What is medical insurance, and is it important?
- Medical insurance in Kenya provides a financial tool that helps cover the cost of medical treatment, including hospital stays, outpatient visits and specialized treatment for critical, chronic and congenital illnesses. It protects families and individuals from the high costs of illnesses or accidents and ensures access to quality healthcare without the financial strain
What are the types of health insurance covers?
- Inpatient cover: This covers hospital stays requiring at least one overnight admission or a day surgery under general anaesthesia
- Outpatient cover: This covers treatment that does not require hospital admission, e.g consultations, diagnostic tests and prescribed medications.
- Additional Covers: These include maternity, dental and optical covers.
Who is eligible for medical insurance in Kenya?
Eligibility varies based on the insurance provider. Specifically
- Newborns (after hospital discharge) born between 37-38 weeks up to 75 years can join most policies.
- Some policies cater to senior citizens or children only.
What factors should I consider when choosing a health insurance cover in Kenya?
- Scope of cover: Ensure the policy covers your specific needs. (Chronic conditions, maternity, outpatient, dental and optical)
- Premiums: How much will I be paying for the medical insurance per year.
- Waiting periods: Time you have to wait before you can access certain benefits, e.g maternity cover, chronic conditions, cancer treatment, etc.
- Copayment and deductibles: Understand how much you will pay out of pocket to access medical services.
- Provider Network/Panel: Confirm if your preferred hospitals and doctors are included.
Are there waiting periods for medical insurance benefits?
Yes, waiting periods apply for some benefits:
- Maternity coverage often requires a 9-12 month waiting period.
- Pre-existing conditions may have a waiting period of up to 1 year, depending on the insurer.
- Emergency treatments typically have no waiting period
- 30 days for acute illness, both inpatient and outpatient
- Up to 2 years for cancer treatment
- Up to 5 years for organ transplant
Can I use my medical insurance outside Kenya?
- Yes, many insurers offer overseas treatment coverage for conditions not treatable locally. The common destination is India. This usually requires a referral and preauthorization from the insurer
What happens if I exhaust my coverage limits?
Once your annual limit is exhausted:
- There are no extensions unless specified by the policy.
- Consider registering for government schemes like SHIF/SHA.
Are dependents covered under medical insurance policies?
Yes, dependents such as spouses and children are often covered:
- Children are typically covered up to 21 years or 25 years if in full-time education.
- Disabled dependents may remain covered beyond this age limit under some schemes
What exclusions should I be aware of?
Common exclusions include:
- Cosmetic procedures
- Experimental treatments
- Certain drugs or devices not approved by the insurer
- Self-treatment and prescription
- Services sought outside the insurer's panel of providers without prior approval.
How do I register for medical insurance in Kenya?
Registration depends on the provider:
- For government schemes like SHA/SHIF, registration is mandatory and can be done online.
- Private insurers require filling out an application form and submitting necessary documents like identification and medical history records.
Can I switch health facilities under my cover?
- Yes, most plans allow you to change your preferred healthcare facility.
What happens if I lose employment but have employer-provided insurance?
- For employer-provided schemes like SHI/SHA, coverage may continue temporarily after job loss.
- Members can transition to individual contributions to maintain their cover private health insurance in Kenya
Are there benefits for preventive care under medical insurance?
Yes, many plans include preventive care, such as:
- Annual check-ups
- Vaccinations
- Family planning services
- Nutrition counseling