You wake up one morning feeling unwell, head to the hospital, and after a few tests, you’re handed a medical bill that leaves you speechless. You confidently hand over your health insurance card, expecting everything to be covered only for the hospital to tell you, Sorry, your policy doesn’t cover this.

Many Kenyans assume that having health insurance means all medical expenses are automatically taken care of. The reality? Every policy has limits, exclusions, and fine print that many people only discover when it’s too late.

So, what does health insurance in Kenya cover, and what might leave you footing the bill? This article breaks it all down so you can make informed decisions, avoid nasty surprises, and get the best out of your medical cover.

How Health Insurance Works in Kenya

Health insurance in Kenya is like a safety net, it helps you manage medical costs, but not everything is covered equally.

There are two main types of health insurance:

Public Health Insurance (SHA – Social Health Authority, formerly NHIF)

• •This is the government-backed insurance scheme, covering millions of Kenyans. It is compulsory for salaried employees and open to self-employed individuals.
• •SHA covers inpatient services fully in public hospitals and some accredited private hospitals.
• •It has limited outpatient and specialist care coverage compared to private insurance.

Private Health Insurance

• •Offered by companies like Britam, Jubilee, AAR, APA, CIC, and more.
• •Covers a wider range of medical services in private hospitals, including specialist consultations, outpatient care, dental, and international medical treatment depending on the plan

Most insurance plans function under a co-pay or reimbursement model:

• •Co-Pay Model – You pay a small fee at the hospital while your insurer covers the larger portion.
• •Reimbursement Model – You pay upfront and later claim the amount from your insurance provider.

Knowing which model applies to your policy can prevent financial surprises.

If you rely solely on SHA/NHIF, you may have limited choices for hospitals and treatments. A private insurance policy provides more options and better coverage but costs more.

What Health Insurance in Kenya Covers

Inpatient Treatment

Most health insurance plans cover hospitalization, which includes:

• •Surgery costs
• •Doctor consultation fees
• •Nursing care
• •Bed charges
• •Intensive Care Unit (ICU) and High Dependency Unit (HDU) stays

SHA/NHIF covers inpatient care in public hospitals and accredited private facilities, while private insurers extend this to specialist hospitals.

Outpatient Services

Outpatient care (treatment that doesn’t require hospital admission) is covered under comprehensive plans and includes:

• •General practitioner visits
• •Lab tests & diagnostics (e.g., blood tests, CT scans, MRIs)
• •Specialist consultations (e.g., dermatologists, cardiologists)
• •Prescription drugs
• •Physiotherapy

SHA/NHIF outpatient cover is limited to basic consultation and minor procedures in accredited hospitals, while private insurance provides broader specialist coverage.

Maternity & Childbirth

• •Most health insurance plans offer maternity cover, which includes:
• •Prenatal check-ups
• •Normal & C-section deliveries
• •Postnatal care

SHA covers maternity fully in government hospitals, while private insurers provide maternity cover in both private and public facilities. Many private insurers impose a waiting period (9-12 months) before maternity benefits apply

Chronic Disease & Pre-Existing Conditions (Limited Cover)

• •Hypertension, diabetes, asthma, heart disease
• •Cancer treatment (chemo & radiotherapy)
• •Dialysis & kidney-related treatments
• •SHA provides limited coverage for chronic diseases in public hospitals, while private insurers often require additional coverage for these conditions.

Emergency & Ambulance Services

• •Emergency medical evacuation
• •Road ambulance services
• •Air evacuation (for premium covers)

Not all plans cover ambulance fees, so check if this is included in your policy.

Specialized Care (On Select Plans)

Some higher-tier health plans cover:

• •Mental health & psychiatric care
• •Fertility treatments (on select insurers)
• •Alternative medicine (acupuncture, homeopathy)

Check policy terms carefully, as these are not included in basic plans

What Health Insurance in Kenya DOES NOT Cover

Cosmetic & Elective Procedures

If it’s not medically necessary, you’re paying out of pocket.

• •Plastic surgery (unless it’s reconstructive after an accident)
• •Botox, liposuction, facelifts
• •Hair transplants

Dental & Optical Care

Standard plans don’t include:

• •Braces & dental implants
• •LASIK eye surgery
• •High-end designer glasses

Some higher-tier private plans offer dental & optical benefits, but SHA/NHIF does not cover them.

Alternative & Experimental Treatments

• •Stem cell therapy
• •Herbal treatments
• •Unapproved cancer treatments

Insurance only covers approved medical procedures

Self-Inflicted Injuries & Drug Abuse Treatment

If your injury is self-harm or from excessive alcohol/drug use, most insurance providers won’t cover your treatment.

Conclusion

Health insurance isn’t a one-size-fits-all solution, understanding what’s covered and what isn’t will help you avoid financial shocks when seeking treatment.