas treatment

When you want to go away on holiday or business, you need to notify your insurance company of this plan. Most companies provide emergency medical travel coverage subject to the inpatient limit. The treatment is restricted to emergencies and not elective treatments. The days can vary from 42 days all the way to 90 days. This depends on the insurance company. Please note in most cases, the treatment will be based on reimbursement so keep all the necessary diagnosis, treatment, and receipt documents to submit when you come back.

  • Lodger Fee

It is every parent’s fear that their child below the age of 12 is admitted to the hospital. Unfortunately, when this happens, insurance companies offer what is called lodger fee services. where the hospital stay cost of the accompanying guardian/parent is taken care of. The lodger fee as defined by the company in most cases can be between 8 years and 12 years. Therefore it is important to understand the policy terms.

  • Post-Hospitalization

After a major admission or surgery, there is a post-operation follow-up that the doctor might need to do so as to ensure that your health is progressing well. In this case, the inpatient will take care of these cases up to the specified limit in the policy and within the specified time limit. In most cases, this time limit is usually 3-4 weeks.

Outpatient Health Insurance Covers

Outpatient health insurance in kenya

Outpatient health insurance acts as a complement to the inpatient health insurance cover. It usually takes care of the services such as diagnosis, treatment, and prescription of the illnesses as discussed in the inpatient health insurance cover benefits above. The cover takes care of all costs associated with the daily visits to your doctor.

So what that means is that whatever is covered under inpatient is also covered under outpatient health insurance cover. The cover does not limit you to a sub-limit as per inpatient but rather the full limit of outpatient. You will find that here things like copayment or deductible apply as well as the waiting periods. You can read more about what they mean here.

The nature of outpatient health insurance is that it is likely to be used during the year and since it doesn’t have sub-limits, it tends to be expensive. It is also optional but not mandatory. It also means it can’t be taken alone but rather it has to ride on inpatient.

Sometimes, to help one make a decision on whether to take outpatient to consider the following:

  1. How much you spend on outpatient a year
  2. How often do you visit the hospital for outpatient cases
  3. Cost vs budget available
  4. Cost-benefit analysis
  5. Your income cycle.

These are just but a few things to look at but they are not exhaustive.

Dental Health Insurance Covers

Dental Health insurance
Dental Health Insurance

Just like the name suggests, it caters to dental expenses as per specified limits in your policy. Most companies cover dental treatment related to simple extractions, difficult extractions, Fillings (temporary, permanent, amalgam, composite, GIC), scaling and polishing, gum surgery, Root canal treatment, pulpotomy & minor Oral surgery
The main exclusions include:

  1. Expenses arising from replacement or repairs of old dentures crowns bridges and plates unless directly caused by accidental injury.
  2. Expenses relating to orthodontic treatment of a cosmetic nature unless directly caused by accident.

Optical Health Insurance Covers

Optical Health Insurance

Just like the name suggests it looks into treatment that is related to the eyes. It takes into consideration the cost of eye treatment, prescribed lenses, and one pair of frames per person every 1-2 years, depending on the insurance company. Lenses may be replaced during the insurance period up to the specified limit.

Some of the exclusions include:

  1. The replacement of frames unless directly caused by an accident gives rise to an injury to an eye.
  2. The replacement of lenses unless advised as part of further treatment.
  3. The cost of contact lenses
  4. Laser/Lasik surgery unless otherwise specified.

Maternity Health Insurance Covers

Maternity health insurance

We have discussed maternity insurance in detail in one of our articles on our blog. You can read more here.

So the summary of the cover is as follows:

  1. Consultation fees prior to delivery: This caters to costs related to seeing your doctor in regard to the prenatal visits
  2. Standard Prenatal testing: This includes the usual testing that needs to ensure the safety of the mother and child
  3. Obstetrician Scans
  4. Post natal consultations
  5. Normal deliveries
  6. C-Sections: whether elective or emergency.
  7. Complications that arise as a result of medical emergencies such as miscarriages.
  8. Some companies will categorically state that any expenses towards medical termination of pregnancies will be accommodated.

Health insurance is subject to change therefore, you need to ensure your agent updates you on any changes that might happen when you are in coverage. We also recommend that you read through the health insurance policy document to get to know the details of your cover inside out.

Details of this article have been taken out of various policy documents there by no means is it exhaustive. If you need help in going through your current health insurance policy document, book a 30-minute FREE consultation to help you understand the best individual health insurance plans

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