black woman patient talking to a doctor for consulting during-health insurance in Kenya

When people were engrossed forwarding the usual stale, copy-and-paste New Year messages; when everyone seemed to be overly engaged making phone calls to their loved ones at midnight at the end of the year; when some of you were all busy counting on the timer in a backyard party somewhere in the world or hunched over your couch or under a warm blanket ready to usher in the new year of our Good Lord, I was lying on some lonely hospital bed. Alone. Just counting the hours to my scheduled surgery. 


But there was one thing that kept bugging me. What if I did not have insurance? The last thing on my mind when I was being wheeled into the emergency room, for the second time in a week, feverish, wobbly and dripping sweat like a running tap, was that I’d be scheduled for immediate surgery. 


Yet, there I was. 


Lying there, all I could think about was how I’d probably be liquidating some savings accounts to cover the hospital bill. And maybe, just maybe, my poor mother would have to do the same. A situation I’ve always tried to avoid. 


And it’s something I have always talked about tirelessly when I talk about financial planning


RISK MANAGEMENT. Having the right insurance policies at your corner. In this case, family or individual health insurance coverage for the self-employed or those without enough coverage from their employers.


But I had been careless in 2023. I had let my health insurance lapse and took longer than expected to settle for an option. I was looking for a better insurer—one with better customer care and great coverage but at a reasonable rate. And I had dragged the decision for no good reason. Until my partner couldn’t take my indecisiveness any longer and I had to finally make up my mind late in October. 


Considering the waiting period of the insurer I settled for, if I had been in this situation sometime in November, my health insurance would not have footed the bill. And so, as I lay there, pondering over the situation, I couldn’t help but wonder… what if? 


So, as we start this year, I will repeat the same message, have the right insurance policies in your financial plan. There are 4 major policies to have;

  1. Health insurance
  2. Home insurance – also referred to as domestic package
  3. Life insurance 
  4. Auto insurance – applies if you have a vehicle 


In this article, however, we will focus mainly on health insurance in Kenya. More specifically, what you need to keep in mind as you shop for a health insurance policy. From what to consider when shopping for coverage to where you can get a comparison list. 


Without further ado, let’s get started! 


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Despair mature black male with scarf suffers from headache, pain, fever, looking at computer


Why Do You Need Health Insurance

There are several advantages to having health insurance:

  1. Ease the financial burden of medical costs – with the ever-rising cost of living, medical costs are not left behind. A simple diagnosis or accident can wipe away your savings. As well as those of your family. Health insurance will help shoulder some of the burden. Even with critical illnesses, where you have to ask loved ones for contributions, you’d probably have to raise fewer funds if you already have insurance. 
  2. Peace of mind for you and your loved ones – have you heard of situations where hospitals decline to offer anything beyond emergency care without cash or insurance? Imagine being in that situation, and your loved ones frantically trying to raise funds so you can get treatment. A health insurance policy offers peace of mind, knowing that in times of medical need, one can seek timely treatment without worrying about the financial repercussions. 
  3. Access to quality healthcare without the burden of exorbitant expenses.
  4. Reducing your tax liability – did you know that KRA allows tax deductions of insurance premiums, including health insurance? You are entitled to a relief of 15% of the total premium or up to a maximum of Kshs. 60,000 per annum. With the current high tax rates that seem to increase with every waking day, this is an excellent way to reduce your tax liability and protect your savings at the same time.


What to Consider When Looking for Health Insurance in Kenya

There are several things to take into consideration. That’s why I recommend taking your time. But don’t take too long either, like I did.  


Black mother and daughter having checkup at pediatrician


1. Your Particular Needs

There are several factors to consider, like your budget. How much are you able to pay in premiums? Are you looking for an individual or family health insurance plan that covers your spouse and kids? Or, are you looking for additional coverage that supplements your employer’s health insurance coverage? Most importantly, what’s your family’s health history? Understanding this can help you ensure comprehensive coverage for critical illnesses. 


Whatever the case, it’s important to ensure that you have comprehensive coverage. Look at your previous year’s health history. And personally, I like to add what I call ‘tax’ to it. Because as we grow older, issues we had not anticipated crop up. So going for higher coverage, i.e., a higher amount of policy limit might cost more but it provides you with ample health insurance coverage. 


2. Outpatient vs Inpatient

Speaking of your needs, you will also have to decide whether you want outpatient, inpatient or both. Outpatient coverage caters to your medical bills when you are not admitted, i.e., getting treatment and going home that same day. Inpatient, on the other hand, requires occupying a hospital bed for a day (day-patient) or a night or more while receiving treatment, including surgeries. 


From experience, I found outpatient premiums to be quite high. The cost of premiums vs what I was getting out of it wasn’t that different. For example, paying a premium of Ksh. 40,000 for an outpatient coverage of Ksh. 50,000. 


So I’ve devised a system where I have a savings account, one of the several sinking funds, for outpatient bills only. This is a system that can work if you feel the outpatient premium is a little out of your budget. And historically, you or your family have probably had few hospital visits. 


But that doesn’t mean you cannot get this coverage for yourself or your family. Again, it all narrows down to your needs. If you spend a considerable amount of time and money on hospital hallways, getting outpatient might make financial sense. 


3. Check the Insurers Network of Hospitals and Providers 

Every insurer has a network of healthcare providers in their network, from general practitioners to specialists, like dentists, ophthalmologists, and specific clinics and hospitals. 


If you already have an established relationship with some providers, it’s best to confirm whether your preferred insurer has them under its network. The reason for this is that when you use a provider outside of the insurer’s network, the costs might be higher and you’d have to foot that extra pay from your pocket. Not forgetting the processing of paperwork trying to claim that money back from your insurer. 


In addition to this, there are health insurance companies with a limited network of providers in some areas, especially in smaller towns and rural areas. For instance, I realized that some of the insurers I had on my list of possible choices had limited providers where I live in Kwale. 


4. Consider the Waiting Period

Unfortunately, most health policies will have waiting periods for various conditions. That means that you don’t automatically get to enjoy the policy the minute you pay for your premiums the first time. 


For example, a lot of pre-existing chronic diseases will have a waiting period of up to 1 year or more after getting the coverage. So, for that first year, your health insurance coverage cannot cater to bills for that specific condition. 


Besides the waiting period for pre-existing conditions, there is also the waiting period for a new entrant. This is for illnesses that you are currently not suffering from as you purchase your policy. The waiting period will depend on the insurer, ranging usually from 30 to 60 days. Remember at the start when I said if I had gotten my coverage sometime in November I’d not have been covered by the insurance during my stay at the hospital? Including the surgery. Because the insurer I use has a waiting period of 60 days. 


The good news, however, is that there is no waiting period for accident-related treatment. Most of the insurance providers I saw during my research did not have this. So, in case of an accident and you’ve just paid your premium and been onboarded by the insurer, they will cater for your treatment. 


Emergency medical service


5. Compare the Premiums and Coverage Provided

Next, make a comparison list of premiums from various insurance providers. Every health insurance provider has its pricing policies, leading to variances in the premium rates. In the same breath, look at the coverage provided by the insurer. 


Some providers will have a low and cheap premium. And while this looks super affordable, the coverage might not be comprehensive enough for you or your family. This will only lead to underinsurance, and you’d have to cater to those bills when the time comes. 


When considering the level of coverage, besides the total sum insured, look at the breakdown of the coverage. I noticed services such as ambulances, air evacuation, lodging fees for a parent accompanying a minor, post-hospitalization care and last expense. Some policies even provide personal accident and medical treatment outside the country.  Of course, with limitations to certain countries. And, if you are planning on starting a family, look at the maternity cover offered under your preferred option, and the limits.


The bottom line is that it’s important to weigh both options and choose a health insurance policy that’s affordable but comprehensive enough for your needs.


6. What Are the Exclusions

As with any insurance policy, there will be exclusions in your health insurance policy. Exclusions are illnesses, conditions or situations that the insurer will not provide coverage. 


Before settling on any policy, ensure that you go through its policy exclusion list. This allows you to know what is covered and not covered by the insurer beforehand. For instance, I realized that most providers have exclusions of issues like intentional self-harm and drug addiction.


7. What’s the Insurer’s History?

Last, but not least, consider the reputation of the insurer you are about to use. Is the company regulated by the necessary regulator? What’s the experience of its previous and current customers? Did the insurer take them in circles when they needed admittance at the hospital? Or during a claim process? What other issues have their customers complained or appreciated them about?


Where to Compare Plans

One way to compare plans is to get in touch with an insurance agent. You can request details from various providers to help you do your comparison. Every insurer has different packages. That means comparing not just an individual provider’s packages but the available packages from different providers. That’s where I recommend this second option for a summarized version. 


The second option is to use Pesa Bazaar. I used them when I was shopping for a health insurance policy on two occasions. So this is not an ad for them but my honest opinion.  


The Pesa Bazaar platform allows you to compare plans based on your needs. So, the very first step is to enter how much inpatient limit you need, whether you or your dependents have any pre-existing conditions, your date of birth and that of your spouse and the number of children. Since this is a family scenario, you can always leave the irrelevant details out—for the single people. The options for inpatient cover limit run from KShs. 500,000 to KShs. 20M. 


I liked Pesa Bazaar’s comparison list because it allowed me to read a summary of what’s covered by each insurer, with a breakdown of sub-limits for each condition, and exclusions. It also gave me a basic idea of how much the premium might cost. In addition, they also provide you with a list of providers within each insurer’s network. 


PS: note that you will have to provide personal details, i.e. name and contact details to view the comparison list. 


How Much Does Inpatient Health Insurance Cost in Kenya

This will depend on many factors, including your age, pre-existing conditions and the level of coverage you need. However, from as low as Kshs. 10,000, you can have an inpatient health insurance policy. The cost will also vary between insurance providers. That’s why it’s essential to do research and have a comparison list. 


Do You Still Need NHIF?

NHIF, the National Health Insurance Fund, has a National Health Scheme named UHC Supacover. For the self-employed, this will currently cost only KShs. 500 per month, an annual premium of KShs. 6,000. Remember that this has to be paid on or before the 9th day of the month. For easier financial planning, I recommend paying the annual amount of KShs. 6,000 at the beginning of the year. 


For outpatient and inpatient care, this is quite reasonable. It provides coverage for you and your dependents, like spouse and children. Although it will often get you medical care only at hospitals under NHIF’s network. These range from government hospitals and private and faith-based hospitals to cancer treatment centres and MRI hospitals. You can check out the full list of providers on NHIF’s website. 


NHIF is the bare minimum health insurance you should have in Kenya, especially if you cannot afford health insurance from private insurers. Finally, always ensure that your NHIF is paid and up-to-date. If there are ever issues, like penalties, ensure that you sort them out as soon as you notice. You don’t want to be on the hospital line or bed trying to fix issues at the last minute.


Do I need health insurance in Kenya?

While not legally mandatory, having health insurance in Kenya is highly recommended. Unexpected medical expenses can quickly disrupt your finances. Health insurance will provide you with financial protection and access to better care.


What types of health insurance plans are available in Kenya?

Kenya offers both public and private health insurance options. Public options include the National Hospital Insurance Fund (NHIF), while numerous private insurers provide a range of plans catering to different needs.


How do I assess my health insurance needs?

Evaluate your health history, consider the medical requirements of your family, and analyze your financial capacity. This will help you determine the level of coverage that best suits your unique circumstances.


What should I consider when choosing health insurance coverage?

Key considerations include the extent of coverage for inpatient and outpatient care, maternity benefits, prescription drug coverage, the network of healthcare providers, and the overall cost and affordability of the plan.


Are pre-existing conditions covered by health insurance in Kenya?

It varies. Some plans may cover pre-existing conditions, while others might have waiting periods or exclusions. Read the policy details carefully to understand how pre-existing conditions are handled by your preferred provider.


How can I research the reputation of an insurance provider in Kenya?

Look for customer reviews, testimonials, and ratings of the insurance company. Additionally, check their financial stability, often available through industry reports or the insurance regulator.


What should I do if I need to make a claim under my health insurance policy?

Familiarize yourself with the claim procedures outlined in your policy. Typically, you’ll need to provide documentation such as medical bills and reports. Contact your insurance provider for guidance through the process.


Do I need individual or family health insurance if my employer provides coverage?

While your employer’s coverage is beneficial, having individual or family health insurance ensures comprehensive protection. It can cover specific needs, and in case of job changes or unforeseen circumstances, it provides continuity and additional financial security. Consider it as a valuable supplement to employer-provided coverage.


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