What Does Medical Insurance Cover in Kenya?

What does medical insurance cover in Kenya? This is a question that many people ask me all the time. It is time we put it to rest. I will list diseases and conditions that medical insurance covers in Kenya, especially the private health insurance. I will also list the things that private medical insurance does not cover so that you can make an informed decision on the next course of action in covering yourself and your family.

Private medical insurance coverage is wide, comprehensive, and detailed. I may not list everything, but I will be detailed enough, naming almost all the conditions and diseases under medical insurance coverage. However, it is important to note that the benefits included in a private medical insurance depend on the premium you pay. Low-budget medical insurance cover is usually basic and includes only the most common conditions/diseases, while the premium cover will include a wide scope of conditions.

In simple terms, I will just list conditions usually considered in private health insurance, regardless of the premium charged to have the conditions included in your cover.

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Diseases and Conditions Covered By Private Medical Insurance

Inpatient Hospitalisation

Inpatient hospitalisation refers to the treatment you receive when you are formally admitted to a hospital overnight or for at least 24 hours. 

Inpatient cover includes hospital room and bed charges, meals provided, doctor’s fees, nursing care, medication given during admission, surgery and theatre costs, laboratory tests, and all other medical costs incurred during your admission.

You don’t just get admitted to a hospital. There are those conditions that make you stay overnight. These conditions include major surgeries such as appendix removal, complications that develop due to illness, severe injuries from accidents, pregnancy complications, treatment of chronic conditions such as cancer, and so much more. 

Outpatient consultations

Outpatient cover refers to the same-day treatments and consultations when you visit a hospital or clinic. You do not stay overnight.

What does outpatient hospitalisation entail? It entails doctors consultation fee, treatment for common illnesses, prescription medicines, laboratory tests, diagnostic imaging, minor medical surgeries and procedures, follow-up visits, and other medical needs.

When you visit a clinic for malaria, typhoid, fever, influenza, routine checkups due to chronic conditions, and you leave the same day, that is what we call outpatient hospitalisation.

Surgery and operating theatre costs

Surgery and operating theatre costs fall either under inpatient if you stay overnight or outpatient if they happen the same day. 

They refer to the medical expenses you incur when a surgical procedure is conducted in a hospital operating room. Surgery and operating theatre costs include surgeon’s fees, anesthesiologist fees, operating theatre charges, surgical equipment and instruments charges, medical supplies, medication in use, and post surgery monitoring in the recovery room.

Prescription medications prescribed by a doctor

Another coverage for medical insurance is prescription medications by a qualified doctor. 

The medicines you get to treat or manage a condition are simply covered, and should be obtained from an approved pharmacy or hospital.

This cover includes medicines you get through doctor’s consultations in outpatient visits, inpatient admission, treatment drugs for illnesses, and medication for managing chronic conditions. 

Good examples for prescription medications include anti-malaria drugs, inhalers, blood pressure medication, and insulin for managing diabetes.

Laboratory tests

Medical insurance cover scope also includes laboratory tests for samples like blood, urine, or tissue to diagnose, monitor, or prevent a disease. However, these tests must be ordered by a doctor. 

Examples include Malaria test, blood sugar test, HIV test, and Complete Blood Test (CBC).

Imaging services

These are medical tests that use machines to create pictures of the inner body organs. They are used to diagnose injuries, diseases or internal problems. 

Examples of imaging services include X-rays, CT scans, MRI, and mammograms. These tests must be deemed necessary by a doctor to be covered by medical insurance.

Maternity care

This refers to the care given during pregnancy, childbirth, and post-delivery. However, in private medical cover, it is important to note that the scope of the maternity cover that you add as an extra benefit relates to childbirth/delivery. It covers delivery/childbirth costs, including C-section delivery. 

Pregnancy and post delivery clinic costs are covered under inpatient and outpatient. So here we are talking of the general maternity care, and maternity care scope includes prenatal/antenatal checkups, routine pregnancy tests and monitoring, ultrasound scans, doctor/midwife consultations, hospital delivery costs, C-section, postnatal care, among others. 

In simple terms, maternity care involves covering medical services for pregnancy, delivery, and care for the mother and newborn after birth.

Emergency treatment and ambulance services

This is the coverage that helps in urgent medical attention and transportation to a hospital during a medical emergency.

This cover includes emergency room treatment, stabilization and urgent procedures to save a patient’s life, emergency medical care, medication and tests for emergency treatment.

Ambulance services under the cover include ambulance transportation and medical care provided in the ambulance. 

Specialist consultations

Specialist consultations cover medical expenses incurred when you visit a medical specialist for examination and treatment. 

The cover includes consultation fee, medical examination and diagnosis, follow-up visits, recommendations for tests, procedures, and treatment. 

It basically covers cardiologist, dermatologist, paediatrician, gynaecologist, orthopaedic specialist, and pulmonologist costs, and many more medical specialists’ costs.

Chronic disease management

When we talk of chronic disease management, we talk of coverage that helps you pay for the long-term treatment and monitoring of diseases that last for a long time and usually require delicate care. 

The coverage constitutes regular doctor/specialist consultations, prescription medications, laboratory checks, medical checkups, and education and support programs that help the patient manage their condition. Such chronic conditions include asthma, hypertension, and diabetes, 

Preventive healthcare

Medical insurance covers medical services meant to prevent diseases or detect them early before they become serious. 

The coverage includes annual medical check-ups, health screenings, vaccination and immunisation, health counselling, and routine blood tests. 

Blood pressure screening, cancer screening, blood sugar testing and vaccination programs are some of the items under the scope of preventive health care.

Mental health services

Mental health services are also within the scope of a private medical cover. The services help diagnose, treat, and manage mental and emotional health conditions. 

Mental health services include psychological counselling, therapy sessions, diagnosis and treatment of mental conditions, prescription of mental health treatment, follow-up visits, and mental health monitoring.

Examples of mental conditions include depression, anxiety disorder, bipolar disorder, and post traumatic stress disorder. All these conditions are covered by private medical insurance, but their premiums are high. The insurance will cover consultation l, therapy, and treatment costs.

Dental care

Dental care cover helps you pay for services and treatment related to teeth, gums, and the mouth. 

In most private medical insurance, dental cover comes as an option, but part of dental care is also covered under inpatient and outpatient. 

Dental care pays costs related to dental consultations and checkups, tooth cleaning and oral examination, tooth extractions, treatment of cavities and tooth decay, basic dental fillings, and treatment of gum diseases. 

Optical care

This coverage relates to eye care services and treatment. Optical care is about vision and eye health, and its scope includes eye examination, vision tests, prescription eyeglasses or lenses, treatment for minor eye conditions, and follow-up eye consultations. 

Please know that for private medical insurance, there is an optional optical cover that mainly focuses on eye examination and treatment and prescription glasses/lenses. 

For major eye treatment, including surgery, the coverage is under inpatient.

Physiotherapy and rehabilitation services

Physiotherapy and rehabilitation relate to health services that help patients recover strength, flexibility, mobility, and other physical functions after illnesses, injuries, and surgeries.

 This coverage includes physiotherapy sessions from a trained therapist, exercises to improve strength, flexibility, and mobility and rehabilitation programs after surgery or injury. It also involves pain management treatments and monitoring recovery progress. 

Cancer treatment

You might think cancer treatment is not included in private medical insurance, but it is. 

Cancer treatment coverage helps pay for medical care and treatments used to diagnose and treat cancer.

It covers doctor and specialist consultations, laboratory tests and diagnostic procedures, chemotherapy treatment, radiotherapy, surgery, medication, and hospital admission and monitoring.

Some of the cancers that may be treated are breast, prostate, lung, and cervical cancers.

Dialysis treatment for patients with Chronic Kidney Disease

For patients with chronic kidney disease, private medical cover helps to pay for dialysis procedures, specialised dialysis equipment and machines, doctor and specialist consultations, laboratory tests for monitoring kidney function, and medication related to dialysis treatment.

The cover also takes care of expenses that patients incur during regular treatment sessions needed to maintain health.

HIV/AIDS treatment programs for HIV/AIDS (depending on policy)

HIV/AIDS is also included in the cover. Private medical insurance cover, and certainly public health insurance, helps manage and treat people living with HIV & AIDS through long-term medical care and medication.

Expenses covered include doctor and specialist consultations, medical checkups, HIV testing and diagnostic laboratory tests, antiretroviral therapy (ART) medications, treatment of related infections and complications, and monitoring checks.

Counselling and support services expenses are also covered.

I have not quite exhausted all the benefits/expenses covered by private medical insurance, but those are the most urgent and pressing ones. 

It is also worth noting that there are several things medical insurance does not cover. Maybe they will help you add or rule in a possibility of a condition not mentioned above to be under a high likelihood scope of being under medical cover. 

Things, Conditions/Diseases Not Covered by Medical Insurance 

• Pre-existing conditions such as diabetes and hypertension are not covered during the waiting periods. 
• Cosmetic or aesthetic procedures, for instance, plastic surgery procedures for enhancing appearance.
• Most medical covers do not include fertility treatments such as IVF, fertility drugs, and assisted reproduction procedures.
• Experimental or unproven treatments not medically approved are exempted.
• Suicide attempts or self-inflicted injuries
• Your medical insurance will also refuse to pay if treated outside its approved panel/network of hospitals.
• Over-the-counter medication not prescribed by a doctor.
• Most medical covers in Kenya refuse cosmetic dental procedures such as braces and cosmetic dentistry. 
• Unless medically recommended, most covers refuse weight-loss treatments or bariatric surgery.
• Traditional or alternative medicine. This includes herbal medicine and treatment.
• Injuries related to war, terrorism, and riots are in many times rejected.
• Injuries resulting from illegal activities and/or criminal acts.
• Injuries resulting from extreme sports such as professional racing.
• If a medical cover doesn’t include international coverage, treatment abroad is not accepted.
• Non-medical expenses during hospitalisation, for instance TV subscription and extra meals for visitors
• Most medical covers do not allow long-term custodial care or nursing home care.
• Some infectious diseases during the waiting periods, such as HIV & AIDS. This depends on the policy, though.

The regulation of medical insurance cover is split between the public social health insurance and private insurance, overseen by the Ministry of Health (SHA included) and the Insurance Regulatory Authority (IRA), respectively.

So those benefits and exclusions are seen by the mandated bodies. Allow me to end it there for now. Please leave us a comment in the comments section. Upon request, I can give you a free medical quote, and you can request it right here by chatting with me on WhatsApp. The link is provided below.