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What specific services can one expect when they buy medical insurance? This question is usually important to those who are just joining a health insurance scheme. It is therefore critical to analyze the range of services available in the commercial health insurance plans available in the Kenyan market. Our experts spent some time analyzing medical insurance policies and this guide is the result of their work. The guide looks at health insurance covers based on their classification, limits, and product features.

Difference between Inpatient and Outpatient Cover

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Medical insurance products usually fall into two main classifications. These are the outpatient covers and inpatient covers. Insurance companies use the term “outpatient cover” to refer to services offered to patients who do not need hospitalization for their period of treatment. Usually outpatient services are offered in satellite clinics or in the outpatient wings of large hospitals. Inpatient covers take care of hospitalization costs such as bed, room, and other lodging expenses, in addition to medical expenses. This cover kicks in when policyholders require admission into hospitals to access supervised treatment for a given period.

Key Cover Limits

All medical insurance products usually have cover limits. This is the maximum amount of money the insurance company commits to spend on each benefit in the policy. When taking a policy, the two important policy limits one needs to check are the inpatient and outpatient limits. The inpatient limit is the maximum amount that the insurance company will spend on claims arising from visits to inpatient facilities. Similarly, the outpatient limits states the maximum expenditure on outpatient services. Other features of the insurance policy may have independent or related limits. For instance, many health insurance providers will have a dental policy with a specific maximum limit. This limit may be part of your outpatient cover, or may be separate.

Related: Limits, Exclusions, Copayment and Waiting Period

Product Features

Annual Cover: In medical insurance, an annual cover refers to the total amount of money the insurance company will pay in your stead in the event that you need medical attention. The annual cover includes your inpatient and outpatient cover limits, and may include other components of your policy, such as a dental and an optical cover, and the cost of health checks. The annual cover is usually the first figure an insurance agent will show you when you are shopping for insurance. It is important to know that a higher limit is not the only factor to consider when deciding on the appropriateness of a cover.

Illness Cover: An illness cover deals specifically with sickness resulting from disease causing pathogens. An illness cover insures one against liabilities resulting from bacterial, viral, and other pathogenic causes of disease. It also covers other conditions medically classified as illnesses such as nervous issues, gastrointestinal discomforts, and respiratory concerns. Illness covers usually pay the cost of consulting with medical doctors, the cost of drugs and the cost of laboratory tests and other medical procedures including surgery, imaging, and some classes of physiotherapy. It is important to note that illness covers usually exclude cosmetic procedures, cost of supplements and massage (unless prescribed as part of physiotherapy), among others. The list of exclusions to medical insurance policies is much longer than this, so it is highly advisable to find out which exclusions exist on your cover.

Rehabilitation cover: Some health insurance covers provide cover for rehabilitation costs especially in the event of traumatic injuries. In this case, a rehabilitation cover will pay for the costs of institutionalization, or access to rehabilitation services for the period of illness. Keep in mind that rehabilitation covers also have a limit, and once this limit is exhausted, the patient will need to raise additional financing.

Last Expense

Some medical Insurance companies include a product feature dubbed “last expense” in their insurance policies. Unfortunately, not everyone leaves a hospital alive despite the best care. In the event a policyholder dies, the insurance company usually gives the family of the deceased a benefit termed, “last expense” to ease funeral-planning arrangements. This benefit can be very useful to a family that loses a loved one, especially in the wake of huge medical bills and other incidentals that may have arisen from long periods of treatment. Each insurance company has its own requirements on how this fund is administered, so it is a good idea to find out upfront.

Chronic Conditions

A number of medical insurance companies offer covers that take care of costs associated with the treatment of chronic conditions. Traditionally, chronic conditions were usually left out of health insurance policies because they were an assured expense on the part of the insurance companies. Insurance policies work on the basis that the event insured against is unlikely to occur, and only a few people insured will actually need the cover provided by the policy. However, due to competition, legislation and ethical considerations, many insurance companies currently allow policyholders to get insurance to cover chronic conditions including HIV.

Related: 5 Ways to Get Affordable Health Insurance Quotes

Congenital Conditions

Congenital conditions and illnesses were also previously excluded from insurance arrangements because their presence indicates an expected expense rather than an unlikely one. Congenital conditions in medical terms refer to illnesses or defects present from birth, or have been in existence for a long duration. In this regard, policies that give holders this benefit are expensive, or have lower coverage limits. The rationale is to provide some cushion against medical expenses, rather than to leave potential policyholders who need medical insurance without any resort. Insurance cover against congenital illnesses can also help to take care of the medical expenses of a new child born to a mother whose cover includes this benefit.

Maternity Cover

Nearly all insurance companies now offer a cover against maternity costs for their policyholders. Pregnancy is not a health condition as such, and delivery is assured. These two elements explain why traditional policies did not include the cost of maternal care. In today’s medical insurance market, it is possible to buy a health cover that includes maternal care. For some health insurance carriers, this entails higher premiums and in others, there are tight controls on the limits of the cover. Some covers also take into account the cost of managing congenital illnesses a new baby may come with.

Conclusion

The insurance sector is very dynamic. In this regard, these product features will certainly change in the years to come. Some of the changes are market driven, others are instigated by governments and regulators, while others are initiated internally by the companies, either as a response to business realities, or because of moral suasion and ethical considerations.

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