Step-by-Step Guide to Making a Medical Insurance Claim in Kenya

Medical emergencies don’t announce themselves.

One minute you’re fine — the next, you’re rushing to hospital, worried about your health and how you’ll pay the bills.

That’s exactly why medical insurance exists.

But here’s the reality: many Kenyans only learn how their medical cover works after they fall sick. By then, confusion around claims, hospital networks, documents, and benefit limits can turn an already stressful moment into a nightmare.

If you’ve ever asked:

• How do I make a medical insurance claim in Kenya?
• What documents do I need?
• Why do some claims get rejected?
• What happens during emergencies?

You’re in the right place.

This complete guide walks you through everything you need to know about making a medical insurance claim in Kenya — step by step — in simple, practical language.

Why Understanding the Medical Claims Process Matters

In Kenya, medical insurance is regulated by the Insurance Regulatory Authority, which sets standards for insurers, benefits, and claims handling.

But even with regulation in place, many policyholders still struggle because:

• They don’t understand their benefits
• They visit non-panel hospitals unknowingly
• They miss critical documents
• They don’t know their waiting periods
• They assume “insurance covers everything”
• They fail to disclose pre-existing medical conditions during application

The result?

Delayed claims, rejected reimbursements, unexpected hospital bills, and frustration when you need help the most.

Knowing how medical claims work before you fall sick can save you time, money, and unnecessary stress.

Types of Medical Insurance Claims in Kenya

There are two main ways medical insurance claims are handled in Kenya.

1. Cashless (Direct Billing) Claims

This is the most convenient option.

How it works:

• You visit a hospital within your insurer’s approved network (panel hospital)
• Present your insurance card or policy number
• The hospital contacts your insurer for approval
• Once approved, the insurer pays the hospital directly
• You only settle exclusions, co-payments, or amounts above your limit

Best for: Routine outpatient visits, admissions, maternity care, surgeries, and planned procedures.

2. Reimbursement Claims

This applies when:

• You visit a non-panel hospital
• You receive emergency treatment
• The hospital does not support cashless billing

How it works:

• You pay the hospital yourself
• Collect all required documents
• Submit a claim to your insurer
• Wait for reimbursement

This process requires careful documentation and patience.

What You Need Before Making a Medical Insurance Claim

Think of this as your claims checklist:

• Active medical insurance policy
• National ID or passport
• Membership card or policy number
• Doctor’s notes or discharge summary
• Original invoices and official receipts
• Prescriptions and laboratory reports
• Completed claim form

Missing even one document can delay or block your claim.

Step-by-Step Guide to Making a Medical Insurance Claim in Kenya

Let’s walk through both claim types in detail.

OPTION A: Cashless / Direct Billing Claims

Step 1: Visit a Panel Hospital

Before treatment:

• Present your insurance card or policy number
• The hospital verifies your cover with the insurer
• Benefits, limits, and waiting periods are checked

If your policy is active and benefits are available, treatment proceeds.

Step 2: Medical Assessment and Treatment

The doctor examines you and prescribes treatment.

For major services such as:

• Hospital admission
• Surgery
• Specialized scans or procedures

The hospital submits a pre-authorization request to the insurer.

Treatment begins only after approval is granted, unless it’s a medical emergency.

Step 3: Hospital Submits Claim

After treatment:

• Hospital sends invoices directly to the insurer
• You sign discharge documents
• You pay for excluded services (if any)
• You top up any excess amount where the total bill exceeds your policy’s benefit limit

You leave without chasing paperwork — except for required top-ups or documentation follow-ups.

OPTION B: Reimbursement Claims

This option requires more effort from the policyholder.

Step 1: Pay for Treatment

You settle the hospital bill in full.

Request:

• A detailed invoice
• An official receipt
• Medical report or doctor’s notes

Without these, reimbursement will likely be rejected.

Step 2: Fill in the Claim Form

Provided by your insurer or insurance advisor.

You’ll fill in:

• Personal details
• Policy number
• Diagnosis
• Treatment date
• Hospital name

Ensure all information matches your policy records exactly.

Step 3: Submit Documents

Attach:

• Completed claim form
• Original receipts
• Medical notes and reports
• Prescriptions

Submit via email, insurer portal, or physical submission.

Step 4: Wait for Processing

The insurer reviews:

• Policy status
• Available benefits
• Waiting periods
• Diagnosis and disclosure history

If approved, reimbursement is processed within 14 working days and paid via bank transfer or mobile money.

Delays mostly occur when documents are missing, unclear, or submitted late.

Common Reasons Medical Claims Get Delayed or Rejected

This is where most policyholders get stuck:

• Missing or incomplete documents
• Visiting non-panel hospitals without approval
• Policy still within waiting period
• Exceeded benefit limits
• Pre-existing conditions not disclosed at application
• Incorrect member details
• Submitting photocopies instead of original receipts
• Non-compliant invoices from providers

Understanding your policy prevents most of these issues.

How Long Do Medical Insurance Claims Take in Kenya?

There’s no universal timeline, but generally:

Cashless claims: Handled instantly at the hospital once approved.

Reimbursement claims: Processed within 14 working days after complete documents are submitted.

Incomplete paperwork is the main cause of delays.

Waiting Periods Explained (Very Important)

Most medical policies include waiting periods:

• General illnesses: usually 30 days
• Maternity: 10–12 months (often optional)
• Chronic conditions: varies by insurer
• Pre-existing conditions: often excluded initially or covered after long waiting periods

Tips to Make Your Medical Claim Process Smoother

Protect yourself by following these tips:

• Always confirm hospital panel status
• Understand your benefit limits and exclusions
• Keep copies of all documents
• Ask about pre-authorizations
• Declare pre-existing conditions honestly
• Submit reimbursement claims on time
• Work with a knowledgeable insurance advisor
• Save your insurer’s emergency contact details

Insurance works best when you’re informed.

How Step by Step Insurance Supports You During Medical Claims

At Step by Step Insurance, we don’t just sell policies — we support you throughout your healthcare journey.

Before You Get Sick

• Explain benefits clearly
• Help you choose panel hospitals
• Break down waiting periods and exclusions
• Match you with cover that fits your budget and needs

During Treatment

• Assist with hospital authorizations
• Guide you on required documents
• Communicate with insurers on your behalf
• Help resolve approval delays

After Treatment

• Help prepare reimbursement claims
• Follow up on pending payments
• Support dispute resolution
• Ensure you receive what your policy promises

We act as your claims partner, not just your agent.

Frequently Asked Questions (FAQ)

Final Thoughts

Medical insurance in Kenya is powerful — when you know how to use it.

The claims process doesn’t have to be confusing or intimidating. With the right knowledge, proper documentation, and reliable support, you can focus on healing instead of chasing hospitals or insurers.

Whether you’re new to medical insurance or already covered, take time to understand your policy.

And remember — you don’t have to navigate this alone.

Ready for Stress-Free Medical Insurance Support?

If you need help choosing a medical cover, understanding your benefits, or making a claim, reach out to Step by Step Insurance today.

We’ll guide you — step by step — from policy selection to claim settlement.

Your health matters.
Your peace of mind matters.
And we’re here to protect both.