How does medical insurance work?

Medical insurance helps you pay for eligible healthcare expenses, depending on the benefits, limits, and conditions of your policy. You pay premiums to an insurer, and in return, the insurer provides financial protection for the medical services specified in your plan. In Kenya, medical insurance may cover services such as hospital admissions, doctor consultations, diagnostic tests, prescribed medication, surgery, and maternity care, depending on the plan you choose.

How does it work in practice?

1. Choose a Medical Insurance Plan

   Select a plan that suits your healthcare needs, budget, and the people you want to insure. Consider whether you need inpatient cover, outpatient cover, maternity benefits, or other medical benefits.

2. Pay Your Premiums

   Pay the required premiums according to the agreed payment terms to maintain your cover. Check your policy for the consequences of missed or late payments.

3. Visit a Healthcare Provider

   When you need treatment, visit a healthcare facility covered by your plan. Depending on the insurer's procedures and the treatment required, you may need to obtain pre-authorisation before receiving certain services.

4. Receive Medical Treatment

   Your policy may cover eligible treatment within the applicable benefit limits. Depending on your plan and the healthcare provider, the insurer may settle the bill directly with the facility, or you may need to pay first and request reimbursement.

5. Understand What You Must Pay

   You may need to pay some expenses yourself if they exceed your benefit limits, fall under an exclusion, or are subject to a co-payment, deductible, or other policy condition.

What Does Medical Insurance Usually Cover?

Depending on your plan, benefits may include:

• Inpatient care: Hospital admission, surgery, and eligible treatment received while admitted.
• Outpatient care: Doctor consultations, prescribed medication, and diagnostic tests without hospital admission.
• Maternity care: Eligible pregnancy-related services and childbirth expenses, subject to applicable waiting periods and limits.
• Dental and optical care: Specified dental treatment, eye examinations, and optical benefits where included.
• Emergency treatment: Eligible emergency medical services, subject to the policy terms. Not every medical insurance plan includes all these benefits.

What Should I Check Before Using My Cover?

Before receiving treatment, confirm that the healthcare facility is covered by your plan, whether pre-authorisation is required, what limits apply, and whether you will need to make any out-of-pocket payments.

Remember: Medical insurance does not automatically cover every treatment or medical bill. Your policy documents determine the benefits available, exclusions, waiting periods, and applicable limits.

Need help understanding your options?

BimaLight can help you find an insurance agent who can explain available medical insurance plans and help you identify cover suited to your needs.