It would be very interesting if men were the ones who got pregnant as I am sure that would have resulted in medical insurance policies being more sensibly structured as opposed to what we have currently.

When my wife got pregnant was the first time I seriously interrogated a health insurance policy, as with many of us our first interaction with insurance is for our cars. Mainly because it is a statutory requirement and without it one would end up spending large amounts of money to get police officers to look the other side and if not, it would still cost you a day at the magistrate’s courts.

Due to the fact that it is a legal requirement we try and take out the cheapest policy possible at times even acquiring fake certificates, which makes one wonder if we appreciate that even though the policy is a legal requirement the accrual of benefits is solely to the car owner. So, why anyone in their right senses would take out a third-party cover is beyond my comprehension but that’s the peculiar Kenyan for you.

Back to my pregnant wife, I realised that the cover was only for a caesarean delivery, for the uninitiated this is where the baby is delivered through a surgical procedure as opposed to naturally through the birth canal. The reason this was covered is that it would now be a classified as a medical procedure akin to having one’s leg amputated, I have no idea how I thought that example was relevant.

What this resulted in was many women, who did not want to go through the crawling, gnawing and growling process of natural childbirth at Pumwani as it was all they could afford to pay for out of pocket, even though they already had a medical insurance cover, would then opt for caesarean delivery.

How the insurance companies hadn’t noticed a disproportionate increase in caesarean section deliveries at most of the high-end hospitals still baffles me to this day as over the years I had been party to installing ERP solutions at a number of HMOs, could it be our usual data phobia and technology for technologies sake or were the returns so high that this did not trigger any alerts, but I digress.

A caesarean delivery usually costs three to four times a normal delivery (NHIF maternity capitation Normal 6,000/-, Caesarean 18,000/-) with the additional likelihood of infection as well as future medical complications increasing tenfold.

Since most gynaecologists and underwriters are of the male gender it would explain why the practice continues to this day, the former to make more money and the latter to avoid thinking.

If that was not bad enough, the pregnancy tests and prenatal clinic visits were also not covered under the standard medical packages.

Since the pregnancy test was not covered the insurer never got to know that their policyholder was pregnant who would then see the doctors under other medical conditions such as nausea, unbearable back pain, loss of interest in their husbands (not sure if this is covered, yet) and many other pregnancy-related discomforts.

It is a documented fact that most complications that would arise at delivery are best mitigated when identified early but for some reason, our actuaries prefer to play Russian roulette instead of basing their products on documented research.

With the fact that most HMOs, for a long time, had exactly the same exclusions in their policies indicated either a case of incest and thus inbreeding or plain cartel behaviour, I suspect the former as the latter would require some serious cerebral cortex activation.

After many years of this archaic method of cover, a disruptor jumped into the fray in the name of Resolution Health, whose insurance cover included maternity whether normal delivery or caesarean. Suddenly the number of caesarean deliveries dropped drastically then due to the inbreeding within the industry this spread like wildfire across the industry, inbreeding does have its benefits it seems.

Resolution Health continues to disrupt the insurance industry especially as relates to implementing technology-driven engagement.

In the same breath, more recently I was out looking for insurance cover for our family, as now two of our children are now over eighteen, in the previous year we had been forced to take out 3 separate covers so as to be able to accommodate the three adults and two children in the family. Did I mention that the previous insurance company never got in touch with me either before or after the cover had lapsed? Note, we had made zero claims in that year.

For many months before the previous cover lapsed I kept seeing a huge billboard by APA Insurance on “Health Insurance covers that are tailor-made for your family”.

I must have seen that billboard over 100 times thus when it came time to renew our policy they were top of mind so the next time I passed by the billboard I stopped and struggled to pick the contact information.

Later, I contacted the organisation but there seemed to have been a disconnect between the billboard and the organisations internal systems, so I switched to the internet to see if I could get a more reliable contact, but thanks to googles algorithm which found it prudent to bring me a different organisations contact in response to my search “group insurance cover for families”, APA was not even on the first page.

I thus decided to keep my interaction on the internet so I responded to the chat window that popped up and proceeded to have a back and forth for a while with me sharing all the pertinent information about what I was interested in.

That all went flawlessly and at the end of the interaction I was advised that an agent would get in touch with me to complete the other process, manual paper filling. They did finally call, after two days, but they were clueless about what I had already shared with the online chat agent which was an indication that there was a breakdown in the handshake from digital to analogue, maybe it should have remained digital.

I instantly told off the person to go get better briefed as I was not going to engage in a redundant process and soon after I took my displeasure online using President Trump’s preferred mode of communication, Twitter.

The CEO, Mr Peter Nduati, took up the issue and I had a policy document on my desk within the day and I am happy to say the cover met all our requirements which were, a single cover for all of us and with a group, not individual limits, it also included all my dependent adults.

Even though I am positive about my experience with this particular provider I have a strong feeling that due to their blanket requirement on people over fifty years of age, I smoothly crossed over recently, I will most likely be scouting for a more adaptive provider if they remain rigid in demanding that I spend the equivalent of half the premium to take a myriad of medical tests that are not backed by any of the data they have occupying storage space on their servers.

In addition, there is an obsession with providing inpatient cover but to charge exorbitantly for outpatient, something that even NHIF (yes, that government monolith) has realised is myopic. A flu not treated right could easily escalate into a serious cardiac or respiratory condition that would then require millions to treat yet an early treatment at an outpatient facility would have averted the need for hospitalisation.

As clearly as day follows night, someone will respond to me with the statement that people tend to abuse outpatient covers, I think if someone goes to see a doctor just because they have a cover has much greater problems that need to be addressed than fraud, but if you can share data on this being such a large issue I will stand corrected.

I appreciate that before the advent of information systems (pre-1980) monitoring outpatient activities would have been restrictively expensive but today it would cost less than a trip to a roadside public toilet. But it seems that the phobia for data, whose treatment is sadly not covered by most health insurance offerings, denies many organisations with the opportunity to harness the resulting information that can be generated and even less on utilising artificial intelligence.

Over the past many years, most HMOs have collected millions of data points relating to their policyholders and service providers, it is thus time they leveraged this resource to develop products that meet the needs of their local customers and not just copy and paste obsolete models from other markets.

Disclaimer: This article is neither a sponsored nor a promoted post in support of any particular organisation or the demonising of another but a call for our health insurance companies to stop being lazy in the products they are offering the public but to become innovative, dynamic and agile.

In closing, if the heading of this article was “Insurance companies and maternity cover” would you have read this far? Please share your comments and responses below.

Written by

Robert Yawe
Empowering your ICT team through complete infrastructure visibility

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