Types & Benefits Health Insurance Plans in Kenya

The health insurance sector in Kenya has several types of insurance policies targeting the general public. These plans are devised to meet the needs of Kenyans seeking insurance covers for their families and for companies requiring covers for their employees. Here are the key types of insurance policies that you will find in the Kenyan market.

1. Inpatient cover: Inpatient cover refers to policies that provide compensation for costs associated with hospitalization. Impatient covers come into effect when the policyholder is admitted to hospital. This cover is typically more expensive that other types of cover because in addition to the direct costs of treatment, it also covers policyholders from the liabilities associated with accommodation costs in the medical facility. Some insurance companies require policyholders to get clearance before accessing inpatient facilities. In these cases, the company seeks to make sure that the case requires hospitalization, and is not just a frivolous hospitalization request.
2. Outpatient cover: By far the outpatient cover is the most common type of health insurance cover. The outpatient cover protects policyholders from liabilities associated with access to outpatient facilities. In this case, a policyholder accesses health services in a hospital or clinic accredited by the insurance company and after receiving treatment the policyholder does not remain resident in the health facility. Outpatient covers tend to be cheaper than inpatient covers because all the costs incurred are treatment related. It does not have the accommodation component that usually inflates the cost of outpatient covers. However, outpatient covers do not usually exist on their own. Typically they are bundled with the outpatient cover
3. Low cost covers: In the recent years, some companies have developed low cost covers targeting the low-income segment of the country. These covers have low cost premiums and provide access to a limited range of inpatient and outpatient services. The most popular among these covers is the Linda Jamii cover targeting SMEs and other small groups. Low cost medical insurance covers in Kenya are provided by insurance companies that are willing to work with low cost hospitals. Some of them have co-payment plans to reduce the risk of frivolous visits to healthcare facilities
4. Medium and high cost covers: Medium and high cost covers are the most common types of health insurance covers in Kenya. Usually, these covers are paid for by employers in order to give their employees a health policy as part of the remuneration package. High ranking company employees are usually afforded higher cost covers while middle and low level workers get  medium cost covers. In practice, insurance companies have a graduated schedule showing the amount of premiums versus the cover limits. In some cases, the insurance companies give additional benefits that are otherwise found in a funeral cover, should a policyholder pass on.
5. Maternity cover: The maternity cover is also available in the Kenyan market. This cover is usually included as an enhancement of a basic health insurance policy. Maternity cover usually meets the costs of hospitalization, including delivery and any eventualities such as congenital illnesses that may result from the pregnancy. Due to its nature as an “assured risk”, the maternity cover in many ways is a customer retention element  used by insurance companies.

Benefits of a Health Insurance policy

In health insurance, the term “benefit” has a distinct meaning to it, and usually refers to the specific commitments the insurance company makes to policyholders. If you bought a health insurance policy today, the following are some of the benefits you will enjoy.

1. Covers cost of consultation: The cost of consultation varies widely in Kenya, from a few hundred shillings in low cost hospitals to a several thousand shillings in high end hospitals. The cost of seeing a doctor is usually covered by the insurance company, and is the first benefit you will have when you buy a health insurance policy.
2. Covers cost of specialists: Specialists such as gynecologists, dermatologists, psychiatrists and others, usually have a higher consultation fee. In case a general doctor (general practitioner) refers you to a specialist, the insurance company will meet the cost associated with your visit to the specialist. You should however consult your insurer to find out whether they have an approved panel of consultants before seeing a specialist.
3. Covers cost of lab-work: Health insurance policies usually cover the costs associated with lab tests. It is important to highlight this benefit because not all medical conditions will require medical testing before treatment can be administered. That said, some insurance companies will require you to notify them if certain tests are recommended so that they can issue their approval.
4. Covers cost of medicine: Meeting the cost of drugs is also one of the benefits a health insurance cover should provide. In this case, the medicine may be obtained from the hospital’s pharmacy, or from a chemist accredited by the insurance company. In general, health care policies do not cover the cost of non-medical supplements and cosmetics, even if they are recommended by a doctor.
5. Covers cost of hospitalization: In the event a policyholder is hospitalized, the insurance company will meet the costs associated with hospitalization. In this case, the insurance company will pay for accommodation (bed) as well treatment costs. Accommodation in a hospital increases the cost of healthcare because the hospital must operate several departments to support the patients. These departments include catering services, laundry services, among others. The hospital also must be in operation full time, which means hiring more staff members
6. Covers cost of Ambulance: Some covers may include an ambulance  benefit. In this case, the insurance company provides an ambulance to take you to hospital should you need on. Some policies also include an air rescue component in partnership with air ambulance services. This benefit may require the payment of additional premiums.
7. Cash Back for days hospitalized: In some cases, the policy may also include a “cashback” clause where the insurance company pays out a daily allowance for everyday the policyholder is hospitalized. The rationale is that long term hospitalization may lead to loss of income. The cash paid to the policyholder helps to even out loss of income during the days they are hospitalized.

How Health Insurance Claims Process Works

Health insurance is an interesting type of cover in various ways. First, it’s the only cover that deals directly with your health, arguably your most prized asset. Secondly, the health insurance cover can be claimed in bits as needs arise, as opposed to other covers where you can only make one claim. When it comes to claims, here is how the claims process works.

1. Claim as you go: Health insurance claims are made when you visit a hospital access medical services. When you visit a hospital to access treatment, the insurance company will pay for your treatment based on the cover limits of your policy. You can make claims as many times as you need to provided you have not exceeded your limit
2. Co-payment: Most insurance companies will have a copayment policy on their cover. This works a bit like “excess” in the motor insurance cover. What this entails is that each time you visit a health facility, you will have to pay a fixed amount to the hospital. The specific amount varies from hospital to hospital and also varies according to specific policy. The goal of copayment is to discourage frivolous visits to healthcare institutions.
3. Exclusions: The third issue you need to bear in mind is that health insurance usually comes with certain exclusions. These exclusions may include some medicines and procedures that do not meet the threshold for services that can be insured against. The most common exclusions are cosmetics procedures, food supplements, and elective procedures.As you plan your health insurance, remember that Pacific Group is here to support you all the way.

Conditions excluded from Health Insurance Policies in Kenya

It is important to note that health insurance policies do not cover all medical conditions unconditionally. Covering these conditions may go against the principles of insurance. Insurance aims at providing cover from risks that affect a relatively small number of people from among those insured. Situations that veer from this norm makes it hard for insurance companies to offer services. Here is a list of some of the conditions that insurance companies do not cover in their policies

• Pre-existing & chronic conditions: Insurance companies are not obliged to cover a policyholder who joins their scheme after the onset of a medical condition. For instance, a policyholder who has an organ defect (say failing kidneys) does not have the right to demand an insurer to cover the costs associated with his treatment of the disease had been detected earlier than the effective date of their policy.
• congenital defects: These are defects that affect unborn children, and are usually detected before, during or after birth, and in some cases later in life. In recent years, some medical insurance policies have found ways of covering congenital effects but usually have a cover limit.
• War and kindred risks: These are risks associated with war. In wars, the number of casualties are usually much higher than an insurance company can afford to compensate using the ordinary insurance models. In order to keep the liability levels manageable, health problems associated with war and kindred risks are not insurable
• cosmetic surgery unless caused by an accident: insurance companies do not pay for elective cosmetic surgery and procedures. Elective cosmetic surgery does not qualify for a risk, and is a deliberate choice by an individual. On the other hand, a health policy will cover a cosmetic procedure if it is required to restore normalcy to the looks of a policy holder. This may be the result of burns, wasting infections, or any other ailment causing physical deformity.
• Treatment other than a registered doctor of medicine: This policy exclusion means that a medical insurance policy will not pay for treatment accessed from a traditional doctor, medicine man, acupuncture practitioner, or even a trained conventional doctor who is not licensed to practice. The challenge here is that insurance relies on formal health systems to calculate costs, while informal health systems do not have enough in common to allow for proper calculation of premiums. At the same time, some of their treatments are not scientifically tested, hence there is no way of assessing their efficacy.
• Intentional self-injury: This exclusion stems from the understanding that insurance is meant to cover risks, and not premeditated events
• Drunkenness: Injuries or problems associated with drunkenness can be considered to be self-inflicted, and the policyholder should have been well aware of the consequences. These conditions are therefore not insurable
• HIV/AIDS related illnesses: In the former years, HIV/AIDS was not curable (and still isn’t), and was more difficult to manage. Things have changed much over the last two decades, and insurance companies are less worried about covering HIV/AIDS. This in addition to laws outlawing the discrimination of HIV patients has virtually eradicated this exclusion
• Dental and Optical Conditions: Some covers still do not cover dental and optical conditions unless specifically included in premium calculations. Even in cases where these two conditions are covered, some exclusion still apply, such as limit in eye glasses, and dental procedures a policy holder may access