Steps of Making a Medical Insurance Claim in Kenya

 When you are sick and are referred to a doctor/clinic for medical care, you are expected to call your Kenyan insurer to inform them about your treatment and to find out whether there are any limits on your medical insurance policy.
It is usually recommended that you do this at every step of a claim in order to be sure that all changes in treatment or medication are known by your insurer and are covered by your policy. Remember that any excess on your medical plan will have to be paid by you to the hospital.

So what steps should you follow when making a health insurance claim?

1.       Read your policy document carefully

Each Kenyan medical insurance company has its own claims process which must be followed strictly. You can’t make a successful claim by assuming that you know what you are doing. So, regardless of whether you have worked with other Kenyan health insurers before, make sure to read your current policy document carefully and to understand all the processes involved in making your claims. Just before visiting a private hospital for treatment, go through the small print of your policy or check the insurer’s website for guidance on making a claim.

2.      Speak with your doctor or health care provider

It is usually important to discuss your condition with your doctor and learn about the steps the treatment would take. Your doctor may either treat you or refer you for private treatment. Make sure that your doctor is listed with your provider or that your policy allows treatment by your doctor and that no problems would arise when making a claim. On the contrary, when referred by your doctor for private treatment, you must find out whether the referral is open (referral letter not addressed to any specific consultant) or named (referral letter lists the name of the specialist). Confirm with the terms and conditions of your policy to see whether your Kenyan insurer accepts treatment wherever you are referred. Insist that you are referred to a specialist or hospital that meets your policy’s terms and conditions.

3.      Call your medical insurance provider

Once your treatment is scheduled, call your insurer and explain your situation. The information you will provide when you call your insurer will differ from one insurer to another, but the following is commonly required:

a.       Your policy number

b.      Details about your medical condition

c.       Details of where you are treated/referral details

d.       Details of what your doctor told you

After informing your insurer of your impending treatment, you are now free to get treatment being sure that you are covered.

4.      Call your medical insurance provider again after you have been treated

After you have been treated, call your insurer to inform them of the steps that have been taken and the costs involved. Make sure there is a clear outline of how all the charges should be paid, including consultations or treatment fees. Remember, you will pay and claim the money back, or your insurer will just pay the doctor/hospital directly. When the medical insurance company is to pay the doctor/hospital directly, the treatment bills will be sent directly to your insurer.

5.       Never be afraid to complain

If your medical insurance claim does not go as you expected or feel that the insurer has treated you unfairly, you are free to complain to the Insurance Regulatory Commission. Speak first with the insurance company, but if you find them unhelpful then take the necessary steps.