What Does Your Medical Insurance Cover? What Are Its Limitations?

Typically, private medical insurance (health insurance), settles the cost of your private treatment when you fall ill. Nevertheless, medical insurance does not cover you for everything and plans vary from one insurer to the other.
In fact, each plan (product) is usually designed to meet the cost for testing and treating essential medical conditions (often acute conditions), that respond quickly to therapy.

So what does a typical medical insurance plan include?

(a)     Inpatient treatment: Most Kenyan health insurance policies cover the costs of inpatient treatment (cases where you need a bed in hospital for the day or overnight), including all the tests and surgical procedures.

(b)     Outpatient treatment: While most Kenyan medical insurance policies cover outpatient treatment (cases where you see a doctor, have diagnostic tests and get a prescription and leave clinic), the amount you can claim for the treatments may be capped. Cheaper plans cover very few types of outpatient treatment and come with lower caps.

(c)     Hospital accommodation and nursing care: The costs of in-hospital stay and limited nursing care are included in most medical insurance policies in Kenya.

(d)     Exclusive drugs: Some medical plans include covers for the costs of specific drugs.

(e)     Extra cover: Policies differ on the other items included in the coverage. For instance, psychiatric treatment which has a thin line between curable illness (covered) and long-term care (not covered) is rarely included in medical plans. Only comprehensive policies have coverage for psychiatric treatment. Similarly, while comprehensive policies include a private ambulance, complementary therapies, home nursing, parental accommodation for children in hospital, and a 24-hour advice line, many do not.

What items are not included in a medical insurance?

Your medical insurance policy will not pay for long-term treatment, such as kidney dialysis, long-term illness like asthma, drug abuse, non-essential cosmetic treatment and normal pregnancy.

Types of Medical Insurance

There are two primary types of medical insurance, moratorium insurance and fully underwritten insurance. A moratorium plan will require you to give limited information to your insurer while a fully underwritten insurance requires a full medical history. In terms of benefits, a fully underwritten policy offers a wide coverage, though it is typically more expensive. On the other hand, a moratorium policy comes with blanket exclusions on some pre-existing conditions, although it is cheaper.

Some Kenyan insurers have specialist policies. For instance, some offer policies strictly designed for the over-55s or ones that focus on a particular disease, like cancer. In fact, modular, pick-and-mix style medical plans are becoming more common in Kenya, offering tailored coverage that includes inpatient treatments as well as the unique needs of the insured person.

Are there alternatives to medical insurance?

As well as accessing care through the National Health Insurance Fund (NHIF), there are many alternatives to private medical insurance. For instance, there are healthcare cash plans that require members to pay a monthly fee and then claim back the cost of certain basic treatments. There are also critical illnesses cover plans, where you pay for coverage of a specific serious illness. You can use such alternatives depending on your needs and budget.