How to find out what your medical cover is not covering

Most people do not know and cannot interpret their insurance cover package information and as such, experience challenges. PHOTO | FOTOSEARCH

The country’s private medical insurance penetration has remained at a dismal 2.7 per cent, with only 19 companies offering medical covers, according to Association of Kenya Insurers 2017 report.

The government, through its Big Four Agenda, has committed to achieve universal healthcare coverage by 2022, with the aim of increasing insurance penetration from its current 17 per cent as provided through the National Hospital Insurance Fund (NHIF).

With the indication that NHIF is the vehicle that will administer the UHC plan, it is important to create awareness on how Kenyans can easily access medical services and demystify insurance package information.

Most people do not know and cannot interpret their insurance cover package information and as such, experience challenges when accessing healthcare for pre-existing and chronic conditions. Clarity, visibility and information on access and the rules applied are a challenge for the majority of consumers.

Pre-existing conditions are largely defined as any condition or disease a person has received treatment for before being enrolled in a medical cover. Examples of these are diseases such as diabetes, hypertension, lupus among others. In some instances, pregnancy can also be considered a pre-existing condition where a person was pregnant before they enrolled in a medical cover.

Pre-existing and chronic conditions are ordinarily classified as high risk as the treatment for such cases, for example diabetes and cancer, could averagely range from anything between Sh800,000 and Sh2 million or higher and as such, the need for consumer awareness on access to this cover.


One of the ways consumers can be aware of their benefits and know which pre-existing conditions are offered in their medical plans, is through digital platforms such as smart cards and their associated mobile applications that provide information from their insurance provider during a sign-up.

For control purposes, access to these covers through an insurance plan requires what medical administrators refer to as pre-authorisation, which is not always disclosed to consumers. This is where the scheme administrator must consent to the member receiving treatment for their pre-existing condition and provide consent to the hospital that they will undertake to settle the incurred medical cost.

Ordinarily, pre-existing and chronic conditions are covered as a sublimit of the overall inpatient benefit and this is something most Kenyans are not privy to. Sublimit means the benefit is embedded within the overall inpatient cover. Upon utilisation of the pre-existing benefit, this also automatically reduces the overall member’s inpatient benefit whenever someone seeks treatment for a pre-existing condition.

A concept rule known as “waiting period/time” is also commonly applied for such conditions, which consumers need to be aware of in their medical covers. Waiting period is defined as the period after paying the first premiums that the consumer has to wait before he/she can access treatment for the pre-existing and chronic condition. Consumers must enquire from their various medical providers whether the pre-existing benefit package has a waiting period or not.

One of the ways to know about this is a keen review of their medical policy document which is provided when one is enrolled in a medical plan.

For those Kenyans who find it laborious to go through piles and piles of ‘fine print’, use of smart cards and associated mobile applications provides information.

Ms Muiruri is a healthcare professional