Medical Insurance Cover | Everything you Should know

Welcome to our revised guide on why having a medical insurance cover is beneficial to your life. Above all, the Insurance of home or car is a no-brainer. Though, some people aren’t sure why health or medical insurance cover is a good idea. And by all means, the choice of a medical insurance cover carrier reflects on the quality of care you want to receive.

For instance, private medical insurance cover ensures that you need medical treatment in the future. This simple, yet profound fact is the driving force behind an ever-growing medical insurance sector not just in Kenya, but the entire world in general. You don’t have to worry about NHS waiting lists or paying for the cost of the treatment.

However, medical insurance will pay all or some of your bills. Furthermore, there is a choice of a private hospital from an agreed list by your insurer. Most hospitals offer a private en-suite room, TV and a choice of food rather than a normal patient. Hence, without good health, it’s difficult to achieve an important goal.

What is a Medical Insurance Cover?

By definition, a Health or a Medical Insurance Cover is an insurance that covers the whole or a part of the risk of a person incurring medical expenses, spreading the risk over numerous persons.

In that case, by estimating the overall risk of health care and health system expenses over the risk pool. And in the end, an insurer can develop a routine finance structure. Such as a monthly premium or payroll tax, to provide the money to pay for the health care benefits. Especially specified in the insurance agreement.

The benefit is administered by a central organization such as a government, agency, private business, or not-for-profit entity.

According to the Health Insurance Association of America, health insurance is defined as “coverage that provides for the payments of benefits as a result of sickness or injury.

It includes insurance for losses from accident, medical expense, disability, or accidental death and dismemberment.”

Why does a Medical Insurance Cover Matter?

Having health insurance is important for several reasons. Uninsured people receive less medical care and less timely care, they have worse health outcomes.

And therefore, lack of insurance is a fiscal burden for them and their families. Furthermore, the benefits of expanding coverage outweigh the costs for added services.

Safety-net care from hospitals and clinics improves access to care but does not fully substitute for health insurance.

These findings are supported by much research, although some cautions are appropriate in using these results. Below are more possible benefits;

1. Health is irreplaceable

Unlike the vast majority of things in life, health is one of the truly irreplaceable aspects. A lot of attention is currently dedicated to encouraging healthy living habits.

This is because doctors have known that it’s better to keep in good health rather than to try to fix it once broken. Some of the key sources of threats to our health include hereditary illnesses, communicable diseases, and lifestyle diseases.

In addition to these threats, there is also always the risk of accidents occurring.

2. It’s affordable

The number of people taking up health insurance has been on the rise. Two key trends are responsible for this. First, more companies are bundling health insurance as one of the benefits they give to their employees.

This is in effect increasing the number with a health insurance cover. Secondly, the emergence of low-cost health insurance policies that offer basic cover for policyholders. The low-cost covers are in line with the hugely influential role SMEs are playing in the Kenyan market.

As such, the cost of medical insurance cover is affordable. As there is always a policy that meets the health needs of any person in the country.

On a different note, the affordability of medical insurance in Kenya evaluates the value of one’s health. It turns out that what may seem expensive at first to be an affordable component of health insurance.

3. Accidents do happen

Finally, you need to have a health insurance plan for the reason that accidents happen. Accidents may have detrimental effects on your health.

As already discussed above, germs and genetics are not the only threats to our health. A freak accident leads to a loss of health. In some cases, managing your injuries after an accident may be a very expensive affair.

A good insurance policy helps you to get back on your feet as you work to get back to good health.

4. It earns you a tax relief

The Kenyan tax procedures assure you of tax relief of 15% on the premiums you pay per annum. This goes to bring down the cost of medical insurance by that much.

If you spend Kshs 50,000 on premiums for a health insurance policy in one year. Then you get a tax relief of Kshs 7500.

What are the Benefits of a Health Insurance Cover?

In Health Insurance Kenya, the term “benefit” has a distinct meaning. It usually refers to the specific commitments the insurance company makes to policyholders.

Whereby, if you get a medical insurance policy today, the following are some of the benefits you will enjoy.

1. Covers cost of the consultation

The cost of consultation varies widely in Kenya. From a few hundred shillings in low-cost hospitals to several thousand shillings in high-end hospitals.

The insurance company usually covers the cost of seeing a doctor. Hence, its the first benefit you get when you buy a health insurance policy.

2. Covers cost of specialists

Usually, specialists such as gynecologists, dermatologists, psychiatrists, and others have a higher consultation fee. In case a general doctor (general practitioner) refers you to a specialist.

The insurance company meets the cost associating with your visit to the specialist. However, consult your insurer to find out whether they have the approval by a panel of consultants before seeing a specialist.

3. Covers cost of lab-work

Medical insurance policies usually cover the costs associating with lab tests. It is important to highlight this benefit.

As it’s not all medical conditions require medical testing before administering treatment. That said, some insurance companies will require you to notify them. As a result, a recommendation for certain tests 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 hospital’s pharmacy provides medicine, or from a chemist that has approval from the insurance company.

In general, health care policies do not cover the cost of non-medical supplements and cosmetics. Even with a recommendation from a doctor.

5. Covers cost of hospitalization

In the event a policyholder is in hospital, the insurance company will meet the costs that associate with hospitalization. In this case, the insurance company will pay for accommodation (bed) as well as treatment costs.

Accommodation in a hospital increases the cost of health care 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 the hospital should you need on.

Some policies also include an air rescue component in partnership with air ambulance services. This benefit requires the payment of additional premiums.

7. Cash Back for days of hospitalization

In some cases, the policy may also include a “cashback” clause. Here, the insurance company pays out a daily allowance for every day the policyholder is in hospital. The rationale is that long-term hospitalization may lead to loss of income. The cash paid to the policyholder helps to even out the loss of income during the days they are in the hospital.

What are the Health Insurance Cover Plans?

When it comes to a Health Insurance Cover, you have choices when you shop for health insurance.

And if you’re buying from your state’s Marketplace or from an insurance broker, you’ll choose from health plans organized by the level of benefits they offer. Like bronze, silver, gold, and platinum.

Bronze plans have the least coverage, and platinum plans have the most. If you are under 30, you may also be able to buy a high-deductible, catastrophic plan.

How is health insurance cover different?

Each one pays a set share of costs for the average enrolled person. The details can vary across plans.

In addition, deductibles — the amount you pay before your plan picks up 100% of your health care costs — vary according to plan, generally with the least expensive carrying the highest deductible.

  • Platinum: covers 90% on average of your medical costs; you pay 10%
  • Gold: covers 80% on average of your medical costs; you pay 20%
  • Silver: covers 70% on average of your medical costs; you pay 30%
  • Bronze: covers 60% on average of your medical costs; you pay 40%
  • Catastrophic: Catastrophic policies pay after you have reached a very high deductible ($7.350 in 2018).  Catastrophic plans must also cover the first three primary care visits and preventive care for free, even if you have not yet met your deductible.

Above all, these plans help to meet the needs of Kenyans seeking insurance covers. You will also see insurance brands associated with the care levels.

Some large national brands include Aetna, Blue Cross Blue Shield, Cigna, Humana, Kaiser, and United.

How does the Health Insurance Cover work?

Eventually, a Health Insurance Cover is an interesting type of cover in various ways. In the first place, it’s the only cover that deals directly with your health, arguably your most prized asset.

Secondly, you can claim the health insurance cover in bits as needs arise. Opposing to other covers where you can only make one claim.

In reality, each insurance brand may offer one or more of the following plans.

Four common types of plans:

Take a minute to learn how these plans differ.

All in all, being familiar with the plan types can help you pick one to fit your budget and meet your health care needs.

When it comes to claims, here is how the claims process works.

a. 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 pays for your treatment based on the cover limits of your policy. You can make claims as many times as you need until you exceed your limit

b. Copayment

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. Pay a fixed amount to the hospital.

The specific amount varies from hospital to hospital. Also according to the specific policy. The goal of copayment is to discourage senseless visits to healthcare institutions.

c. 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 does not meet the threshold for services to insure against. The most common exclusions are cosmetics procedures, food supplements, and elective procedures. As you plan your health insurance, remember that Insure Afrika is there to support you all the way.

Which are the Best Health Insurance Cover Plans?

The health insurance sector in Kenya has several types of insurance policies targeting the general public.

For their families or companies that require covers for their employees. Here are the key types of insurance policies that you will find in the Kenyan market.

(a) Inpatient cover

Inpatient cover refers to policies that provide compensation for the costs of hospitalization. Impatient covers come into effect when the hospital admits policyholders. This cover is typically more expensive than other types of cover.

In addition to the direct costs of treatment, it also covers policyholders from the liabilities. That 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. Rather than a senseless hospitalization request.

(b) Outpatient cover

By far the outpatient cover is the most common type of health insurance coverage. The outpatient cover protects policyholders from liabilities that associates with access to outpatient facilities.

In this case, policyholder access to health services in a hospital or clinic that the insurance company accredits. Thereafter, receiving treatment the policyholder does not remain resident in the health facility. Outpatient covers are usually cheaper than inpatient covers because of all the incurring costs relating to the treatment.

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  bundle with the outpatient cover

(c) Low-cost covers

Recently, some companies have been developing low-cost covers that target 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 by insurance companies in Kenya mostly work with low-cost hospitals. Some of them have co-payment plans to reduce the risk of non-serious visits to healthcare facilities

(d) Medium and high-cost covers

Medium and high-cost covers are the most common types of health insurance covers in Kenya. Usually, employers pay for these covers. In order to give their employees a health policy as part of the remuneration package.

High ranking company employees usually afford higher cost covers while middle and low-level workers get medium-cost covers. Most insurance companies have a graduate schedule showing the number of premiums versus the cover limits.

In some cases, the insurance companies give additional benefits that are otherwise found in a funeral cover. If a policyholder passes on.

(e) Maternity cover

The maternity cover is also available in the Kenyan market. This cover is usually 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 that insurance companies use.

How do I get the best Health Insurance Cover?

Whenever you are buying anything, whether it’s vegetables or a new house, there is usually this good feeling you get when you are sure you have been given the best prices possible.

Health insurance is no exception. You deserve to feel good about how much you’ve spent on your health insurance in Kenya. If this is something you would like for yourself, here are some tips.

Compare quotes 

First, you can get very good prices for health insurance if you will first use our online quote comparison service.

We have spent the last few years perfecting this service to ensure everyone in Kenya looking for insurance can get quotes for a wide range of insurance products. In this case, our service allows you to compare the prices and features of insurance policies from leading insurance companies in Kenya.

Before you set out on an odyssey to find the most competitive rates for insurance products in Kenya, stop by our

Talk to agents

Next, we encourage you to talk to trusted insurance agents who offer health insurance services. Insurance agents will give you the benefit of insider information, and will most likely help you to save some money.

Agents know which products will give you the best value for your money and they are also likely to know which companies have products meeting your needs, as well as any offers in the prevailing market.

Keep in mind though that an agent makes money from commissions, and the higher the cost of insurance, the more likely they are to sell you expensive products. You must be tactful when speaking to an agent and don’t settle until you have what you consider to be a fair deal.

Representatives talk

Another way to get the best deals is just to go to the source. You can choose to talk to company representatives personally so that you hear from them what they have and how they intend to meet your needs as an insurance consumer.

While this puts you in touch with the best information, you will end up with more than just the information you need. You will feel the full force of the insurance companies’ marketing departments. You can see why this can be exhausting. Nonetheless, if you have the time, strength and stamina, then it may be the best way of getting and comparing quotes.

Ask for referrals

Finally, you can also find great deals by asking for referrals from your friends and associates. This should be relatively doable if we are well linked via social media channels.

If you’d like a no-stress approach to getting the best quotes, then we think that using our online quote comparison service might be your best bet.

What are the National Health Insurance Fund benefits?

The National Hospital Insurance Fund (NHIF) is a government-run medical insurance service. With the eventual goal of offering universal healthcare for all Kenyans.

Everyone in Kenya requires to be members of the fund. The fund is the main source of medical insurance for civil servants. It is quite important to be a paid-up member of NHIF.

This is because of the benefits this membership affords you as a person. Learn more about the benefits of using the National Hospital Insurance Fund (NHIF).

Here are some of the benefits.

1. Health insurance is issued net of NHIF costs

When you buy a commercial medical insurance policy from a local healthcare provider such as Jubilee insurance, Britam, resolution insurance or any other medical insurance companies in Kenya. Your insurance calculates the net of the NHIF contribution to your hospitalization.

Since membership in NHIF is mandatory for employed persons. Thus, health insurance companies assume that everyone who buys additional insurance from them is actually buying Additional Insurance. The policy benefits, therefore, calculates as net of the amount NHIF should pay.

2. Subsidizes the cost of hospitalization

The second reason why everyone should consider NHIF membership is that it subsidizes the cost of treatment. In recent times, NHIF has been expanding its scope of coverage. Until recently, NHIF has been refunding providers only when a member is hospitalized.

However, in recent times, the fund has been working towards refunding even costs associated with outpatient services. A recent media report indicates that NHIF will start paying for costs associated with the treatment of cancer, and the cost of dialysis.

This is a welcome move given that most people in Kenya do not have robust privately funded medical insurance covers.

3. Is relatively cheap to pay

Finally, the cost of NHIF members is relatively cheap. Hence, the benefits are competitive especially in the case of hospitalization.

One of the key advantages of the NHIF is that one pays the medical insurance costs monthly rather than annually. Thus, making it affordable. Also, the rates are affordable even for low wage workers. NHIF members contribute from Kshs 500 per month.

These costs are lower than for any other cover. For instance, Linda Jamii requires members to pay 12,000 per annum, meaning that the monthly charge is Ksh 1000. Having an active membership with the NHIF is a smart decision for every discerning Kenyan.

How do I Choose the Best Health Plans?

How do you arrive at an appropriate decision regarding the type of health insurance policy you should buy? If this question is currently bothering you, then you are the perfect person to see this.

The choice of a medical insurance policy is an important one. It has implications relating to the type of care you can access. It will also have an impact on the limits of care you can access. Here are some of the key factors that you need to consider.

Needs assessment

First, carry out a needs assessment to see what you are looking for. When we speak of needs, we mean your needs and those of your dependents.

Your needs will mostly be defined by your current state of health, which will have an influence on how frequently you need medical attention. The type of care you will need is also a good consideration to make.


The next thing you need to look at is your budget. How much are you willing and able to spend on health insurance? While someone would feel safest having all the benefits a medical insurance policy can buy, spending too much money on one item can compromise your financial plans, especially if you have many dependents.

In this case, make a decision on how much you can spend on health insurance based on your needs and based on your capacity. The whole point of this exercise is to make sure that you get the best possible deal for your budget. At times, the cost of a policy is not always an indicator that you are buying a good policy.

Benefits assessment

Thirdly, with actual policy documents, assess the benefits associated with each policy. Compare the limits of each policy to see just how much would be available to you.

In addition, look at the complete list of benefits provided by each of the policies you are considering. It is wise to pick policies whose benefits match your needs as closely as possible.

Company choice

Finally, decide on your preferred insurer. It’s a reality that some health insurance companies have better products and customer service than others, even if their policies may be more expensive. Finding a company that fits within your needs is an important thing in this situation.

Once you have understood what your needs are, compare the policies available, assessed the benefits of these policies, and finally, you have settled on a provider, then and only then, are you ready to buy health insurance.

Which are the Exclusions of Medical Insurance Cover?

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 with insurance. 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 liable 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 of treating the disease earlier than the effective date of their policy.

Congenital defects

These are defects that affect unborn children. 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 associating with war. In wars, the number of casualties is 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 in accident

Insurance companies do not pay for elective cosmetic surgery and procedures. Elective cosmetic surgery does not qualify for a risk cover and is a deliberate choice by an individual.

On the other hand, a health policy will cover a cosmetic procedure. If it requires to restore normalcy to the looks of a policyholder. This may be the result of burns, wasting infections, or any other ailment causing physical deformity.

Treatment other than registered 

This policy exclusion means that a medical insurance policy will not pay for treatment. For instance, from a traditional doctor, medicine man, acupuncture practitioner. Or even a conventional doctor who doesn’t have a license to practice.

The challenge here is that insurance relies on formal health systems to calculate costs. While informal health systems have no enough in common to allow for proper calculation of premiums. At the same time, some of their treatments don’t test scientifically. Hence there is no way of assessing their efficacy.

Intentional self-injury & drunkenness

This exclusion stems from the understanding that insurance means to cover risks and not premeditating events

Injuries or problems that associate with drunkenness are considered to be self-inflicting. Hence, the policyholder should be 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 against 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 you cover these two conditions.

Some exclusion still applies, such as the limit in eyeglasses, and dental procedures a policyholder may access.

Does Reputation matter in Medical Insurance?

Of course, it is critical to determine the reputation of your preferred health services provider before making commitments. If you can, ask hospitals and clinics what sort of relationship they have with the medical insurer.

Then, find out whether the relations are smooth. Talk to your friends too, and other referrals. To get their views on the services by the medical services provider.

The market reputation of a provider is an indication of how well the company provides services to its members. Hence, a good point of reference when making decisions regarding healthcare insurance.

The Health Insurance Cover Carrier

Depending on your lifestyle, it is important to consider the geographical reach of your carrier. Consider first, does the health insurance provider have a network of partner hospitals.

That helps cover all your main areas of operation. This is to ensure that you will have access to a hospital from any of your areas of operation. Secondly, whether the health insurance carrier allows you to use the hospitals of your choice.

For instance, if you look at the Linda Jamii product from Britam. You will discover that the list of hospitals that participate in it do not include the major private hospitals in Nairobi. This is indeed, to keep the costs of healthcare affordable both for the insurer and the insured.

Other health insurance companies may insist on copayment plans if you visit the major private hospitals. Thus, consider all these factors as you buy your medical insurance.

Always compare Costs and Services

Consider the costs of premiums, in the context of the size of cover available for your use. Cheap medical insurance coverage does not always mean that it is a better deal. A company may give you an inferior cover at a low cost, which fails to meet your needs.

On the other hand, a high-cost cover is also not the same as a high-quality cover. Examine the cover to ensure that you are getting the most value for your money.

One of the best ways of doing this is to fill in our online medical insurance quote form. To compare medical insurance quotes from different providers.

Summing Up,

One of the most frustrating situations you can find yourself in, is obviously, not being able to access your medical insurance cover provider. Or even, when you need advice or have an inquiry, especially during emergencies without any fruitation.

For this reason, call the company to find out how helpful they are. Also, try sending an email or an SMS to see which medium attracts the quickest and most comprehensive response. Check out their website to see whether you can find the list of hospitals in their network.

Then, call some of those hospitals to confirm they actually have a relationship with this potential insurer. This is especially important if you access services from specific hospitals in the company’s role. However, do your research well to ensure that you get the best medical insurance cover possible on your current budget.

Related Sources;

I hope the above-revised guide on the benefits of a medical insurance cover was useful.

But, if you’ll have additional questions, recommendations or even suggestions, please Contact Us. Or even, feel free to share your insights in the comments box below this post.

Finally, there are more Adequate and Credible Sources that are for general public information and reference purposes only.

Including, the Independent, InsureAfrika, Resolution Insurance, Capital News, jmexclusives (health & fitness research blog), etc.

Below are more related and useful topic links;

  1. Why is Healthy Eating important?
  2. Urine Color » What It Indicates About Health
  3. WIBA (Work Injury Benefits Act) Overview
  4. Physical Fitness on Beginners Weight Training
  5. Fruits Benefit To Our General Health

Here: Licensed Insurers – Insurance Regulatory Authority

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