What Do Health Insurance Companies Look for Before Giving You Medical Cover in Kenya?

A little story from Nakuru

16-year-old Brian lives with his parents in Nakuru. One Saturday morning, Brian fell while playing football at Afraha Stadium. His arm hurt badly.

His parents rushed him to Nakuru Level 5 Hospital.

The doctor asked one simple question.

"Do you have health insurance?"

Brian's father smiled.

"Yes."

The hospital checked their insurance card before treatment.

Brian later asked his dad something interesting.

"How did the insurance company decide to give us this card?"

That is a very smart question.

Let's find out.

 

The problem

Imagine you suddenly need surgery that costs KES 250,000.

Or your child needs treatment worth KES 80,000 after an accident.

Most families cannot pay such amounts from their savings.

That's why many people buy health insurance.

But insurance companies also need to know who they are covering. They ask several questions before saying "yes."

They do this so they can calculate the risk fairly for everyone.

 

What is health insurance?

Health insurance is an agreement.

You pay a premium every month or every year.

The insurance company promises to help pay hospital bills when you become sick or get injured.

Think of it like many families putting money into one big basket.

When one family needs hospital treatment, money comes from that basket.

 

Why do insurance companies ask questions first?

Imagine your friend wants to lend you his car.

Before he does, he may ask:

• Can you drive? 

• Will you take care of it? 

• Where are you going? 

He asks because he wants to know the risk.

Health insurance companies do the same thing.

They want to understand your health before they promise to pay your future hospital bills.

 

What do insurance companies look for before giving medical cover?

1. How old are you?

Age is one of the first things insurers check.

Young children usually visit hospitals for common illnesses.

Young adults often stay healthier.

Older people may need treatment more often.

Age helps insurance companies estimate future medical costs.

That does not mean older people cannot get insurance.

It simply helps calculate the premium.

 

2. Are you already sick?

Insurance companies ask whether you already have a medical condition.

Doctors call these pre-existing conditions.

Examples include:

• Diabetes 

• High blood pressure 

• Asthma 

• Heart disease 

• Cancer 

Some companies cover these illnesses immediately.

Others ask you to wait several months before they pay for treatment related to that condition.

They explain these waiting periods before you buy the cover.

 

3. Have you stayed in hospital before?

The insurer may ask questions like:

• Have you had surgery? 

• Have you been admitted recently? 

• Have you received long-term treatment? 

These answers help the company understand your medical history.

 

4. What do you do for work?

Some jobs carry higher risks.

For example:

• Construction worker 

• Miner 

• Security guard 

• Long-distance truck driver 

Office workers usually face fewer physical dangers.

Higher-risk jobs sometimes lead to different premiums.

 

5. Do you smoke or drink alcohol?

Smoking increases the chance of serious illnesses.

Heavy alcohol use can also affect health.

Some insurers ask these questions because they influence future medical costs.

Always answer honestly.

 

6. How many people do you want to insure?

Some people buy insurance for themselves.

Others buy family cover.

The company asks:

• Are you covering your spouse? 

• Are your children included? 

• How old are the children? 

This helps calculate the total premium.

 

7. Which hospitals do you want to use?

Insurance companies work with selected hospitals.

Some plans cover treatment at:

• Small private clinics 

• County hospitals 

• Large private hospitals 

Plans that include premium hospitals usually cost more.

 

8. How much cover do you need?

Different people need different limits.

One person may choose:

• KES 500,000 

Another family may choose:

• KES 2 million 

Higher limits usually mean higher premiums.

 

9. Can you pay the premium?

Insurance works best when premiums are paid on time.

Companies ask whether you want to pay:

• Monthly 

• Quarterly 

• Every six months 

• Once a year 

They want to know whether the payment plan suits your budget.

 

10. Is the information you gave true?

Insurance companies trust customers.

They also verify information.

If someone hides a serious illness, the company may reject a future claim.

Honesty helps both sides.

 

What happens during a medical check-up?

Some health insurance plans ask applicants to take a medical examination.

This often happens when:

• You want a very large cover. 

• You are older. 

• You disclosed a medical condition. 

Doctors may check:

• Height 

• Weight 

• Blood pressure 

• Blood sugar 

• Urine sample 

• Blood sample 

The results help the insurer understand your health.

 

Kenyan examples of hospital costs

Medical treatment Average cost (KES)

Outpatient consultation                           2,000–5,000

One night hospital admission.                8,000–20,000

Normal delivery (private hospital)          60,000–120,000

Caesarean section.                                    120,000–250,000

Appendix surgery.                                       180,000–350,000

Cancer treatment (selected cases)           500,000–2,000,000+

These figures are illustrative and vary by hospital, doctor, and treatment.

 

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Can someone be denied health insurance?

Sometimes.

A company may decide:

• to offer cover immediately, 

• to delay cover for certain illnesses, 

• to charge a higher premium, or 

• not to offer a particular plan if the risk is very high. 

Every insurer has its own underwriting rules.

That is why comparing different providers helps.

 

Why should you always tell the truth?

Let's be honest.

Some people think hiding an illness will make insurance cheaper.

That can cause serious problems later.

If an insurer discovers false information during a claim investigation, it may refuse to pay a claim that should have been covered if the information had been disclosed properly.

Honesty protects you.

 

What can make buying health insurance easier?

Here are a few simple tips:

• Carry your national ID or birth certificate for children. 

• Keep past medical records ready. 

• Tell the truth on every question. 

• Ask about waiting periods. 

• Ask which hospitals belong to the provider's network. 

• Compare several insurance plans before deciding. 

 

Why does health insurance matter?

Nobody plans to become sick.

Nobody plans to break a leg.

But illness can happen to anyone.

Health insurance protects your savings.

It also helps families get treatment quickly without worrying about finding large amounts of money at the last minute.

 

Frequently Asked Questions

1. Do all health insurance companies ask for medical history?

Most do. Some ask only a few questions, while others request detailed medical information depending on the type of cover.

2. What is a pre-existing condition?

It is an illness or medical condition you had before buying the insurance policy, such as diabetes, asthma, or high blood pressure.

3. Can children get health insurance in Kenya?

Yes. Children usually join a family health insurance plan or a dedicated children's cover offered by some insurers.

4. Will I always need a medical examination?

No. Many individual and family plans do not require one. Larger covers or older applicants may need medical tests.

5. Can I buy health insurance if I already have diabetes?

Yes, many insurers provide cover for people with diabetes, although they may apply waiting periods, exclusions for specific treatments during an initial period, or adjusted premiums depending on the policy.

 

Final thoughts

Buying health insurance is a little like joining a football team.

The coach wants to know who is joining before the match starts.

Insurance companies ask questions for the same reason.

They want to understand the risks before promising to pay future medical bills.

When you answer honestly and choose the right cover, you give yourself and your family a better chance of getting quality healthcare without facing overwhelming hospital costs.

Your next step is simple: compare different health insurance plans, read the policy carefully, and choose one that matches your family's healthcare needs and budget.