medical insurance

Medical Insurance, Health Insurance, Family Medical Cover

With an insurance penetration of 2.34% as per 2019 statistics, medical insurance is definitely out of reach to many Kenyans. Only 15.8% of the Kenyan population has a medical cover with 80% of this 15.8% of population having been covered by NHIF, the rest of the 20% have a private medical cover.

Why have a private medical cover?

The cost of health care has sky rocketed in the recent years. For Kenyans who only have an NHIF cover, they may not be able to access quality medical care because the cover limit and choice of hospitals is limited. It’s even worse for individuals or families who don’t have a basic nhif medical cover.

A private medical cover can be purchased by individuals both in the informal sector and those in the formal sector. If you are covered by your employer and you would want to enhance your medical cover, it is important to buy an additional private medical cover to ensure that you are adequately covered. There is also a senior citizen medical cover for the elderly generation who are retired or advanced in age and may not be able to access the conventional medical cover. This cover for those above 60 years of age is usually referred to as Seniors Medical cover.

Medical cover can be purchased by individuals (families), small scale enterprises (with less than 10 employees) and corporate organizations with more than 10 employees.

Eligibility of members

Most insurers cover members from the age of 18 at entry to maximum age of 65 years and dependants from birth to 18 years. For dependants above 18 years and still in school, the cover can be extended up to 25 years with proof of schooling. For senior citizens medical cover, the eligible age is from 60 to 80 years at entry. Some insurance companies covers the member for life as long as the client keeps on renewing their cover by paying premium on an annual basis.

Benefits of having a Medical Insurance cover

A medical insurance cover gives you peace of mind because you don’t have to worry of medical emergency costs. The medical cover caters for expenses such as;
- Consultation fees
- Specialist Fees
- Prescribed drugs
- Diagnosis including XRAYS, MRI’s, CT Scans, Laboratory tests, ultrasounds
- Treatment or management of Pre-existing conditions like HIV AIDS, Congenital conditions
- Management of Chronic conditions
- Maternity Costs
- Physiotherapy Prescribed
- Hospitalization due to an accident including dental and optical following an accident
- General Health Check-ups
- Children vaccinations
- Bed Charges including accommodation net of NHIF
- Daycare surgery for minor surgical treatment
- Emergency air and road evacuation
- Overseas medical coverage when one is outside East Africa mainly for business or holiday
- Overseas referrals mostly in India
- Cover can also be extended to cover pandemics like COVID 19

What is the best Medical Insurance Cover limit for me?

Medical Insurance inpatient limits ranges from as low as Kshs 300,000/- to a maximum limits of Kshs 10,000,000/-. It is very important to have NHIF Cover as medical insurance will mostly cover net of what NHIF is expected to cover. Outpatient limits are from a low limit of Kes 35,000 to a higher limit of Kes500, 000/-.The limit of cover one opts for, determines the premium to pay and the hospital panel list you will be allowed to access by the insurer. It’s important to note that Inpatient cover is mandatory while outpatient is optional.

Key areas to check for when choosing a medical cover

While the overall limits of medical covers may look similar at a glance, it’s important to take note of the key sub-limits. These include sub-limits for pre-existing conditions, maternity, Pandemics like covid 19, Dental and optical treatment
- Some benefits are not covered up to the full limit. It is important for us to help you Check which company offers the highest benefits on these sub-limits.
- Copay- Some companies will require the client to pay a certain amount of money before they are treated on out-patient in some service providers. This mostly applies to individual medical cover thus it’s important to choose a cover with lowest co-pay amount or with no copay.
- Panel of hospitals-Check if your cover gives you access to the hospitals you would want to access and ones with quality health care.
- Premiums payable- most clients check premiums first without comparing the three points mentioned above. We advise that when comparing premiums, consider the above key points.
At earnest we will guide you on getting the best medical cover. Contact us today

Main Exclusions in Medical insurance cover are

Cosmetic Surgery unless caused by an accident
Family planning and infertility/impotence related conditions unless agreed on
Treatment other than by registered medical practitioner eg traditional doctors, Acupuncturist, Herbalists
Intentional self-injury, drunkenness, drug abuse, addiction and suicide.
Naval, Military or Air Force operations.
Expenses recoverable under any other insurance e.g. N.H.I.F
Beauty Treatment
Contamination by radioactivity from nuclear fuel, waste or fission.
Weight Management.
Experimental treatment.
Pandemic and Epidemic Occurrences unless included in the cover

Key areas to check for when choosing a medical cover

CAPITAL CORP. SYDNEY

WILD KEY CAPITAL

LECHMERE CAPITAL

Why have a private medical cover?