Taking medical insurance in Kenya? Here are the dos and don’ts

Health or medical insurance is a contract that requires an insurer to pay either part of all of your healthcare costs in exchange for a monthly premium. When you take up health insurance, your insurer will typically settle your medical, surgical, prescription drugs, and sometimes dental and optical expenses.

The do’s

Your current health status: If you have one or more medical conditions that require continuous care such as diabetes or heart disease, you may want to consider a plan with lower deductibles and lower co-payments. Financial advisor and the founder of The Acemt Consulting, Rhina Namsia says that this also applies if you think you may be expecting a baby in the coming year. “You may pay a higher premium, but your overall out-of-pocket costs may be lower,” she says. Factors such as the age of the applicant, location of residence, health status, type of health insurance plan, use of any substance can affect the premiums you will pay.

Review the provider list and benefits list: The majority of health plans have a list of health providers. If you see a doctor who is on this list, you’ll pay less out of pocket than if you go outside the network. “If you want to keep your own doctor and go to a certain hospital, make sure they’re on the provider list,” says Namsia. All individual and small medical plans have to cover hospitalisation, emergency services, laboratory tests, maternity and newborn care, outpatient care (doctors and other services received outside the hospital), paediatric services, prescription drugs, and preventive services. However, Namsia says that the specifics of each medical scheme may differ. Be sure to read the medical plan’s Evidence of Coverage.

Ask the right questions: Call the member services department of the health plan you’re considering or talk with someone in your human resources department. Which doctors, hospitals, clinics, or pharmacies participate in the plan? How much does it cost to go out of the in-plan network? Am I covered during a travel emergency? What are the premium and out-of-pocket costs? What is the most I’ll have to pay out of my own pocket to cover expenses? Exactly what benefits are covered by the plan and what isn’t covered? How are disputes about a bill or service handled?

Compare various health insurance policies: A wide range of plans is available with similar coverage but different costs. Comparing similar plans can be helpful at the time of purchasing a medical plan. Once you make a comparison of the available plans, you can settle for what suits your health and financial needs best.

Do the math: Find out the factors that can affect your health insurance premium and use them to calculate the possible cost of the policy. The cost can be calculated with the help of an online health insurance premium calculator which most insurers have on their websites. Some of these factors are:

• Age of the applicant
• Location of residence
• Health status
• Type of health insurance plan
• Use of any substance

The don’ts

Don’t skip the Inclusions and Exclusions: This includes what is covered and what is not covered by your health insurance policy. “Go through the terms and conditions. This will give you an idea of whether you can file a claim for a specific situation,” says Namsia.

Don’t give false information: Failing to disclose information or giving false details could cause an insurer to fail to honour their mandate when you have a medical need. It also means that you could end up being underinsured or overinsured. This would mean you cannot claim for the coverage you require when under-insured and you will be paying more for coverage you don’t require when over-insured.

Don’t be afraid of rejection: An insurer can reject your health insurance application or a claim. In both cases, get to know the reason for the rejection. If your application is rejected, you can reapply after correcting the concerned areas. If a claim has unfairly been rejected, you may opt to seek legal redress.

Renewals: According to Nancy Aketch, the founder and director of Taraji Insurance Agency, your renewals must be timely. Failing to pay your premiums in the agreed timelines, and failing to renew your agreement may lead to disqualification or long waiting periods. Bear in mind that health insurance policies usually have a waiting period for certain pre-existing diseases.