Medical emergencies are unpredictable, and having a reliable health insurance plan ensures that you and your loved ones are protected against unforeseen medical expenses. In Kenya, a variety of health insurance options cater to diverse needs, there is inpatient coverage and outpatient cover. Whether you’re seeking coverage for yourself, your family, or your employees, understanding the available plans is crucial.

Types of Health Insurance Covers in Kenya

1. Inpatient Cover: This plan caters to medical expenses incurred during hospital admissions, the insurance company will specify what is covered and what is not covered and the limit provided for each. The various limits of coverage and conditions are usually considered when calculating the premium or amount charged on an inpatient health insurance cover.

Overall Benefit amount

This is the limit amount that the cover gives the individual/family – This amount mostly covers accidents and accident-related cases as well as general illnesses that are not Chronic some cover Acute Conditions as well.

• Bed

This is the amount covered in accommodation charges at the hospital per night, this cover often comes with a SHA (formerly NHIF) rebate – this means the amount the insurance company gives you is minus the SHA rebate. i.e. if your bed limit is 10,000/-, SHA provides 4,480/- your insurance company will give you 5,520/- not 10,000/- if you do not have SHA then you pay the 4,480/- per night out of pocket.

• Lodger Fee for Accompanying Parent/Guardian

This is often for children under the age of 10, some covers go until 12, and some might be higher. This is where the parent/guardian who comes to stay with the child while in hospital is covered meaning they don’t have to add any additional fee.

• Emergency Evacuations

This can depend on Road Ambulance depending on your Overall Benefit amount or Road and Air ambulance.

• Accidents and Acute Conditions

Often these are the ones covered by the Overall Benefit amount and have mostly no waiting period. Acute conditions are health conditions that develop rapidly, typically last for a short period, and are often treatable. Some insurance companies may put a limit on the number of days.

• Newly diagnosed Chronic Illness

This is an illness that the beneficiary did not have before being covered by the company but is newly diagnosed with it. This amount is usually given once and after the illness is termed Pre-existing and shall fall under that budget limit. This illness in most insurance companies usually has a specific limit less than the overall limit given. i.e. if you have a cover for 1,000,000 this might be 300,000-700,000 depending on the insurance company you are covered by. It is important to check this line.

• Chronic, Pre-existing Illnesses, Congenital conditions & HIV/AIDS

These are conditions that last a year or more and require ongoing medical attention. In most covers this has a waiting period and if newly diagnosed some companies might say they cannot give you a cover until you are done with treatment. Waiting period therefore mostly means after you are treated not during treatment. This time ranges between 1 and 2 years or more depending on the insurance company. This part also has a specific limit just like the Newly diagnosed above which is usually much less than the Overall limit (some insurance companies may have the same limit but this is rare) important to note that the limit here is usually less than the Newly diagnosed amount.

• Psychiatric and Psychological Illnesses

This also usually has a waiting period (1/2 years, depending on the company) They also usually have a set limit lower than the overall limit.

• Post Hospitalization days after discharge

This is the amount you pay after you have been discharged but may be coming back for a check-up etc. This is often given several days, usually may depend on the conditions sub-limit, and may also be on the reimbursement process.

• Neo-natal and prematurity conditions

This is after the birth of a newborn, usually has a waiting period just like maternity, and also the amount is less than the overall limit

• Accident-related inpatient Dental and Ophthalmologist treatment

accident-related inpatient dental and ophthalmology treatment refers to medical expenses covered when a person requires hospitalization due to an accidental injury affecting the teeth or eyes. This coverage is specifically for treatment necessitated by trauma or an accident, rather than routine dental or eye care. Has no waiting period just liked an accident but has a limit lower than the overall limit

• Non-accident-related Inpatient Dental and Eye Treatment.

Usually has a waiting period of (1-2 years depending on the company you are covered with) The limit is usually much lower than accident-related as well.

• Gynecological surgery

Usually has a waiting period and the limits are also much lower than the overall limit.

• Last Expenses

These are expenses that come after death, some covers have that depend on the illness or accident clauses. If it is a family cover, some have the limit set for each member as a stand-alone benefit. The limit is usually around 50-200,000 depending on one cover.

• Maternity: Normal Delivery, C-section

This covers maternity costs, Normal delivery, C Section delivery whether elective or emergency. Some cover Maternity complications as well before and after delivery. This mostly has a waiting period (usually about a year) and also a limit less than the overall limit i.e. 50,000-300,000 depending on your cover.

• Covid-19 Treatment

This was introduced due to Covid 19, it is just a cover for COVID cases, usually the covers give you a time period on the number of days to be covered by this claim depending on your cover. Also has a limit less than the overall limit provided.

• Overseas treatment

Depending on the company you are covered with and the premium being paid. You have an option of getting treatment overseas vs non and this also has a fund limit in some companies.

1. Outpatient Cover: Outpatient health insurance in Kenya provides coverage for medical expenses incurred without requiring hospital admission. This means that beneficiaries can access consultations, diagnostic tests, prescription medication, minor procedures, and specialist visits without the need for an overnight stay in a hospital.

• Dental and Optical Cover
• Annual wellness check-up
• Vaccines
• Pre-existing conditions
• Antenatal and postnatal delivery
• Supplements covered

Co-pays: This is where the insurance cover may set an amount that you may have to pay in the specific institutions you visit, mostly for outpatient costs. Limits range from 500-3,000 KES they could be more as well.

Critical Illness Cover in Kenya
Critical Illness Cover works in Kenya as a financial safety net, paying a lump sum upon diagnosis of a covered severe illness. It complements medical insurance by covering non-medical expenses or loss of income during recovery.
✅ Lump Sum Payment: Paid directly to the insured upon diagnosis of conditions like cancer, stroke, heart attack, kidney failure, or organ transplants.
✅ No Hospital Bills Required: The payout is not tied to hospital receipts; it’s meant for income replacement, specialized treatment, or lifestyle adjustments.
✅ Waiting Period: Policies typically have a waiting period (e.g., 90 days from policy start) before claims can be made.
✅ Survival Period: Some require the insured to survive 14-30 days post-diagnosis to qualify for payout.

Critical illness insurance in Kenya typically includes coverage for:

• Cancer (Various types, depending on the insurer)
• Heart attack & Stroke
• Open Heart Surgery
• Paraplegia
• Renal/Kidney failure (Requiring dialysis or transplant)
• Accidental Brain damage
• Coma
• Dementia, Parkinsonism
• Major Organ transplants
• Paralysis (Permanent or severe cases)
• Multiple sclerosis
• Severe burns & Accidental disabilities

You need to check with your cover to see exactly what they cover; this cover is usually a cover on its own. Important to note also is some of these covers provide that the cover is on the First diagnosis of a critical illness.

Providers in Kenya offering Critical Illness Cover include:
• Britam Critical Illness Cover
• Jubilee Insurance Critical Illness Benefit
• CIC Life Assurance Critical Illness Rider
• ICEA Lion Critical Illness Rider
Note: Critical Illness Cover is often bundled as a rider on life insurance but can also be standalone. It is not a substitute for medical insurance but helps maintain financial stability if an illness limits your ability to work.

The benefits cover from 2.5 million thereabout to 15 million. The term of Cover ranges from 10-50 years for most depending on the age you get the cover; minimum age is 18 years – maximum is 65 years.

When selecting the cover, it shall give you options of the products they have i.e. Whole life with a death rider or disability rider, Accidental death/disability with the same death rider or disability rider this means they pay when you die, when disabled, Severe illness, etc.

The premiums are paid monthly or annually for the number of years required before the illness hits and you need the lumpsum amount i.e. for a 15 million lumpsum cover one could pay between 5000-6000 monthly depending on one’s cover.

Who Needs a cover like this?

• Individuals with a family history of chronic illnesses
• Self-employed professionals or business owners who may not have employer-sponsored medical coverage
• Anyone looking for financial security in case of severe illness

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Stay tuned for Part 4: Choosing the Right Health Insurance Plan