It is 2019 and Kenyans still have issues accessing Health Insurance because of poverty, miss-education and fraud. Only 20% Kenyans have medical cover. It is almost impossible to pick out the best medical insurance companies in Kenya because of the statistics of health insurance fraud. Just this week, AAR Medical Insurance in Kenya had a public ‘digital fight’ with their 9-year-long client: Boniface Mwangi. This was in form of two hashtags, #AARInsuranceFacts and #HealthInsuranceFraudsters.

Who Pays for Healthcare in Kenya?

Grim figures paint a hollow picture of Kenya's healthcare - Health Insurance Fraud
Grim figures paint a hollow picture of Kenya’s healthcare – Health Insurance Fraud

A dramatic rise in health insurance fraud cases is a main source of concern for health insurance providers in Kenya.

KPMG, a global London-based audit firm, three years ago said insurance premiums in Kenya could be 20 per cent lower if fraud was curbed.

Achieving Universal Health Coverage (UHC) in both developed and developing countries can be an arduous and complex task.

Issues regarding inadequate financial and human resources for healthcare facilities, as well as a lack of accountability within the governance of health systems, are continuing to threaten the ability of nations to achieve coverage for all their citizens.

Police should not use live bullets - boniface mwangi
Police should not use live bullets – boniface mwangi

Most Searched for Health Insurance Companies in Kenya:

  • AAR Medical Insurance
  • Jubilee Medical Insurance Kenya
  • Resolution Health Insurance
  • Britam Health Insurance
  • UAP Health Insurance

Only 20% Kenyans have medical cover. This means only nine million out of about 45 million Kenyans are covered.

These searches are mostly related to people who are looking for stories of Health Insurance Fraudsters so as to see which company they can settle on.

Medical costs are also high and the majority of Kenyans are jobless, which makes healthcare a luxury.

Recent Healthcare News in Kenya:

1. Bungoma County’s fictitious Health Scam after 30 Million swindled from the county budgetary funds

2. Business Today: The insurance perspective with Catherine Karori Bosire 4/1/2017

3. NHIF scam: 20 individuals, Webtribe LTD face charges over ksh 1.5 billion Health Insurance Fraud

Twenty individuals will be charged alongside Webtribe Limited for the loss of 1.5 billion shillings at the National Health Insurance Fund as the hunt for suspects widens.

But as the DPP casts his net wider, a report by the NHIF board details just how the money was lost through tender games, as the National Health Insurer contracted a supplier for a revenue collection system, and paid through the nose.

Just before you leave…

Here’s an article that we highly recommend you to read now.

It is a look into the Destructive Myths about Virginity that need to be Forgotten Now. More about How Society uses the Concept of Virginity to control Women.

Make sure you read the comments too. Just to see how different people think when it comes to sexuality. Click here to open the article in a new tab.

Internews Data Dredger - Politics of health - Mapping Kenyan doctors internews kenya
Internews Data Dredger – Politics of health – Mapping Kenyan doctors internews kenya – Health Insurance Fraud

Health Insurance Fraud in Kenya Uncovered:

IRA’ s Insurance Fraud Investigation Unit (IFIU) reported that health insurance fraud takes place primarily via fraudulent claims.

The Insurance Regulatory Authority (IRA) fourth quarter report for 2015 showed that insurance companies lost Ksh 367 Million up from Ksh 103 Million in 2014, to fraud.

Here are some of the fraudulent practices in the Kenyan health insurance sector:

  • Two tier pricing
  • Frivolous services
  • Impersonation

1. TWO TIER PRICING

Some hospitals will charge you more for services if you present an insurer’s card as opposed to if you pay in cash. This practice may not be illegal, but it naturally leads to a disadvantage for health insurance providers and their clients.

It means that clients are put in situations where they can exhaust their covers very easily. In pure business terms, why should you pay more for a service compared to others accessing the same service?

Two-tier pricing is also used in some pharmacies and specialist laboratories that accept health insurance cards.

Similarly some pharmacies opt to give patients drugs options based on the highest margin they can get. In many cases, several medicine brand will meet the prescription provided.

It is easy to see how a pharmacist may opt for higher end drugs and charge at the highest possible price point because the insurance company is not there to negotiate the price.

State insurer spends Sh1.7bn on treatment of kidney ailments Internews Data Dredger - Health Insurance Fraud
State insurer spends Sh1.7bn on treatment of kidney ailments Internews Data Dredger – Health Insurance Fraud

2. FRIVOLOUS SERVICES

Some hospitals also commit fraud by commissioning frivolous tests to unsuspecting patients. Once a doctor orders a test, many patients usually don’t ask questions regarding the tests ordered.

In many cases, the patients simply go along. Paying patients tend to be more assertive to inquire about the necessity of tests. Insured patients on the other hand tend not to ask questions because the insurance company will pick the tab anyway.

Some medical facilities take advantage of this and order unnecessary tests as a way of inflating the reimbursements they will receive from insurers.

3. IMPERSONATION

Impersonation happens when someone else, other than the insured person, accesses medical services using the credentials of the insured person.

Another form of impersonation is where an insured person presents his card for billing in a pharmacy on a prescription written for someone else.

In both cases, the person who receives services and care is not the insured person. This type of impersonation is illegal and can land someone in jail.

Outside of provider networks this Health Insurance Fraud is also committed by people who make fake cards, and write prescriptions, sometimes in concert with pharmacists to access expensive drugs for resale. Source: Insure Afrika

Health Care Insurance Fraud In Kenya Uncovered
Medical Health Insurance Fraud In Kenya Uncovered

Boniface Mwangi’s Experience with AAR Medical Insurance:

Before you continue reading this, I highly recommend this article about How Kenya has Failed her Youth written by Boniface Mwangi.

It is an honest, emotional and critical perspective on the current state of Kenya in relation to Radicalisation of Youth and Terrorism. Click here to open the article in a new tab.

In November 2016, l gave a speech on how the Kenyan middle class is only a phone call away from poverty. If you or your loved one is diagnosed with a terminal illness, and you don’t have a lot of money, you’ll end up being bankrupted. At the time, I hadn’t yet discovered another truth; that a health insurance cover isn’t a guarantee that your insurer will pay for your treatment when you need them to do so.

On October 19, 2017, an overzealous police officer shot me with a teargas canister, at close range. I was treated at Kenyatta Hospital and discharged, but later on developed a large swelling on my left breast, where the canister hit me. After the swelling healed, l was left with a big cyst, often referred to as a man boob. So one side of my chest was more swollen than the other. It didn’t bother me at first, but after a lot of prompting from my wife and friends, l decided to have it checked and, subsequently, made a decision to have it surgically removed this year.

You are more likely to be killed by a police officer than a thug in Kenya:

Kenyansare five times more likely to be shot dead by police than by armed robbers, according to a new report that highlights failures in British attempts to help reform the country’s police force.

Police shot close to 70 per cent of the 1,868 people who died from gun wounds in Kenya in the last five years. The next deadliest perpetrators, armed robbers, were responsible for only 14 per cent of the deaths.

 Mike Pflanz – Telegraph

I made an appointment with a doctor, at a hospital and the surgery was set for 22nd March 2019. My insurer agreed to cover the costs. My family and I have been faithful members of AAR since 2010. The night before the surgery, on 21st March, I received a phone call from a Ms. Sheila Mbogo, informing me that they were not going to pay for my surgery, as they considered the cyst to be a pre-existing condition, for which the waiting period is two years. TWO YEARS! She further stated that l was a new client.

Kenyan riot police search the the Kibera slums for supporters of Kenya's opposition leader Raila Odinga Photo- GETTY IMAGES
Kenyan riot police search the the Kibera slums for supporters of Kenya’s opposition leader Raila Odinga Photo- GETTY IMAGES

Why? Well, last year my cover lapsed for 3 months, and at the point of renewal, the insurance claims I was considered to be a new member. My conversation with Sheila concluded with an agreement that l needed to get the rejection from the medical insurer in writing and, once it was done, she would give me a call.

Unfortunately she never called back and I thought it must have been a misunderstanding that had then been resolved. After all, the hospital had already been given clearance by the insurer for my surgery. I went for the surgery on 22nd March and, thankfully, the cyst was successfully removed.

You are only a phone call away from poverty – @bonifacemwangi Click To Tweet

In the afternoon, while still recuperating from the effects of the anesthesia, the hospital administrator walked in with a letter that had been delivered by AAR, stating that they would not settle my bill. Still groggy, I tried to call my insurance agent to clarify.

The person to whom we paid our premiums, Sam Ng’ethe, Business Manager AAR, wasn’t picking my wife’s calls. I then called the AAR switchboard and spoke to a lady called Josephine from the AAR Care team. l explained my issue and she promised to call back.

You are only a phone call away from poverty – Boniface Mwangi

Hours went by without a phone call and l resorted to tweeting about it. After a lot of back and forth calls, I finally spoke to a Ms. Carolyne Nekesa. She spoke to her team and, three hours later, got back to me saying she had consulted with her bosses and, my faithfulness to AAR insurance notwithstanding, told me l was considered to be a new client since l had delayed to renew my cover last year. She flatly refused to address the lies that Sheila, Josephine and the team had told me before. Lies that Sheila had called my wife to say they would not cover my surgery. (What exactly was the lie?).

The company was emphatic that, according to their terms and conditions, l was a new client; terms that Sam did not disclose when we renewed our health insurance last year. The hospital was kind enough to release me without payment, to avoid accumulation of additional hospital bills and we agreed to settle in time. Thank God everything went well with the surgery and the hospital.

Health Insurance Company – Profit over Health:

Health insurance companies in Kenya take our personal health for granted, especially when people with valid medical covers are denied healthcare. There are health insurance companies who are still collecting premiums, but you cannot use their cover in any of the private hospitals because these insurers simply don’t honor their obligations. The reason health insurance companies can do that and get away with it, is because we have very weak protection laws. We are used to being taken advantage of. I was lied to by not one or two AAR employees, but three of them.

Service Commitments And Stakeholder ObligationService Commitments And Stakeholder Obligation
Service Commitments And Stakeholder Obligation

They are confident nothing will happen to them, perhaps because they were speaking under the authority of their bosses; after all, they are not in the ethics business. Conducting health insurance business for the sole aim of making profits is purely evil. Doctors take the Hippocratic oath; a promise that they will do everything possible to help their patients and to have high professional standards in their work.

What binds the medical insurance companies to do the right thing? Nothing. Zero. Profit is their “silent” oath. They do not train doctors or support medical schools. They have people specifically hired to write contracts that are hard for ordinary folks like you and me to understand, so that they can try to evade paying when you make a claim.

The Kenyan government trains doctors who also work in private practice, while on public hospital’s payroll. l wish the public hospitals would have an electronic sign-in and sign-out system for doctors working in their hospitals, and a big display board indicating doctors on duty and what time they are supposed to be there. I believe that it would help to know which health insurance companies and private hospitals are working with doctors who should be rotating in public wards. 

Everyday people are fundraising to pay a medical bill for someone, but if National Hospital Insurance Fund (NHIF) was well run – with no fake patients being taken to India for fake medical treatment and private hospitals conspiring with NHIF to steal from us – that is all the medical cover Kenyans would need. 

We can’t satisfy the greed of private health insurance firms and we must demand that the health ministry provides quality, affordable healthcare for all, otherwise these health insurances continue to thrive at our expense and the majority of Kenyans cannot afford life-saving healthcare. The right to health is a basic human right, guaranteed by the Constitution of Kenya.

What’s your medical story? It’s time to name and shame them. Use the hashtag #HealthInsuranceFraudsters Click To Tweet

Article 43 (1) (a) provides that every person has the right to the highest attainable standard of health, which includes the right to healthcare services, including reproductive healthcare. Let’s demand that right. I am sharing my story and l hope anyone who has suffered in the hands of Health Insurance companies can also share their stories as well. What’s your medical story? It’s time to name and shame them. Use the hashtag #HealthInsuranceFraudsters

Grim figures paint a hollow picture of Kenya's healthcare
Grim figures paint a hollow picture of Kenya’s healthcare