Confused about Health Insurance In Kenya? 8 Terms Simplified
In our journey of selling health insurance in Kenya, we often come across some questions after using a certain term, “What does that mean?” In most cases, it is in regards to some terms that are commonly used in insurance that tend to be confusing or not used in the same way as in everyday conversation.
Here we shall take a closer look at the top 8 insurance terms that we have found to be confusing to clients.
Table of Contents
Health Insurance In Kenya: Waiting Period Explained
The waiting period in insurance means the period in which an active cover cannot be used to make a claim for a particular sickness or condition. In most cases, this applies to new covers or first-time insurance takers in a particular insurance company.
For example, your cover might indicate no waiting period for accidents. This means that the medical cover you have once it is active, in case of an accident, you can get treatment immediately. Another one can be 21 days for outpatient illness services. This means your cover becomes active from the 22nd day after the cover becomes active for outpatient service.
The common waiting period for most health insurance policies in Kenya is as follows:
| Nature of Illness | Waiting period |
|---|---|
| Accident | 0 days |
| Illness | 30 days |
| Cancer treatment | 3-6 months |
| Declared Pre-existing/chronic/congenital conditions(both inpatient and outpatient) | 12 months |
| Cancer treatment | 10-12 months |
| Cance treatment | 24 months |
| Outpatient including dental and optical | 14-30 days |
Another determining factor of the waiting period is whether the type of cover taken is an individual plan, SME Plan, or corporate plan. An individual plan has more and longer waiting periods. SMEs have shorter or no waiting periods which can be waived if the SME is transferring cover or willing to pay an extra premium. As for corporates, most have the waiting periods waived.
Health Insurance In Kenya: Copayment
Copayment in medical insurance means the flat fee that the insured person pays to access certain or specific services from their covers. Most health insurance plans in Kenya have this as part of the outpatient service plan.
The amount payable varies from insurer to insurer. The amount payable can be as low as KES. 200 to as high as KES.2,000. This option is made mandatory in most individual health insurance plans while SMEs and Corporates have the option to waive it. However, if an SME or corporate business chooses not to have copays an extra premium is charged.
A more detailed explanation of the same:
Health Insurance In Kenya: NHIF Rebate
All health insurance providers in Kenya have a condition in their inpatient covers when it comes to the bed limit payable per plan which must be paid for NHIF. At the point of discharge, the hospital will require you to have your medical insurance card and an active NHIF card to pay for a specific amount towards the cost of the bed. This amount varies from hospital to hospital depending on NHIF hospital categorization A, B, or C and also the contract between NHIF and the hospital.
In the event, you do not have NHIF or it is not active, this amount is paid by you in cash and you cannot claim it back from the insurance company. International medical insurance providers such as Allianz/Henner or Aetna do not have this condition.
Health Insurance In Kenya: Sublimit
One thing that most clients do not like about local insurance providers is what is called a sublimit. A sublimit is where certain and specified types of illnesses and conditions are not covered up to the full inpatient limit the client has taken.
For example, if you take an inpatient cover limit of KES. 1 Million, you need to note that illnesses such as pre-existing/chronic/congenital conditions (discussed below) are not covered up to the KES. 1 Million rather, they are covered up to say KES. 200,000 per year. This means that any amount above KES. 200,000 will be paid for by the client.
Some international medical insurance providers, therefore, give better coverage as they accept specified illnesses up to the full inpatient limit. Take time to go through the various plans and choose the best sublimit for you.
Health Insurance In Kenya: Pre-existing Conditions
Health insurance defines a pre-existing condition as a medical condition, declared or not, that the prospective client is aware of before taking cover. An example can be a broken hand.
These conditions are usually subject to a waiting period of up to 12 months by local health insurance providers in Kenya across all plans. Unlike the SMEs and corporates who have the option to negotiate the waiver of this waiting period, individual clients do not have the option to.
After the waiting period, the client can seek treatment of the condition up to the specified sub-limit of your medical plan.
Health Insurance In Kenya: Chronic Conditions
Similar to pre-existing conditions, a chronic condition is defined as an illness with no known treatment/cure, can be managed through the use of medication, needs constant treatment and management, can reoccur, and can change your body in one way or another. For example diabetes, high blood pressure, and chronic kidney conditions among other. You can see a more comprehensive list here.
These illnesses sometimes have a tendency not to be discovered at the time a prospective client is signing up for insurance. As a result, the insurance companies have added two ways in which they address this particular issue.
Chronic Condition diagnosis within the first 6 months after being on the cover
When this happens, the condition is assumed to have been known from or before the start of cover therefore the 12-month waiting period applies. The amount one can claim for the treatment is up to the specified sublimity as per your plan such as after the first 12 months.
Chronic Condition Diagnosis After the First 6 months of being on the cover
When this happens, your insurance provider in most cases will accept the claim. The treatment of this kind of condition is also limited to the sublimit provided by your insurance plan.
Health Insurance In Kenya: Congenital Conditions
This can be defined as abnormalities that arise during the uterine development of the fetus. These abnormalities can be present at birth or develop later on in life. The coverage for such is subject to the 12-month waiting period or as specified by your plan. It also has a specified sublimity to which one is covered.
Examples of his kind of conditions include a hole in the heart and Down syndrome among others. A list of such can be found here.
Health Insurance In Kenya: Exclusions
All plans of health insurance in Kenya have a set of conditions, illnesses, and sicknesses that are not covered. These are referred to as exclusions. They are provided in the medical insurance policy and common ones include attempted suicide and self-harm, alcohol and substance abuse, and sexually transmitted diseases excluding HIV/AIDS just to state a few.
This means that the insurance company will not cover any claim submitted for such conditions.
We at Amssurity aim at providing you with all this information so as to make the best decision for your health insurance in Kenya.
In case you want someone to take you through your health insurance plan or need to talk to someone about how to get health insurance in Kenya, we are your go-to and trusted insurance agency in Kenya.
You can reach us on +254 762 065 500 via call or Whatsapp or get a free quote now and we shall call you to discuss the same.
Amssurity Insurance Agency will help you get the best health insurance in Kenya.
How much does health insurance cost in Kenya
There are several factors that determine the cost of health insurance in Kenya which have been discussed at length in one of our articles. However, it is important to note that there are four major categories of medical insurance that you need to be aware of towards healthcare in Kenya:
- National hospital insurance fund: this is a social insurance scheme in Kenya that is working towards universal health coverage. Caters to the majority of NHIF Category and B hospitals
- Budget health insurance: this private health insurance cover caters to specific hospitals in NHIF Category A and Category B hospitals. These also happen to be the cheapest health insurance in Kenya under the private health insurance arrangement. For more details on the same, read this article.
- High-cost medical insurance: this private health insurance coverage caters to specific NHIF categories A, B, and C hospitals with specific clauses that guide you towards getting medical help. This class of health insurance has the best medical insurance in Kenya.
- International medical insurance: One of the most expensive options for medical insurance in Kenya but caters exclusively to the major private hospitals in Kenya.