MEDICAL INSURANCE – WHAT YOU NEED TO KNOW
Let’s begin with some comments that are said of insurance in general but more so Medical insurance.
“Insurance is a hoax; Insurance Companies are thieves; Insurance companies take your money but when
you need them they are not there for you.”
Are the comments common? Have you said these words at least once? Have you thought about these
comments? Then this article is for you.
There are a few tips on how to decide on a medical insurance and understanding what you are covered
for.
A) WHAT IS YOUR NEED
Your need is the reason you are looking for cover.
Some of the needs covered are:
1) Pregnancy
Are you currently expectant or planning to get pregnant? Is the cover you are interested in going to
cover an existing pregnancy?
2) Pre-existing and chronic conditions
(a) A Pre-existing condition is any health condition one has prior to buying an insurance cover.
These include diseases or conditions that one has at the point of buying cover. If for instance,
you had an accident and had a cast put on your foot that is already a pre-existing condition.
Fibroids, kidney stones are other examples of pre-existing conditions that may be already
existing despite being diagnosed after buying insurance.
(b) Chronic Illnesses are health conditions that are recurrent and are managed by taking continuous
medication. Some of these include diabetes, high blood pressure, Psychiatric illnesses, HIV etc.
Most Individual medical insurance will only cover pre-existing and chronic condition after 1 year of
getting the medical insurance cover. The insurance will also not cover the illness to the full inpatient
limit but will cover it to a sublimit.
When buying cover, it’s important to check the sublimit that applies to the illness and know that it will
only be available on renewal of the cover i.e. in the case of individual and family medical insurance.
For corporate and SME (Small and Medium Enterprise) medical insurance will in most cases cover pre-
existing and chronic conditions within the first year of cover but to a sublimit. So when buying insurance
cover please take note of the applicable sub limits on your inpatient benefit.
3) Congenital diseases
These are diseases, illnesses or conditions that one is born with. Some examples of congenital diseases
are like sickle cell anaemia, Cleft lip, Leukaemia etc.
Most Individual Medical Insurance covers will cover these ailments on renewal which is after 1 year of
joining cover and they are also covered to a sublimit just like in the case of pre-existing and chronic
conditions.
Corporate and SME medical insurance cover them within the first year subject the stated congenital
sublimit.
Most Insurance companies define Small and Medium enterprises (SMEs) as a group of 3 principle (main)
Members to 10 or 15 people, while Corporate organisations are defined as 15 principle members and
more.
It is very important to disclose the above conditions/ailments (Congenital, Chronic and pre-existing
conditions) at the point of applying for medical cover so that the terms of your cover are spelled out
clearly. If you are not happy with the terms, it’s advisable to speak to your agent or broker so they may
look for a favourable cover that suits your needs.
B) BUDGET
Budget is another consideration while choosing medical insurance cover. There are low cost medical
covers and premium covers across the Industry. The difference is usually on the cover limit and the
hospital panel one can visit
C) BED LIMIT
Are you particular about the room you are hospitalized in and do you prefer your own privacy when
sick? Then it is advisable to purchase the higher inpatient limits like a cover of Ksh 3M and above. Covers
below this, would allow you a ward bed which are the hospital beds usually separated by a curtain.
D) LIST OF HOSPITALS/SERVICE PROVIDERS
Most people have preferred hospitals and doctors that they frequently visit. In that case the one needs
to ask for the list of service providers that they can visit with the choice of cover taken.
Some insurance companies however have introduced Micro insurance which is a low budget cover that
is also restrictive on the hospital one can go to.
E) EXTRA BENEFITS INCLUDED IN COVER
Some covers allow for the principal member and spouse one annual check-up a year. Some have a last
expense benefit for the principle (Main) member and others have a personal accident cover.
Last expense is funeral cover. For most Insurance companies it is a free benefit for main member but for
dependant is can bought at an extra premium. Personal accident is a benefit paid to the next of Kin in
case the main member dies from an accident.
F) EXCLUSIONS
Finally, there may be things that are not covered on the product that you may have chosen. Most
application forms have the exclusions summarised in them. It’s advisable to peruse through and seek
clarification on what is not understood.
This article was written by Alice Siaga, Insurance Expert at the SNDBX, a one-stop-shop collaborative space that brings together 31+ different professional service experts who work together to help entrepreneurs to grow and scale and entrepreneur support institutions to succeed in their programs.