Understanding Private Medical Insurance
Private medical insurance (also called private health insurance or medical cover) is additional health coverage you buy from insurance companies. It works alongside your SHA/SHIF to give you more options and better service.
Think of it this way:
- SHA/SHIF = Your basic coverage (mandatory, government-run)
- Private insurance = Extra coverage (optional, your choice)
SHA/SHIF vs Private Insurance
What SHA/SHIF Covers
- Public hospital visits
- Some private hospitals (contracted)
- Basic medicines
- Essential treatments
- Emergency care
- Maternity services (normal delivery)
- Most surgeries
Limitations:
- Long waiting times
- Crowded facilities
- Limited choice of doctors
- May not cover all private hospitals
- Basic medication options
What Private Insurance Adds
- Access to top private hospitals
- Shorter waiting times
- Private rooms
- Choice of specialist doctors
- International hospitals (some plans)
- Advanced treatments
- More medicine options
- Dental and optical (some plans)
- Outpatient cover (some plans)
- Faster service
Who Needs Private Insurance?
Consider It If You:
-
Want faster service
- Don’t want to wait weeks for appointments
- Need quick access to specialists
-
Prefer private hospitals
- Nairobi Hospital, Aga Khan, MP Shah, etc.
- Better facilities and comfort
-
Have chronic conditions
- Need regular specialist visits
- Require expensive medications
-
Travel frequently
- Need coverage outside Kenya
- International medical evacuation
-
Have young children
- Children get sick often
- Want immediate pediatric care
-
Can afford it
- Premiums range from KES 5,000 to KES 50,000+ per person per year
- See it as investment in health
You May Not Need It If:
-
Budget is tight
- SHA/SHIF is sufficient for basic needs
- Focus on emergency fund first
-
Rarely sick
- Young and healthy
- No chronic conditions
-
Comfortable with public facilities
- County hospitals serve you well
- Don’t mind waiting
-
Have employer cover
- Company provides good medical insurance
- Covers family too
Types of Private Medical Cover
1. Inpatient Only
What it covers:
- Hospital admission (staying overnight or longer)
- Surgeries
- ICU care
- Specialized treatments requiring admission
Cost: KES 5,000 - 20,000 per person/year
Best for: People who can pay for clinics/outpatient but want protection from big hospital bills
2. Outpatient Only
What it covers:
- Doctor visits
- Lab tests
- X-rays and scans
- Prescription medicines
- Physiotherapy
- Minor procedures
Cost: KES 10,000 - 30,000 per person/year
Best for: Families with children who visit doctors often but rarely get admitted
3. Comprehensive (Inpatient + Outpatient)
What it covers:
- Everything inpatient covers
- Plus everything outpatient covers
- Usually dental and optical too
- Maternity (some plans)
Cost: KES 25,000 - 100,000+ per person/year
Best for: People who want complete coverage and can afford it
4. Last Expense / Funeral Cover
What it covers:
- Funeral expenses when you die
- Transportation of body
- Burial or cremation costs
Cost: KES 2,000 - 10,000 per person/year
Best for: Everyone—relieves family of funeral burden
5. Critical Illness Cover
What it covers:
- Lump sum payment if diagnosed with serious illness
- Cancer, stroke, heart attack, kidney failure, etc.
- Use money however you want (treatment, bills, time off work)
Cost: KES 5,000 - 30,000 per year (depending on sum insured)
Best for: Breadwinners, people with family history of serious disease
Key Features to Compare
1. Annual Limit
What it means: Maximum the insurer pays in one year
Examples:
- Basic plans: KES 500,000
- Mid-range: KES 1,000,000 - 3,000,000
- Premium: KES 5,000,000+
Tip: Higher limits cost more but protect you from catastrophic bills
2. Hospital Network
What to check:
- Which hospitals accept the insurance?
- Are your preferred hospitals included?
- Nairobi Hospital? Aga Khan? Karen Hospital?
Tip: Big networks give you more choices
3. Waiting Periods
Common waiting periods:
- Pre-existing conditions: 12 months
- Maternity: 10-12 months
- Dental/optical: 3-6 months
- Normal treatment: 30 days
Tip: Get insurance before you need it, not when you’re already sick
4. Exclusions
Commonly NOT covered:
- Pre-existing conditions (for first year)
- Cosmetic surgery
- Fertility treatments (IVF)
- Drug/alcohol abuse treatment
- Self-inflicted injuries
- Injuries from dangerous sports
- War/terrorism injuries
Tip: Read your policy document carefully
5. Co-Payment
What it means: You pay a percentage, insurer pays the rest
Example: 10% co-pay
- Bill is KES 100,000
- You pay KES 10,000
- Insurer pays KES 90,000
Tip: Plans without co-pay cost more but you pay nothing at hospital
6. Deductible (Excess)
What it means: Amount you pay before insurance kicks in
Example: KES 10,000 deductible
- Hospital bill is KES 80,000
- You pay first KES 10,000
- Insurer pays remaining KES 70,000
Tip: Higher deductibles = lower premiums (you save if you don’t get sick)
7. Renewability
Guaranteed renewable: Insurer can’t cancel as long as you pay
Non-guaranteed: Insurer can refuse to renew
Tip: Always choose guaranteed renewable
8. Age Limits
Entry age: Maximum age to buy new policy (often 65)
Exit age: When coverage ends (often 80-85)
Tip: Buy young—it’s cheaper and easier
Top Insurers in Kenya
1. Jubilee Health Insurance
Known for:
- Large hospital network
- Good customer service
- Comprehensive plans
Plans: Inpatient, outpatient, comprehensive Starting price: ~KES 15,000/year
2. AAR Insurance
Known for:
- Own clinics and hospitals
- Direct billing (no paying then claiming)
- Fast service
Plans: Inpatient, outpatient, comprehensive Starting price: ~KES 20,000/year
3. CIC Insurance
Known for:
- Affordable plans
- Wide network
- Family packages
Plans: Inpatient, outpatient, comprehensive, critical illness Starting price: ~KES 12,000/year
4. Britam Health Insurance
Known for:
- Flexible plans
- Good for families
- Wellness programs
Plans: Inpatient, outpatient, comprehensive Starting price: ~KES 15,000/year
5. UAP Old Mutual
Known for:
- Affordable basic plans
- Growing network
- Simple claims process
Plans: Inpatient, outpatient, comprehensive Starting price: ~KES 10,000/year
6. NHIF Supa Cover
Known for:
- Top-up to SHA/SHIF
- Affordable for those already in NHIF/SHIF
- Access to more hospitals
Plans: Various top-up options Starting price: ~KES 5,000/year
Note: Prices vary by age, health status, and coverage level. These are approximate starting points.
Choosing the Right Plan
Step 1: Assess Your Needs
Ask yourself:
- How often do I visit doctors?
- Do I have any chronic conditions?
- Which hospitals do I prefer?
- Can I afford to pay for small bills but need protection from big ones?
- Do I have children? Elderly parents to cover?
Step 2: Set Your Budget
Rule of thumb: Don’t spend more than 5-10% of income on medical insurance
Example:
- Income: KES 50,000/month = KES 600,000/year
- Budget for insurance: KES 30,000-60,000/year
- That covers basic comprehensive for one person or inpatient for a family
Step 3: Compare Quotes
Get quotes from at least 3 insurers:
- Visit insurer websites
- Call their offices
- Visit an insurance broker
- Use online comparison tools
Compare:
- Premium (cost)
- Annual limit
- Hospital network
- Waiting periods
- Exclusions
- Co-payment/deductible
Step 4: Check Insurer Reputation
Research:
- Read reviews online
- Ask friends/family
- Check with Insurance Regulatory Authority (IRA) for complaints
- Visit IRA website: ira.go.ke
Red flags:
- Frequent claim rejections
- Long claim settlement times
- Hidden charges
- Unprofessional customer service
Step 5: Read the Fine Print
Before signing:
- Read entire policy document
- Understand all exclusions
- Note all waiting periods
- Check renewal terms
- Clarify anything unclear
Ask questions:
- What exactly is covered?
- Which hospitals can I use?
- How do I make a claim?
- What happens if I miss a payment?
- Can I add dependents later?
Making Claims
Direct Billing (Cashless)
How it works:
- Visit contracted hospital
- Show your insurance card
- Hospital verifies with insurer
- Receive treatment
- Hospital bills insurer directly
- You pay nothing (or just co-pay/deductible)
Best for: Convenience, no upfront money needed
Reimbursement
How it works:
- Visit any hospital (doesn’t have to be contracted)
- Pay the bill yourself
- Collect all receipts and medical reports
- Submit claim to insurer
- Insurer processes (usually 7-14 days)
- Money sent to your bank account
Best for: Flexibility to use any hospital, emergencies
Claim Requirements
Usually need:
- Claim form (from insurer)
- Original receipts
- Doctor’s notes/discharge summary
- Lab results (if any)
- Prescriptions
- Your ID copy
- Insurance card copy
Tips:
- Keep all medical documents
- Submit claims promptly (usually within 30-90 days)
- Follow up if delayed
- Take photos/copies before submitting
Common Mistakes to Avoid
1. Not Disclosing Pre-Existing Conditions
Why it’s bad: Insurer can reject claims or cancel policy
Do instead: Disclose everything honestly; some insurers cover pre-existing conditions after waiting period
2. Buying Too Little Coverage
Why it’s bad: Annual limit runs out, you pay huge balance
Do instead: Choose limit that covers most likely scenarios (minimum KES 1,000,000 recommended)
3. Not Reading Exclusions
Why it’s bad: Surprises when you try to claim
Do instead: Read policy document, understand what’s not covered
4. Letting Policy Lapse
Why it’s bad: Lose coverage, have to reapply (may be denied), restart waiting periods
Do instead: Set reminders, pay on time, use auto-debit if available
5. Not Using Preventive Services
Why it’s bad: Miss chance for early detection of diseases
Do instead: Many plans cover annual checkups—use them!
6. Choosing Based Only on Price
Why it’s bad: Cheapest plan may have poor network, high deductibles, or bad service
Do instead: Balance cost with coverage quality and service reputation
7. Not Reviewing Annually
Why it’s bad: Needs change, better plans emerge, you may be overpaying
Do instead: Review your plan every renewal, compare with other options
Combining SHA/SHIF with Private Insurance
How They Work Together
Option 1: Use SHA/SHIF as primary
- Go to SHA-contracted public hospital
- If not satisfied or need more, use private insurance for private hospital
Option 2: Use private insurance as primary
- Go to private hospital first
- Private insurance covers bill
- SHA/SHIF is backup if annual limit exhausted
Option 3: Top-up plans
- Some insurers offer plans specifically designed to top-up SHA/SHIF
- Cheaper because they only cover what SHA doesn’t
Best practice: Use SHA/SHIF for minor issues, save private insurance for serious cases (makes it last longer)
For Families
Family Plans vs Individual Plans
Family plan:
- One policy covers spouse and children
- Often cheaper than individual policies for each
- Usually covers children up to 18-25 years (if in school)
Individual plans:
- Separate policy for each person
- More expensive but more flexibility
- Can tailor each person’s coverage
Tip: Get quotes for both and compare total cost
Covering Parents
Challenges:
- Older people cost more
- Many pre-existing conditions
- Some insurers won’t accept new members over 65
Options:
- Add parents to your plan while they’re younger
- Look for insurers with higher age limits
- Consider inpatient-only to reduce cost
- Pool money with siblings to cover parents
Children
Good news: Children are cheapest to insure (usually KES 5,000-15,000/year)
Tips:
- Add children from birth (no pre-existing conditions)
- Choose plans with good pediatric networks
- Outpatient cover valuable for children (they get sick often but rarely need admission)
Tax Benefits
Good news: Medical insurance premiums are tax-deductible up to KES 15,000 per year
How it works:
- Pay insurance premiums
- Keep receipts
- Claim as deduction when filing tax returns
- Reduces your taxable income
Example:
- You earn KES 600,000/year
- Pay KES 15,000 in medical insurance
- Taxable income reduces to KES 585,000
- Save about KES 4,500 in tax (30% bracket)
Note: Applies to individual taxpayers, not companies paying for employees
Take Action
If You’re Considering Private Insurance:
- List your health needs and preferences
- Set a realistic budget
- Get quotes from at least 3 insurers (Jubilee, AAR, CIC, Britam, UAP)
- Compare carefully using the features listed above
- Ask questions before committing
- Start with inpatient-only if budget is tight (protects from biggest bills)
- Read policy document thoroughly
- Buy sooner rather than later (waiting periods start from purchase date)
If You Already Have Private Insurance:
- Review your plan this month
- Check if it still meets your needs
- Compare with current market offerings
- Use your annual checkup if included
- Ensure you’re paying on time
- Keep all your medical documents organized for easy claiming
Private medical insurance isn’t for everyone, but for many Kenyans, it provides peace of mind and better healthcare access. Combined with SHA/SHIF, it ensures you and your family can get good care when you need it most. Evaluate your situation, compare your options, and make the choice that works for your health and budget.