Hundreds of critically sick patients are facing premature deaths due to the failure by the national health insurer to pay for their medical procedures.

The worst hit are patients seeking medical procedures at private facilities in Kenya, with the National Hospital Insurance Fund (NHIF) authorising as little as Sh50,000 for procedures that require upwards of Sh1.5 million.

This has forced the affected patients to seek treatment at public hospitals, which are usually congested and ill-equipped. Others have resorted to using their personal savings or holding harambees to meet the costs of care.

Only last week, a patient at a leading hospital in Nairobi had to seek assistance from friends after NHIF approved only Sh400,000 of the Sh1.5 million she had requested for a coronary bypass procedure.

“My father got sick and we managed to see a cardiologist at the hospital in Karen who did a coronary angiography, which showed that his left artery had blocked,” Stella Nanjala told People Daily yesterday.

“He prescribed a procedure that would cost Sh1.5 million. When we sought preauthorisation, the NHIF only approved Sh400,000, leaving us in confusion.”

The same week, a patient at a hospital in Eldoret received only Sh50,000 of the Sh1.2 million he had requested for a kidney transplant.

The situation is compounded by delays of outright failure by the health insurer to grant authorisation requests for patients seeking surgical operations and other specialised medical care.

Patients at private health facilities are being treated to delayed or denied preauthorisation requests for funding, leaving thousands with few options for care.

NHIF has apparently not been adhering to the stipulated timeline of 24 hours to respond to pre-authorisation requests.

Last month, preauthorisation requests from at least 30 patients undergoing chemotherapy were rejected by a health facility in Kisumu without specified reasons, with NHIF advising those affected to seek medical care at government facilities.

In the same period, a similar fate befell 25 patients who had been receiving chemotherapy at a private facility in Nairobi’s Kilimani area. The delays have resulted in some patients having to reschedule procedures, while others have had to incur additional expenses by staying at a hospital longer than necessary while awaiting the procedures to be pre-authorised or digging deeper into their own pockets to fund urgent medical interventions.

Unjustified rejections

Besides unjustified rejections of authorisation for valid requests, patients also accuse NHIF of approving low reimbursements for preauthorised requests, and thus technically denying care to the critically sick.

The hardest-hit patients are those seeking care for cancer and kidney disease at private facilities. Some have had to cut short their chemotherapy or dialysis after NHIF failed to approve preauthorisation requests, approved smaller amounts of money for procedures or referred patients to government hospitals.

Several cancer patients are increasingly being denied care at private hospitals, with NHIF insisting on referring them to government hospitals, where oncology services are not easily accessible due to congestion, faulty equipment, lack of qualified personnel or a shortage of drugs.

The danger of patients being referred to government hospitals is that they have to begin the process anew even if one had already undergone several chemotherapy sessions, a process that leaves cancer patients vulnerable to the re-emergence of a more aggressive cancerous growth.

NHIF approves amount of money for procedures depending on the health facility, said said chief executive Elijah Wachira, who denied claims that requests had been denied.

Health facilities, he said, fall under two categories – comprehensive and non-comprehensive. Under the first category, NHIF covers all-inclusive services, while under the second, members may be required to pay from their own pocket for services offered.

“NHIF continues to honour the contracts it entered into with hospitals and its members,” Wachira said.

“Members who go to government and most faith-based facilities will have all their bills covered, while those who visit high-end private facilities may have only the fee for bed being covered. This has been the procedure.”

For those on chemotherapy and dialysis, he said, NHIF always decides the amount of money to be released depending on the facilities and need.

NHIF has exposed several patients to untold suffering due to arbitrary decisions it has been making over the past month, said Dr Brian Lishenga, the chairman of the Rural Private Hospitals Association.