How many of you guys here have medical insurance covers? Have you guys read the fine print of your cover?

For example, how many of us know that the insurance companies put sub-limits in your cover?

For example you’ve paid for a 5 million inpatient cover then get a stroke and are admitted. They can get out of paying your entire bill by claiming the strike was caused by your high blood pressure and your policy has a sub-limit of only 200K for chronic conditions.

If you get a cover for your newborn and they get admitted with, say, an umbilical hernia, they’ll get out of paying for the surgery bill by saying an umbilical hernia is a congenital condition and the sub-limit for congenital conditions is only 100k. Saa hiyo cover ni ya 10M.

Did you know if you get injured while in a bar, some insurance companies won’t pay your hospital bill? Eg. you’re in the bar watching your favorite EPL team playing, drinking soda/water then a fight (which you weren’t involved in) broke out & you got injured by a flying stool.

Also, did you know the insurance companies won’t pay for anything that can be paid for by NHIF? You get a stroke and need an urgent MRI scan, they refuse to give an LOU for the MRI saying ask NHIF to pay for it. Saa hiyo uko ICU & NHIF take no less than 48-72hr to give approvals.

Also, if you don’t have NHIF, they’ll say you pay for anything NHIF could have paid for out of pocket. This includes any scans, bed rebates, part of the amount NHIF pays for surgical packages, dialysis among other things. To them, kama hauna NHIF, shauri yako, you shoulda had it.

But one of the things I hate most is when someone takes a cover with one insurance company which then takes a cover for you with a different insurance company. So, say you paid AON for your cover then they pay Jubilee to cover you. The games they play when your bill comes...

Your bill comes, Jubilee say they won’t cover it. You insist they pay the bill, they send you to AON. You go to AON, they say they’re not the ones covering you, can you please go back to Jubilee. Back and forth, back and forth they’ll take you hadi you can go mad.

Sometimes having a broker can help with these situations coz you (or your employer) put pressure on the broker who then puts pressure on the company and they have no option but to pay if they want to keep the broker’s business and the broker wants to keep your business.

Anyway, read the small print on your medical policy. Pay extra attention to the exclusions, the sub-limits & the waiting period as well if there’s any. Check if they cover chronic conditions and to what limit. And please find out if you’ve been pawned off to another company.

I spent the afternoon arguing with an insurance company about a patient that had a whole 5M inpatient limit but they only paid 300k of his almost 1M hospital bill because chronic illness sub-limit. Which the patient wasn’t aware of by the way.