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Conditions excluded from Health Insurance Policies in Kenya
It is important to note that health insurance policies do not cover all medical conditions unconditionally. Covering these conditions may go against the principles of insurance. Insurance aims at providing cover from risks that affect a relatively small number of people from among those insured. Situations that veer from this norm makes it hard for insurance companies to offer services. Here is a list of some of the conditions that insurance companies do not cover in their policies.
Pre-existing & chronic conditions: Insurance companies are not obliged to cover a policyholder who joins their scheme after the onset of a medical condition. For instance, a policyholder who has an organ defect (say failing kidneys) does not have the right to demand an insurer to cover the costs associated with his treatment of the disease had been detected earlier than the effective date of their policy.
congenital defects: These are defects that affect unborn children, and are usually detected before, during or after birth, and in some cases later in life. In recent years, some medical insurance policies have found ways of covering congenital effects but usually have a cover limit.
War and kindred risks: These are risks associated with war. In wars, the number of casualties are usually much higher than an insurance company can afford to compensate using the ordinary insurance models. In order to keep the liability levels manageable, health problems associated with war and kindred risks are not insurable
cosmetic surgery unless caused by an accident: insurance companies do not pay for elective cosmetic surgery and procedures. Elective cosmetic surgery does not qualify for a risk, and is a deliberate choice by an individual. On the other hand, a health policy will cover a cosmetic procedure if it is required to restore normalcy to the looks of a policy holder.
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This may be the result of burns, wasting infections, or any other ailment causing physical deformity.
Treatment other than a registered doctor of medicine: This policy exclusion means that a medical insurance policy will not pay for treatment accessed from a traditional doctor, medicine man, acupuncture practitioner, or even a trained conventional doctor who is not licensed to practice.
The challenge here is that insurance relies on formal health systems to calculate costs, while informal health systems do not have enough in common to allow for proper calculation of premiums. At the same time, some of their treatments are not scientifically tested, hence there is no way of assessing their efficacy.
Intentional self-injury: This exclusion stems from the understanding that insurance is meant to cover risks, and not premeditated events
Drunkenness: Injuries or problems associated with drunkenness can be considered to be self-inflicted, and the policyholder should have been well aware of the consequences. These conditions are therefore not insurable
HIV/AIDS related illnesses: In the former years, HIV/AIDS was not curable (and still isn’t), and was more difficult to manage. Things have changed much over the last two decades, and insurance companies are less worried about covering HIV/AIDS. This in addition to laws outlawing the discrimination of HIV patients has virtually eradicated this exclusion
Dental and Optical Conditions: Some covers still do not cover dental and optical conditions unless specifically included in premium calculations. Even in cases where these two conditions are covered, some exclusion still apply, such as limit in eye glasses, and dental procedures a policy holder may access.