Insurance is an essential part of financial planning and risk management for individuals and businesses in Kenya. With a growing economy and rising incomes, the demand for insurance products has expanded rapidly over the past decade. However, the claims and coverage process remains complex for many policyholders. This article provides an in-depth review of insurance claims and coverage analysis in the Kenyan market.
Introduction
The insurance industry in Kenya has seen remarkable growth in recent years. Total gross written premiums reached KES 230 billion in 2021, reflecting a 9% increase from 2020 according to the Insurance Regulatory Authority (IRA). Health insurance recorded the highest growth at 16%, followed by motor insurance at 10%. This upward trend is expected to continue as economic expansion and development drives demand.
However, despite the growing uptake of insurance, the claims process continues to be tedious and opaque for many consumers. Policyholders often find it difficult to determine the adequacy of their coverage and successfully make claims when the need arises.
To improve insurance penetration and protect consumers, a deeper understanding of the claims and coverage analysis process is required.
Insurance Market Overview and Regulations
The insurance industry in Kenya is governed by the Insurance Act, which is implemented by the Insurance Regulatory Authority (IRA). There are 48 registered insurance companies offering products across life, health, motor, property, marine, aviation, agriculture and other segments.
The IRA has put in place prudential guidelines and regulations to protect consumers, such as requiring insurers to submit claims statistics, have dispute resolution frameworks, and adhere to specific policy wordings.
However, the lack of uniform standards and inconsistent enforcement remains an issue. The IRA has been undertaking market conduct surveys to enhance compliance and is working to establish a policyholders compensation fund. Overall, stronger regulations have positively shaped the growth of the insurance sector.
Common Coverage Gaps and Claims Issues
Despite regulation, consumers still encounter several challenges related to claims and inadequate coverage. Some of the common issues include:
Excessive exclusions – Most policies contain exclusions which limit the scope of coverage. While reasonable exclusions are justified, some insurers add ambiguous, unfair or excessive exclusions which restrict payouts.
Incorrect or insufficient covers – Many individuals and businesses underestimate their risks and hence purchase covers that are inadequate for their specific needs and exposures. This results in uninsured losses when claims arise.
Lack of policy understanding – Policy wordings tend to be complex for average consumers. Lack of understanding of policy terms, exclusions, deductibles and claims procedures often hinders successful claims.
Claims rejection – Insurers may reject claims due to pre-existing conditions, late reporting, insufficient documentation or other technical grounds, even when the loss is legitimate from the policyholder’s perspective.
Delayed claims – The claims review and approval procedure is lengthy and bureaucratic in some firms, causing delays even for valid claims. This affects cash flows and operations for policyholders.
Disputes over claim amount – There are often disputes between insurers and consumers regarding the claim amount payable, with each side quoting different policy provisions to justify their stance.
Fraud risk – Fraudulent and exaggerated claims also raise insurers’ suspicion of all claims and prompt stricter scrutiny. However, this should not impede genuine claims.
The Claims Submission Process and Requirements
To avoid having claims rejected or delayed, it is important for policyholders to understand the claims submission process and fulfill the insurer’s requirements. The typical claims process includes:
Prompt notification – Immediate intimation about the loss event and intent to claim. This is essential as insurers can repudiate delayed claims.
Registration of claim – Submission of First Information Report with case details, which is recorded in the insurer’s system.
Investigation – Insurer appoints a surveyor to inspect damages and investigate circumstances.
Document submission – Policyholder provides necessary documents such as claim form, police report, invoices, KRA valuation report, etc. as required.
Assessment – The insurer reviews surveyor’s report, documents and policy terms to arrive at claim admissibility and amount.
Approval/Rejection – Insurer approves or rejects the claim based on investigation and assessment.
Settlement – For approved claims, the insurer disburses claim amount through agreed mode of payment.
To ensure smooth processing, it is advisable to submit relevant documents promptly. The surveyor can also guide on specific requirements. Maintaining proper documentation and following up periodically also helps.
Insurance Claims Dispute Resolution
In case of claims rejection or dispute over the payout amount, policyholders can adopt the following mechanisms to resolve the issue:
- Negotiation – Further negotiations with the insurer’s claims team presenting additional facts and data.
- Ombudsman – Filing a complaint with the Insurance Ombudsman if the claim amount is within their pecuniary jurisdiction.
- Mediation – Seeking mediation through the Mediation Accreditation Committee.
- Arbitration – Referring the matter to arbitration by certified arbitrators under the Arbitration Act.
- Litigation – Approaching the Courts, typically the High Court, as a last resort if other methods fail.
The Office of the Ombudsman and Mediation Accreditation Committee provide cheaper and quicker dispute resolution avenues compared to litigation. Consumers are advised to exhaust these options first before filing a suit.
Harnessing Technology for Better Claims Management
Insurers are increasingly leveraging technology to improve claims processing and resolution. Some of the emerging tech-led trends include:
- Online/Mobile submission – Digital submission through insurer portals and mobile apps for faster processing.
- Tech tools for TPA/surveyors – Handheld devices and AI to aid investigation and accurate assessment of damages.
- Claims Tracking – Online dashboards to track status in real-time.
- Document Digitization – Electronic document submission minimizing physical paperwork.
- Data Analytics – To identify fraud patterns and improve risk selection/pricing.
- Chatbots – Automated chatbots to handle policyholder queries on claims to reduce turnaround time.
While technology is enhancing efficiency, human intervention in claims assessment cannot be entirely replaced. Technology is an enabler, but sincere service is key.
Tips for Consumers on Insurance Coverage and Claims
Here are some tips for consumers to optimize insurance coverage and effectively make claims in Kenya:
- Analyze your risks and adequately insure assets and income sources. Seek professional advice if unsure.
- Read policy documents thoroughly and clarify any doubts to understand exclusions and procedures.
- Maintain proper records, invoices, valuations and documentation to aid claims submission.
- Intimate claims promptly and submit documents diligently adhering to all requirements. Follow-up regularly.
- If claim is rejected, thoroughly understand the reason and grounds for dispute before initiating talks or litigation.
- Opt for mediation mechanisms for dispute resolution rather than lawsuits.
- Leverage technology aids provided by insurer for smoother engagement. However, follow-up personally too.
- Look beyond claims. Build a trustworthy long-term relationship with insurer.
Common Types of Insurance Claims in Kenya
Now that we have covered the overall claims process, let us examine some of the most common types of insurance claims in Kenya and the specific aspects to consider for each.
Motor Insurance Claims
Motor insurance is mandatory in Kenya, but underinsurance and gaps in coverage are common. Here are some tips for motor claims:
- Opt for comprehensive motor cover not just third-party liability cover to protect your vehicle adequately.
- Note exclusions like drunk driving, unlicensed drivers, etc. that can invalidate claims.
- Keep copies of driving licenses, roadworthiness test certificates and other documentation up-to-date.
- Take detailed photos of the damaged vehicle from multiple angles. Get a police abstract.
- Ask for valuation from approved assessors. Be involved in the assessment.
- For third-party claims, get contact details of the other driver and note all vehicle details.
Medical Insurance Claims
Medical costs have risen sharply in Kenya, making medical cover critical. Some key aspects for health insurance claims:
- Check if your policy has any co-payments, sub-limits or exclusions for specific procedures, pre/post-hospitalization, etc.
- Get proper discharge summary, diagnostic reports, doctors’ prescriptions and itemized bills from hospital.
- Submit pre-auth form before planned treatments or procedures.
- If claim is rejected, verify if treatment was as per policy terms. File complaint if unjust.
Travel Insurance Claims
Travel policies provide coverage against problems like trip cancellations, lost luggage, medical emergencies while travelling. Points to note:
- Purchase overseas travel cover if travelling abroad. Check exclusions like adventure sports.
- For overseas hospitalization, gather documents detailing diagnosis, treatment and expenses.
- For trip cancellation, submit proof of reason for cancellation and bills/refund details.
- For lost baggage, get proof from airlines and receipts of replacement purchases.
Home Insurance Claims
Home insurance provides protection against damage to your home and contents within. Key steps during home insurance claims:
- Inform insurer immediately after any incident, loss or damage to your home.
- If due to theft/burglary, file a police complaint. Furnish a copy later to the insurer.
- Allow inspection by insurance surveyor and provide necessary assistance.
- For damage claims, conduct emergency repairs to prevent further loss. Keep repair bills.
- Submit invoices/receipts of lost valuables to establish ownership and value.
Business Insurance Claims
There are extensive risks like property damage, employee injuries, lawsuits that can impact businesses. Key aspects for business insurance claims:
- Take stock of all your risks and get appropriate covers for assets, revenue loss, legal liability, workers’ comp etc.
- Carefully report incidents like employee accidents, supply chain disruptions, machine breakdowns etc. to insurer along with supporting documents.
- Be thorough with loss assessment. Claim any residual expenses not covered even after receiving compensation from vendor/client if any.
- For liability claims filed against your company, take legal advice before responding or agreeing to a settlement. Involve your insurer.
- Maintain transparency in all documentation and communication regarding claims.
This covers some of the major types of insurance claims in Kenya and how to approach them. Being mindful of policy terms, prompt reporting, proper documentation and following up can help ensure smooth settlement of valid claims.
Challenges and Outlook for Insurance Claims in Kenya
While insurance claims processes are gradually improving, some challenges persist both from an industry and consumer perspective:
Industry Challenges
- Managing fraud risk while not impeding genuine claims
- Lack of integrated information systems and data sharing between insurers
- Constraints in conducting thorough policyholder due diligence
- Delays due to over-reliance on physical paperwork and manuals
Consumer Challenges
- Lack of awareness regarding policy provisions and claims procedures
- Inability to accurately estimate risks and hence being underinsured
- Lack of documentation especially for personal assets
- Unwillingness to share data openly with insurers due to privacy concerns
However, the outlook is also positive. Insurers are collaborating more with stakeholders and investing in digitalization. The Insurance Act amendments also expand consumer protection.
Greater consumer education by the IRA and players will improve compliance. Introduction of micro and innovative insurance products can also deepen penetration.
Overall, a transparent, efficient and ethical insurance claims processes can hugely benefit both consumers and the industry in the long run.
Conclusion
With a rising economy, growing middle class and improved risk awareness, insurance uptake is bound to expand in Kenya. However, for the full benefits to be realized, attention must be paid to educating consumers, simplifying products, using technology appropriately and constantly improving the claims process.
Transparency and open communication between insurers and policyholders will be the key. Insurers must view claims settlement not as a cost to be avoided but an opportunity to retain trust. Likewise, consumers should approach insurance with financial prudence and with complete facts.
Collaboration between insurers, regulators and industry associations will also be vital to tackle persistent issues like fraud, delays and disputes through data sharing, automation and consumer redressal mechanisms.
If these best practices are implemented consistently, insurance can play a pivotal role in securing lives and businesses in Kenya.
