The Ultimate Guide to Health Insurance: How to Pick the Right Plan for You

health insurance

Health insurance is an essential part of life. In today’s world, it’s important to have the right coverage to protect yourself and your family in the event of a medical emergency. Thankfully, there are many plans out there that can suit your needs and provide you with protection from the high cost of healthcare services should an unexpected illness or accident occur. This article will give you all the information you need to choose the best health insurance plan for your circumstances and budget.

Why health care in Kenya matters

Your health is the most vital asset you possess in this lifetime. It’s a critical issue in life since it’s difficult to accomplish important objectives if you don’t have good health. Despite its simplicity, this idea is driving the growth of health insurance across the world, particularly in Kenya. What are the most critical reasons why you, your family, and your dependents should get health insurance?

Health is irreplaceable

Unlike the vast majority of things in life, health is one of the truly irreplaceable aspects. A lot of attention is currently dedicated to encouraging healthy life habits because doctors have known that it’s better to keep in good health rather than to try to fix it once broken. Some of the key sources of threats to our health include hereditary illnesses, communicable diseases, and lifestyle diseases. In all these cases, a good health insurance policy can be the help we need should our health start failing.

Health insurance is affordable

The amount of Kenyan citizens acquiring health insurance has been on the rise. There are two main reasons for this. First, more employers are providing health insurance as one of the benefits they offer their employees. This will increase the number of Kenyans with health coverage.

Second, low-cost health insurance plans that include basic cover for policyholders have emerged. This is following the substantial influence of SMEs in the Kenyan economy. As a result, medical insurance is inexpensive since there is always a policy that accommodates the health needs of all Kenyans.

Accidents happen

An accident could have a devastating effect on your health, so it is important to have health insurance. Accidents can occur at any time, as we discussed earlier. Germs and genetics are not the only threats to our health, as we discussed earlier. In some cases, serious injuries are difficult to treat and costly to manage. If you have an accident, a good health insurance policy will assist you in recovering by covering your medical expenses.

You get a tax relief

The Kenyan tax procedures guarantee you a 15% reduction on the premiums you paid in that year. That much will be deducted from the cost of health insurance. If you pay Kshs 50,000 for health insurance coverage in one year, you will be refunded Kshs 7,500 in taxes.

Types of health insurance in Kenya

There are several kinds of health insurance plans available in Kenya to cover individuals and businesses. These plans are designed to satisfy the demands of the people seeking coverage for their families and employees. Here is a list of the most common insurance policies offered in Kenya.

Inpatient cover

Hospitalization expenses are compensated by this type of insurance. Because inpatient insurance provides coverage for accommodation costs in addition to treatment costs, it is typically more expensive than other types of coverage. Before accessing inpatient facilities, some insurance companies require policyholders to get clearance. In these cases, the firm seeks to ensure that the individual requires hospitalization rather than a frivolous hospitalization request.

Outpatient cover

Outpatient coverage is the most common type of health insurance coverage. The outpatient cover protects policyholders from financial losses resulting from outpatient services. A policyholder may not remain in a hospital or clinic after receiving medical services under an outpatient plan. Because all expenditures are related to health care, outpatient plans are often cheaper than inpatient plans. They do not usually provide outpatients alone but are usually included in an outpatient coverage bundled.

Maternity cover

Maternity coverage is also offered in Kenya. Maternity coverage is frequently included as an addition to a basic health insurance policy. Hospitalization costs for childbirth and any potential congenital ailments resulting from the pregnancy are covered. Because maternity coverage is an ‘assured risk,’ insurance companies often use it as a customer retention tool.

High and medium-cost covers

Employees of large-sized organizations usually purchase health coverage in Kenya. These plans are usually compensated for by employers as part of their compensation packages. Employees at higher levels are typically offered more expensive health care, whereas workers at lower levels receive less expensive plans. Insurance companies’ premium amounts are usually outlined on a graduated schedule that shows the number of premiums concerning health plan limitations. In some instances, funeral coverage benefits that are not included in insurance policies are given if a policyholder dies.

Low-cost covers

Some businesses have created economical cover options for low-income individuals in recent years. These services offer low-cost premiums and limited inpatient and outpatient care. The most well-known of these plans is Linda Jamii’s coverage for SMEs and other small groups. Some low-cost healthcare insurance providers are willing to work with low-cost hospitals in Kenya. Co-payment schemes are used to prevent frivolous visits to healthcare facilities to reduce the risk.

Benefits of health insurance in the policy

In health insurance in Kenya, the term “benefit” has a distinct meaning to it and usually refers to the specific commitments the insurance company makes to policyholders. If you bought a health insurance policy today, the following are some of the benefits you will enjoy.

Covers cost of consultation

The cost of consultation varies widely in Kenya, from a few hundred shillings in low-cost hospitals to several thousand shillings in high-end hospitals. The cost of seeing a doctor is usually covered by the insurance company and is the first benefit you will have when you buy a health insurance policy.

Covers cost of specialists

Specialists such as gynecologists, dermatologists, psychiatrists, and, others, usually have a higher consultation fee. In case a general doctor (general practitioner) refers you to a specialist, the insurance company will meet the cost associated with your visit to the specialist. You should however consult your insurer to find out whether they have an approved panel of consultants before seeing a specialist.

Covers cost of lab-work

Health insurance policies usually cover the costs associated with lab tests. It is important to highlight this benefit because not all medical conditions will require medical testing before treatment can be administered. That said, some insurance companies will require you to notify them if certain tests are recommended so that they can issue their approval.

Covers cost of medicine

Meeting the cost of drugs is also one of the benefits a health insurance cover should provide. In this case, the medicine may be obtained from the hospital’s pharmacy, or a chemist accredited by the insurance company. In general, health care policies do not cover the cost of non-medical supplements and cosmetics, even if they are recommended by a doctor.

Covers cost of hospitalization

In the event a policyholder is hospitalized, the insurance company will meet the costs associated with hospitalization. In this case, the insurance company will pay for accommodation (bed) as well as treatment costs. Accommodation in a hospital increases the cost of healthcare because the hospital must operate several departments to support the patients. These departments include catering services, and laundry services, among others. The hospital also must be in operation full time, which means hiring more staff members

Covers cost of Ambulance

Some covers may include an ambulance benefit. In this case, the insurance company provides an ambulance to take you to the hospital should you need one. Some policies also include an air rescue component in partnership with air ambulance services. This benefit may require the payment of additional premiums.

Cash Back for days hospitalized

in some cases, the policy may also include a “cashback” clause where the insurance company pays out a daily allowance for every day the policyholder is hospitalized. The rationale is that long-term hospitalization may lead to loss of income. The cash paid to the policyholder helps to even out the loss of income during the days they are hospitalized.

How to choose an affordable health insurance policy

What’s the right decision concerning health insurance coverage? If you’re currently bothered by this, you’re exactly the person I wished to speak to. Choosing the correct medical insurance policy is a critical decision. It will affect the kind of care you can receive, in addition to the amount. Here are some of the most important variables to think about.

Needs assessment

First, carry out a needs assessment to see what you are looking for. When we speak of needs, we mean your needs and those of your dependents. Your needs will mostly be defined by your current state of health, which will influence how frequently you need medical attention. The type of care you will need is also a good consideration to make.


The next thing you need to look at is your budget. How much are you willing and able to spend on health insurance? While someone would feel safest having all the benefits a medical insurance policy can buy, spending too much money on one item can compromise your financial plans, especially if you have many dependents. In this case, decide on how much you can spend on health insurance based on your needs and based on your capacity. The whole point of this exercise is to make sure that you get the best possible deal for your budget. At times, the cost of a policy is not always an indicator that you are buying a good policy.

Benefits assessment

Thirdly, with actual policy documents, assess the benefits associated with each policy. Compare the limits of each policy to see just how much would be available to you. In addition, look at the complete list of benefits provided by each of the policies you are considering. It is wise to pick policies whose benefits match your needs as closely as possible.

Company choice

Finally, decide on your preferred insurer. It’s a reality that some health insurance companies have better products and customer service than others, even if their policies may be more expensive. Finding a company that fits your needs is the important thing in this situation.

Once you have understood what your needs are, compare the policies available, assessed the benefits of these policies, and finally, you have settled on a provider, then and only then, are you ready to buy health insurance

Conditions excluded from health insurance policies in Kenya

It is crucial to be aware that health insurance policies do not cover all medical conditions unconditionally. Health insurance policies are based on insurance principles that cannot cover these issues. The insurance business is set up to cover a relatively small proportion of people affected by the risks. When patients vary from this norm, insurance companies are unable to offer services. The following conditions are among those not covered by insurance policies.

  • Pre-existing & chronic conditions: Insurance companies are not obliged to cover a policyholder who joins their scheme after the onset of a medical condition. For instance, a policyholder who has an organ defect (say failing kidneys) does not have the right to demand an insurer cover the costs associated with his treatment of the disease that had been detected earlier than the effective date of their policy.
  • Congenital defects: These are defects that affect unborn children and are usually detected before, during, or after birth, and in some cases later in life. In recent years, some medical insurance policies have found ways of covering congenital effects but usually have a cover limit.
  • War and kindred risks: These are risks associated with war. In wars, the number of casualties is usually much higher than an insurance company can afford to compensate using ordinary insurance models. To keep the liability levels manageable, health problems associated with war and kindred risks are not insurable
  • Cosmetic surgery unless caused by an accident: insurance companies do not pay for elective cosmetic surgery and procedures. Elective cosmetic surgery does not qualify as a risk and is a deliberate choice by an individual. On the other hand, a health policy will cover a cosmetic procedure if it is required to restore normalcy to the looks of a policyholder. This may be the result of burns, wasting infections, or any other ailment causing physical deformity.
  • Treatment other than a registered doctor of medicine: This policy exclusion means that a medical insurance policy will not pay for treatment accessed from a traditional doctor, medicine man, acupuncture practitioner, or even a trained conventional doctor who is not licensed to practice. The challenge here is that insurance relies on formal health systems to calculate costs, while informal health systems do not have enough in common to allow for the proper calculation of premiums. At the same time, some of their treatments are not scientifically tested, hence there is no way of assessing their efficacy.
  • Intentional self-injury: This exclusion stems from the understanding that insurance is meant to cover risks and not premeditated events
  • Drunkenness: Injuries or problems associated with drunkenness can be considered to be self-inflicted, and the policyholder should have been well aware of the consequences. These conditions are therefore not insurable
  • HIV/AIDS-related illnesses: In the former years, HIV/AIDS was not curable (and still isn’t), and was more difficult to manage. Things have changed much over the last two decades, and insurance companies are less worried about covering HIV/AIDS. This in addition to laws outlawing the discrimination of HIV patients has virtually eradicated this exclusion
  • Dental and Optical Conditions: Some covers still do not cover dental and optical conditions unless specifically included in premium calculations. Even in cases where these two conditions are covered, some exclusions still apply, such as a limit on eyeglasses, and dental procedures a policyholder may access.

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