What you need to know:
- There is no such thing as a good or a bad medical insurance
- Concern only arises when the company does not honour its commitments to pay for the claims processed
- Or does not remunerate the contracted service providers fairly and in a timely manner
- Or imposes limits on the beneficiaries regarding the hospitals
Kerry* and Allan* met at one of those corporate cocktails where everyone sips an expensive drink and talks about stocks and investments.
They were both bored out of their skulls but could not leave. Kerry’s company was launching a new product while Allan had been dragged along by a friend.
He bumped into her at the lounge outside, one heel off, rubbing her toes back to life before going back in to usher the evening to a close. He offered to hold her shoes, should she need to walk back in barefoot and they both laughed.
They spent the evening at the lounge talking until well past midnight. He dropped her home as she was in no state to drive.
Kerry realised she did not even have Allan’s phone number when she woke up the next day. She shrugged off a pleasant evening and called an Uber to take her back to the hotel to collect her car.
Three months later, she walked into the office after a meeting out with clients and found a bunch of flowers on her desk with a card asking for a repeat date at the same lounge. A year later, the two tied the knot in a simple ceremony with a handful of friends and family.
A colleague referred the couple to me for delivery. She had walked the pregnancy journey with them but was going to be away when the baby was due, hence the transfer at 37 weeks, complete with a birth plan. The hospital tour and bookings were already done. We had only one task left, to process the medical insurance preauthorisation.
Maternity not included
Upon inquiry on how much their maternity cover was, they both looked at me blankly. Kerry was insured by her employer while Allan was listed as her dependant.
They did not known of the limits within the policy as they hardly ever needed to use it.
Kerry urgently reached out to her human resource manager for details. They were both shocked to learn that despite the fact that they had a 5,000,000-shilling inpatient cover, this did not include maternity, whose limit was a measly Sh120,000.
The estimated cost of delivery at their hospital of choice ranged between Sh200,000 and Sh300,000 depending on the mode of delivery. They would definitely need to come up with the difference in cash.
Kerry and Allan are not alone. A majority of Kenyans with a medical insurance are beneficiaries of their employment. Many have no idea what the details of the policy document look like and may not even know that it exists.
These details are only known to the procurement and the human resource department. Rarely do the beneficiaries of this policy get involved in the process of procuring it.
There is no such thing as a good or a bad medical insurance. Concern only arises when the company does not honour its commitments to pay for the claims processed; does not remunerate the contracted service providers fairly and in a timely manner; imposes limits on the beneficiaries regarding the hospitals or providers to seek care from; or have a poor customer relations function.
The benefits available to the insured are based on the agreed negotiations between the insurance company and the client. It is a fine balance between maximum benefits and annual payable premiums.
The one thing universally understood is the cost of premiums. The benefits package is rarely understood by the client for the most part.
For one to be able to negotiate effectively, they must have a basic understanding of certain issues.
First, is the profile of the people being covered. For instance, a company with an elderly employee population will be keen on the provisions for chronic disease care, the maximum amount payable per annum and the flexibility of access to specialised care.
The elderly are more likely to have chronic, age-related illnesses, hence they need to get their medication all year long and be able to access complex treatment.
Not locally available
Conversely, a company with a more youthful population is likely to require adequate outpatient coverage for the family, a substantive maternity package and ensure items like childhood vaccination are adequately catered for.
This is because they are more likely to be having young families with young children needing outpatient care very frequently.
Other contentious benefits include dental care; optical care; contraceptives, treatments for pandemic illnesses such as Covid-19; treatment outside the country for services not locally available; coverage for novel and experimental treatment; physiotherapy; occupational therapy and most importantly, mental health and addiction.
There is great need for clients to know what they are signing up for. There is nothing more distressing than getting onto a new medical insurance cover, only for the company to stop your children from seeing their regular paediatrician because she is not one of the contracted providers. This, unfortunately, directly impinges on one’s constitutional right to access to healthcare by a third party.
Even worse is when one gets to the hospital in the wee hours of the night with a convulsing baby, only to find that they are unable to use their medical cover because of contractual disagreements between the insurance provider and the hospital.
It is the responsibility of every medical insurance beneficiary to know what the policy provides for. This helps them to actually judge whether they are getting value for their money or not. Further, this avoids unnecessary disappointments at the point one needs to flash that card for service.