In my previous topics, I have discussed health insurance for families, seniors/elderly, and children. Today, I will continue to widen the scope and discuss the best health insurance for pre-existing and chronic conditions.
Public health cover through SHA has some coverage for pre-existing and chronic conditions via the Emergency, Chronic, and Critical Illness Fund. This coverage is basic, and as you retain SHA, you need a private health insurance cover for a comprehensive pre-existing and chronic conditions coverage, faster access, private ward accommodation, and specialist doctor panels.
This guide will concentrate on private health insurance and how well they are engineered to cover pre-existing and chronic conditions.
I will take you through the fine print of private underwriters including Britam, Jubilee, APA, AAR, CIC, and GA to understand their coverage and exclusions, so you can select a plan that actually works for you.
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How Private Insurers Define Pre-Existing vs. Chronic Conditions
- Private insurance companies in Kenya or private medical underwriters define pre-existing conditions as any illness, injury, or physical symptom present before the policy start date, whether formally diagnosed or not. Such conditions include past fibroid removal, previous spinal surgery, treated ulcers, among others.
- They also define chronic conditions as long-term conditions requiring ongoing medical management, prescription refills, or monitoring. They include Type 2 diabetes, hypertension, asthma, arthritis, kidney disease among others.
Insurers usually bundle pre-existing and chronic conditions together, under a single “Pre-Existing & Chronic Clause”, subjecting both to special caps and waiting timelines.
They also have another clause for the newly diagnosed chronic conditions, subject to another set of rules as we shall see later on.
The 4 Fine-Print Rules of Private Covers in Kenya
In covering pre-existing and chronic conditions, private insurers have certain conditions in place. These are the 4 fine-prints that you must note.
They include:
The Waiting Period Rule (12 to 24 Months)
When you enroll in a private medical insurance, pre-existing and chronic conditions are not covered by day 1.
Pre-existing and chronic conditions have a awaiting period of 12 to 24 months. This means that if you subscribe to a private health insurance today, you will use it to cover pre-existing and chronic conditions after the first or second renewal depending on the insurer.
Newly diagnosed chronic conditions are covered instantly with no waiting period as long as you have completed the general illnesses waiting period.
However, if you have an existing private medical cover and you want to shift to a different medical underwriter, you can be exempted from the waiting periods on 2 conditions if you show:
- Renewal invitation from your current underwriter or continuous cover certificate
- Usage history of your medical cover.
General illnesses have a 1 month waiting period while critical orocedures, such as cancer/organ transplants often carry 2 to 3 years waiting periods on individual retail plans.
The Sub-Limit Trap
If your medical insurance is of particular inpatient limit, it does not mean that you can use all that inpatient cover on one condition, unless your cover is so so premium like the Britam Milele Platinum Health Plan. Milele Platinum Plan allows you to use the full inpatient limit on pre-existing and chronic conditions.
Within the inpatient limit, there are sub-limits. For example, a plan with a KES 5,000,000 Inpatient Limit may cap chronic and pre-existing treatment at a sub-limit of KES 300,000 to KES 1,000,000 per year.
The higher the sublimits, the higher the annual premium.
Once the sub-limit is exhausted, you will pay out of pocket for that specific condition, even if the main KES 5,000,000 limit is still intact.
Full Disclosure vs. Claim Repudiation
When enrolling for a health insurance, please disclose all the conditions you have.
Non-disclosure will bring you more problems that good.
Before paying a claim, the medical board reviews hospital files during a claim. If the insurer proves a condition existed prior to joining and was omitted from the proposal form, they will repudiate/reject the claim and cancel the policy.
Outpatient Co-pays and Pharmacy Formularies
To manage medical cover misuse, over spending, and deter unnecessary facility visits, medical underwriters have measures put in place.
These measures include:
- Hospital pre-visit co-pays of KES 500 to 2,000 per visit. This is a non-refundable out-of-pocket fee payable directly at the facility cashier prior to seeing a general practitioner or specialist.
- Specialist access restrictions requiring members to be seen by a General Practitioner (GP) first. Direct access to a chronic specialist, such as an endocrinologist or cardiologist, often requires a written GP referral to qualify for cover.
- In regard to chronic refills characterized by frequent consultations exhausting your cover unnecessarily, insurers often waive co-pays for routine monthly prescription refills when dispensed via direct retail pharmacy refill programs or tele-pharmacy platforms.
- Insurers maintain an Approved Drug List (Formulary) created by Pharmacy and Therapeutics (P&T) committees to control pharmaceutical expenditures, which often accounts for 60% to 70% of routine chronic outpatient claims.
- Restricted drug lists, or generic-only replacement mandates to combat brand inflation.
Strategic Ways to Get Better Coverage for Pre-Existing Conditions
Option A: Paying Medical “Loading”
When enrolling in health insurance cover, underwriters allow members to waive or shorten waiting periods by paying an extra percentage premium (medical loading) based on risk assessment.
Option B: Portability and Waiting Period Waivers
Like I have mentioned briefly before, if you are transferring from another health scheme, you can request a waiting period waiver.
You may be required to provide the following list of documents:
- Continuous cover certificate or renewal invite from the previous insurer.
- 1 to 3-year claims utilization history.
Option C: Corporate / Group Scheme Entry
Groups or entities receive better pre-existing and chronic conditions sub-limits and waiting periods than individuals. Waiting periods can also be waived altogether when joining as a group due to their sheer number.
Comparing Leading Private Underwriters in Kenya For Pre-existing and Chronic conditions
| Medical Underwriter | Typical Inpatient Pre-existing and Chronic Sub-limit | Waiting Period | Standout Feature |
| Britam Insurance (Milele Health Plan) | -NO LiMIT (Up to full inpatient limit (Milele Platinum Health Plan) for pre-existing and chronic conditions)-Newly diagnosed chronic conditions up to KES 3,000,000 in the first 2 years and full inpatient limit from the 3rd year | 12 months | -Up to full inpatient limit in Milele Platinum Health Plan-Higher inpatient sub-limits compared to rivals-1st Runner up |
| Jubilee Insurance (J-Care) | -Up to KES 2,000,000 for pre-existing and chronic conditions-Up to KES 3,000,000 for newly diagnosed chronic conditions. | 12 months | -2nd runners up in pre-existing and chronic sub-limits |
| Madison Insurance (Betterlife) | -Up to KES 1,000,000 for pre-existing and chronic conditions-Up to KES 1,000,000 for newly diagnosed chronic conditions | 12 months | Reasonable sub-limits for pre-existing and chronic conditions |
| CIC Insurance (Medisure) | -Up to KES 1,500,000 for pre-existing and chronic conditions-Up to KES 1,500,000 for newly diagnosed chronic conditions | 12 months | Reasonable sub-limits similar to Madison’s Betterlife cover |
| Old Mutual (AfyaImara) | -Up to KES 1,000,000 for pre-existing and chronic conditions-Up to KES 3,500,000 for newly diagnosed | 12 months | Better newly diagnosed chronic conditions sub-limits. |
From the table above, we can make a subtle conclusion. Britam Milele Health Plan has the best coverage for pre-existing and chronic conditions in Kenya. Milele Platinum Plan allows you to consume all your inpatient limit of pre-existing and chronic conditions. Milele Platinum Plan has an inpatient limit of up to KES 10,000,000 shared between the family members or completely unshared where every family member enjoys up to KES 10,000,000 inpatient limit. That means you can use all your inpatient limit/cover of KES 10,000,000 on pre-existing and chronic conditions. This cover is sufficient for you and your family.
The plan is distantly followed by Jubilee J-Care that offers up to KES 2,000,000 limit on pre-existing and chronic conditions in their most premium cover. If you need a modest cover for your pre-existing and chronic conditions, J-Care can be an option.
Other covers you can consider include CIC Medisure, Madison Betterlife, and Old Mutual AfyaImara. They offer moderate pre-existing and chronic conditions coverage that might be suitable for those with average medical needs. However, they may introduce some challenges when planning to upgrade to a better medical care.
Step-by-Step Buying Guide and Medical Assessment Checklist
To buy the right pre-existing and chronic conditions limits for you here is a simple guide for you to follow.
- You need to audit your medical needs. Calculate your annual spend on routine refills, lab tests, and specialist consults.
- Have your doctor draft a clear, current diagnosis summary. That way, you will be able to assess the cover you need.
- When filing your medical proposal form, fill it honestly. Declare all your past hospitalizations, prescription drugs, and surgeries.
- Carefully inspect the plan you are buying. Check the exact sub-limit line item for pre-existing, chronic and congenital conditions before remitting premiums.
Navigating private health insurance with an existing illness or chronic condition comes down to understanding the sub-limits and waiting periods before you sign.
When filing the medical proposal form ensure you disclose all material facts about your pre-existing and chronic conditions. This is to prevent claim rejection or policy cancellation.
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