There are many reasons to apply for health insurance. Aside from the constant threat of sickness and accidental injuries, medical insurance is a safety net in an otherwise unsafe environment. However, before you decide to pick a scheme, be sure to confirm exactly what you’re getting. Some policies are more comprehensive than others. Some have a limited cover while others offer a variety of services. Last time, we took a look at what motor insurance doesn't cover. This week, we take a look at what expenses health insurers leave to the policy holders.

The Basics

Medical insurance deals with outpatient and inpatient care. Outpatient care refers to treatment that can be done within the span of a day without the need for hospitalization. For instance, Resolution Health covers up to KES 35,000 for outpatient services. Their basic policy costs of about KES 16,000 a year in premiums for outpatient care. Jubilee Insurance charges KES 17,000 a year for outpatient treatment.

On the other hand, Inpatient care is a medical services given to patients who have been formally admitted into a medical institution for treatment. Inpatient care is defined by at least one overnight admission in the hospital. Resolution Health charges KES 17000 a year in premiums for basic inpatient treatment.

Other service providers may also include maternity and funeral covers. Jubilee Insurance covers maternity care for KES 30,000 in annual premiums while Barclays has a cover that caters for up to KES 75,000 in funeral expenses.

What They Don’t Cover

All insurance policies include the option to list beneficiaries but some don’t cover extended family members. For married couples, only the children are included as part of the scheme. Resolution Health used to cover a policy holder’s children up until the age of 25. Currently, they only offer a family umbrella cover for children below the age of 21.

Dental and optical medical services are never part of a basic package. All local insurers charge an extra fee for such procedures. Resolution Health charges at least KES 10,000 while UAP’s Afya Imara has no dental or optical covers. EquiHealth, another service offered by UAP covers dental, optical and maternity expenses for KES 6700 a year.

A basic package with Jubilee’s J-Care will not cover anything over KES 1 million. A comprehensive Royal package covers up to KES 5 million a year. So if a surgery costs more than the maximum amount, the patient will be forced to pay for the extra expenses. If they are unable to meet the costs, they risk missing out on major procedures like organ transplants.

Insurers don’t always pay for pre-existing medical conditions. Illnesses like diabetes, asthma and bronchitis and HIV are sometimes covered, but in some cases, they require additional premiums. Some insurers use a cover limit for pre-existing conditions. Resolution Health’s cover limit for HIV/ AIDS is KES 100,000.

Basic medical covers do not cater for healthcare outside of the country. However, with UAP’s Maximed Premium policy, insured parties get access to evacuation services within East Africa. They also receive an organ transplant cover of up to KES 500,000. Ambulance covers have fixed conditions with Resolution Health providing a cover for road travel alone. UAP’s evacuation and ambulance services are subject to the pre-determined cover limit.

In the case of affordable health insurance packages, service providers tend to limit their cover schemes. UAP’s Salama Sure only covers one person per package. Policy holders are forced to create separate accounts for their family members.

CIC’s Bima ya Jamii and Eagle Africa’s Afya Milele Halisi cover a maximum of 4 people per package. However, an Afya Bora scheme from CIC offers a blanket cover of up to 7 people. Anything beyond the maximum limit requires a whole new cover plan.

CIC Insurance’s low-cost Bimaa ya Jamii has an unlimited inpatient cover but no outpatient care whatsoever. UAP’s Salama Sure also has no outpatient cover. Their policy only caters for accidents. Illnesses like coughs, colds, malaria and other forms of influenza are not covered.

APA Insurance offers an ER Card service that costs KES 5000 a year. The card, however, has a benefit limit for only the first 48 hours of treatment. Anything beyond the limit is the responsibility of the card holder. If any complications or extra medical fees are incurred after 48 hours, APA will not pay.