73 Ocean Street, New South Wales 2000, SYDNEY

Contact Person: Callum S Ansell
P: (02) 8252 5319


22 Guild Street, NW8 2UP,

Contact Person: Matilda O Dunn
P: 070 8652 7276


Genslerstraße 9, Berlin Schöneberg 10829, BERLIN

Contact Person: Thorsten S Kohl
P: 030 62 91 92

Essential Health Insurance Components You Should Know 

Health Insurance
Health Insurance In Kenya

Health Insurance In Kenya

When you receive a health insurance quote, you will notice that it has different sections such as benefits, inpatient, outpatients, premiums, chronic conditions, eligibility, and more. Understanding what each component covers is the key to finding the most suitable health insurance plan for you and your loved ones. So, continue reading to learn more about various health insurance components. 


Every health insurance plan has an eligibility section. Eligibility refers to the requirements you must meet to qualify for insurance coverage. Eligibility requirements vary from one health insurance plan to another. Age and pre-existing conditions are some of the key eligibility factors medical insurance providers consider.  Each health insurance plan you come across will have a maximum and minimum joining age for the principal members and the dependants. Pre-existing and chronic conditions also have sublimits and waiting periods that they are subjected to.

Take your time to find out the coverage you qualify for in the health insurance you are considering. Don’t forget to find out whether there are other eligibility requirements that you must meet to qualify for the cover. 

Inpatient Cover

Another section you are likely to come across when you receive your health insurance quote is the inpatient cover section. Inpatient cover refers to all the medical costs you will incur during a hospital stay. Some conditions that might require admission include complex surgeries, childbirth, rehabilitation services, and serious illnesses. Your inpatient cover should help you offset some of the expenses, including:

  • Theatre
  • HDU
  • ICU
  • Hospital accommodation, also known as bed charges (Net of NHIF)
  • Drugs
  • Dressings
  • Nursing care
  • Surgical appliances
  • Doctor fees 
  • Diagnostic tests
  • Physiotherapy
  • Laboratory 
  • Admision due to Accidents 
  • Dental inpatient procedure  
  • Optical inpatient procedures
  • Oversees treatment 

When buying health insurance, remember to find out whether the plan you are about to purchase covers these inpatient expenses and the limits.

Inpatient Limit

When evaluating your health insurance quote, you will notice a section with an inpatient Limit. The inpatient limit means the maximum amount your health insurer can cover for the illnesses defined in the policy each year. For instance, if your cover indicates that your inpatient limit is KES500,000, your insurer can only reimburse you or cater for admission cost of up to KES500,000 in that year. It’s important to note day surgery is covered under inpatient subject to authoprization by your insurer.

Outpatient Care 

Outpatient care, also known as ambulatory care, refers to any treatment that does not need admission. A routine checkup with your doctor is a perfect example of outpatient care. Similarly, emergencies that do not require admission also fall under this category. It’s best to note that outpatient care should not last more than 24 hours. 

Simply put, the stay, not the type of treatment you receive, determines the kind of cover you will get. Most outpatient plans should cover the following:

  • Imaging tests, including CT scans, X-rays, MRIs, and more
  • Minor surgery
  • Consultations
  • Checkups
  • Same-day emergency treatment
  • Chemotherapy
  • Lab tests
  • Mammograms 
  • Colonoscopies
  • Physiotherapy 
  • Prescriptions and more


You will also come across terms like copayment or deductible. Copayment is a fee that you pay to receive outpatient cover treatments in mostly category A hospitals.This copay is a control measure to help control unnecessary visit to the hospitals for the outpatient cover. In Kenya, copayment is in almost all individual health insurance plans, while corporates and SMEs can have a waiver on it depending on the agreement with their insurer. Outpatient cover Is optional choice when looking for a medical insurance while inpatient cover is the Mandatory choice that has to be selected.


Here in Kenya, insurance companies usually have a sublimit. A sublimit is a maximum cover on the specific condition or claim/treatment cost for a mentioned condition eg, pre-existing conditions, Materninty, dental, optical . For instance, if your inpatient cover has a limit of KES 1,000,000, and sublimit of a pre-existing condition of kes 250,000, your insurer will not cover the pre-existing condition beyond the kes 250,000. Instead, if you exeed the 250K per year, you will have to cover the remaining cost from pocket. Note these sublimit are still part of the main limit. In this case, if you uterlized the 250K on a pre-existing condition, the balance on your main cover is kes 750,000.

Pre-existing/ Chronic Conditions

A pre-existing condition is a disease or illness you got before taking a health insurance plan. Common pre-existing conditions include cancer, HIV, hypertension, asthma, diabetes, and psychiatric disorders. It’s best to note that pre-existing conditions have a sublimit and a waiting period. Here are the characteristics of pre-existing conditions:

  • A condition you had before buying a plan for the first time, before renewing your plan, before upgrading, or before reinstatement
  • Any disease or condition diagnosed in the first 90 days of taking a health insurance cover 
  • Any disease or ailment that was diagnosed in the previous year of cover

Maternity Health Cover

Maternity health cover handles all the expenses related to childbirth. Most maternity covers cater for various expenses, including consultation fees, prenatal testing, postnatal consultations, normal deliveries, C-sections, and complications. Some companies have maternity cover as a part of your inpatient while others you have to select as an additional benefit at an extra charge.

Optical and Dental Insurance Cover

The optical and dental health insurance coverage might also be included in your comprehensive cover or taken as a stand-alone. Dental insurance should cover the costs of extractions, root canals, gum surgeries, filling, scaling, polishing, and more depending on your insurer. On the other hand, optical health insurance covers eye treatment, frames, prescribed lenses, and more. 

Final Thoughts 

Please note that we have tried as much as possible to cover most benefits included in various health insurance policies. However, we may not have managed to cover all the components of a health insurance policy. Besides, health insurance policies keep changing. If you need help understanding a health insurance policy, Contact us today to talk to one of our experienced health insurance advisors’. 


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