Pre-Existing Conditions: What Agents Need to Know

"I have high blood pressure. Can I still get covered?"

This is the question that makes new agents freeze.

Pre-existing conditions are one of the most misunderstood parts of health insurance. Get it wrong, and you'll either lose the sale or set up your client for a painful claim rejection.

Here's everything you need to know.

Table of Contents

• What Counts as a Pre-Existing Condition?
• How Insurers Handle Pre-Existing Conditions
• Standard Waiting Periods by Condition
• The Disclosure Problem
• How to Have the Pre-Existing Conditions Conversation
• Finding Coverage for Clients with Pre-Existing Conditions
  • Option 1: SHA (Best for Severe Conditions)
  • Option 2: Group Insurance (Employer or Association)
  • Option 3: Insurers with Shorter Waiting Periods
  • Option 4: Premium Loading Instead of Exclusion
• What to Do When a Client Is Declined
• Common Pre-Existing Condition Scenarios
  • Scenario 1: "I have diabetes, but it's controlled"
  • Scenario 2: "I had cancer 5 years ago, but I'm in remission"
  • Scenario 3: "I didn't disclose my hypertension. Will they find out?"
  • Scenario 4: "I'm healthy but my spouse has a chronic condition"
• Protecting Yourself as an Agent
• Key Takeaways
• Your Action Items
• Next Steps

What Counts as a Pre-Existing Condition?

A pre-existing condition is any illness, injury, or medical condition that existed before the insurance policy start date.

Examples:

• Diabetes
• Hypertension (high blood pressure)
• Asthma
• Heart disease
• Cancer (even if in remission)
• HIV/AIDS
• Chronic kidney disease
• Mental health conditions
• Previous surgeries
• Ongoing medication

The key question: Did the client know about it before applying?

If yes, it's pre-existing — even if they never mentioned it.

How Insurers Handle Pre-Existing Conditions

Different insurers have different approaches:

Most Kenyan insurers use waiting periods. The condition is eventually covered, but not immediately.

Standard Waiting Periods by Condition

Here's what clients should expect:

Pro tip: Always verify waiting periods with the specific insurer before quoting. They vary.

The Disclosure Problem

Here's where it gets tricky.

Clients often don't disclose conditions because:

• They forgot
• They didn't think it mattered
• They hoped no one would find out
• They were embarrassed

The danger: Non-disclosure can void the entire policy.

If a client claims for something related to an undisclosed condition, the insurer can:

1. Reject the claim
2. Cancel the policy
3. Refuse to pay any claims
4. Keep all premiums paid

Your job: Make sure clients understand that honesty protects them, not the insurer.

How to Have the Pre-Existing Conditions Conversation

Use this script:

Step 1: Normalize it "Before we proceed, I need to ask about your health history. This is completely normal — everyone has something. The more honest we are now, the smoother your claims will be later."

Step 2: Ask specifically "Do you take any regular medication?" "Have you been hospitalized in the last 5 years?" "Do you see any specialist doctors regularly?" "Has a doctor ever told you that you have a chronic condition?"

Step 3: Explain the consequences "If there's anything we don't disclose and you later claim for it, the insurer can reject the claim — even if you've paid premiums for years. That's why we want to be thorough now."

Step 4: Reassure "Most conditions are covered after a waiting period. You won't be denied insurance — there'll just be a delay before that specific condition is covered."

Finding Coverage for Clients with Pre-Existing Conditions

Not all insurers are the same. Here's how to help your clients:

Option 1: SHA (Best for Severe Conditions)

SHA has no pre-existing condition exclusions or waiting periods beyond the standard 30 days.

For clients with serious conditions (cancer, kidney disease, HIV), SHA is their best option for that specific condition.

Positioning: "SHA covers your [condition] from day one. Use private insurance for other benefits like private rooms and elective care."

For more: SHA vs Private Insurance

Option 2: Group Insurance (Employer or Association)

Group policies often have:

• Shorter waiting periods
• Higher acceptance of pre-existing conditions
• Lower premiums per person

If your client's employer offers group cover: Help them maximize it before adding individual top-up.

Option 3: Insurers with Shorter Waiting Periods

Some insurers are more accommodating:

Always check current terms. These change.

Option 4: Premium Loading Instead of Exclusion

Some insurers will cover pre-existing conditions immediately but charge a higher premium.

Example: A diabetic client might pay 20–30% more but have diabetes covered from day one.

Ask underwriting if this option is available.

What to Do When a Client Is Declined

It happens. Here's the recovery plan:

Step 1: Find out why Call underwriting. Get the specific reason.

Step 2: Check for appeal Some declines can be overturned with additional medical reports or a doctor's letter.

Step 3: Try a different insurer Underwriting criteria vary. A decline from one insurer doesn't mean decline from all.

Step 4: Offer a partial solution "We couldn't get full cover, but we can cover everything except [specific condition]. SHA will handle that part."

Step 5: Come back later Some conditions improve. A client declined for uncontrolled diabetes might be accepted after 6 months of good management.

Common Pre-Existing Condition Scenarios

Scenario 1: "I have diabetes, but it's controlled"

Response: "Controlled diabetes is still considered pre-existing, but most insurers will cover you after a 12-month waiting period. During that time, diabetes-related claims won't be covered, but everything else will. After 12 months, you're fully covered."

Scenario 2: "I had cancer 5 years ago, but I'm in remission"

Response: "Cancer history requires special underwriting. Most insurers will either exclude cancer permanently or apply a 24-month waiting period. I'll submit to a few insurers and see who offers the best terms."

Scenario 3: "I didn't disclose my hypertension. Will they find out?"

Response: "When you claim, insurers request medical records. If those records show hypertension treatment before your policy started, they'll know. The safest path is to disclose now — we can update your application."

Scenario 4: "I'm healthy but my spouse has a chronic condition"

Response: "Each person is underwritten separately. Your cover won't be affected by your spouse's condition. Their condition will have the standard waiting period."

Protecting Yourself as an Agent

Document everything.

When a client discloses:

• Note it in your records
• Confirm it on the application form
• Get written confirmation if possible

When a client doesn't disclose (and you suspect something):

• Ask again in a different way
• Explain the consequences clearly
• If they still refuse to disclose, document that you asked

Why this matters: If a claim is rejected for non-disclosure, clients sometimes blame the agent. Your documentation protects you.

Key Takeaways

1. Always ask about health history — don't assume
2. Explain waiting periods upfront — no surprises at claim time
3. Disclosure protects the client — make that clear
4. SHA has no pre-existing exclusions — recommend it where appropriate
5. Different insurers have different policies — shop around
6. Document everything — protect yourself

Your Action Items

1. Create a pre-existing conditions checklist for client meetings
2. Save this article for reference during sales calls
3. Know which insurers handle chronic conditions best
4. Use BimaSasa to compare quotes across insurers quickly
5. Read: How to Explain Waiting Periods to Clients

Next Steps

• Practice your pre-existing conditions conversation
• Review your current clients' disclosure forms
• Identify clients who might benefit from SHA + private combination