Dental & Optical Insurance in Kenya - Complete Coverage

Eye Examinations (100% Coverage)

• Comprehensive Eye Exams: Annual or bi-annual full eye health assessments
• Refraction Testing: Determining your correct lens prescription
• Glaucoma Screening: Testing for elevated eye pressure
• Retinal Examination: Detailed inspection of the back of the eye
• Tonometry & Visual Field Testing: Advanced diagnostic procedures

Eyeglasses (Covered Allowance)

• Prescription Frames: KES 5,000-15,000 allowance per year or every 2 years
• Single Vision Lenses: Standard lenses for myopia, hyperopia, or astigmatism
• Bifocal & Progressive Lenses: Multi-focal lenses for presbyopia (age-related)
• Lens Add-ons: Anti-reflective coating, UV protection, blue light filtering
• Safety Glasses: Protection eyewear for workplace hazards (if applicable)

Contact Lenses (Covered Allowance)

• Annual Allowance: KES 8,000-20,000 per year for contact lens supplies
• Soft Contact Lenses: Daily wear, extended wear, or disposable lenses
• Rigid Gas Permeable (RGP) Lenses: For complex prescriptions or keratoconus
• Contact Lens Solutions: Care products and solutions (if included)
• Specialty Lenses: Colored lenses, multifocal lenses, or ortho-keratology

Specialized Eye Procedures (If Covered)

• LASIK Eye Surgery: Laser vision correction (partial or full coverage)
• PRK/LASEK Surgery: Alternative laser procedures for thin corneas
• Cataract Surgery: Removal of clouded lens and implantation of intraocular lens (IOL)
• Glaucoma Treatment: Laser procedures or filtration surgery
• Retinal Procedures: Treatment for retinal detachment or diabetic retinopathy

Dental Annual Limits & Sub-Limits

• Overall Annual Limit: KES 100,000-500,000 per member per year. Once exhausted, remaining costs are out-of-pocket.
• Preventive Care Sub-limit: Often unlimited (100% covered) as insurers want to encourage preventive visits.
• Basic/Restorative Sub-limit: Typically KES 50,000-200,000 per year (70-80% covered after deductible).
• Major Treatment Sub-limit: Usually KES 30,000-150,000 per year (50-60% covered after deductible).
• Orthodontics Lifetime Limit: Many policies cap orthodontic coverage at KES 200,000-400,000 total, not annual.
• Annual Deductible: Typically KES 500-5,000 per person per year (preventive care usually exempt).

Optical Annual Limits & Sub-Limits

• Overall Annual Limit: KES 50,000-200,000 per member per year for eye exams and vision correction.
• Eye Exam Coverage: Fully covered (100%) typically once per year or once every 2 years.
• Eyeglass Allowance: Fixed allowance (KES 5,000-15,000) per year or every 2 years for frames and lenses.
• Contact Lens Allowance: Fixed allowance (KES 8,000-20,000) per year as alternative to glasses.
• LASIK/Refractive Surgery: Often limited to KES 100,000-200,000 per eye or excluded entirely.
• Annual Deductible: Usually KES 500-2,000 (often waived for preventive exams).

Key Limitation Points

Be aware of these common restrictions:

• • Frequency Limits: Some plans limit cleanings to 2x/year or glasses replacement to every 2 years
• • Waiting Periods: Major dental work may have 6-12 month waiting periods on new policies
• • Lifetime Maximums: Especially for orthodontics and refractive surgery
• • Pre-existing Conditions: Dental issues present at policy inception may be excluded for 12+ months

Will my dental insurance cover my wisdom teeth extraction?

Yes, wisdom teeth extraction is typically covered as a basic restorative procedure (70-80% coverage after deductible). However, surgical extractions or complications may be covered at lower percentages. Check your policy details.

Can I claim for orthodontics (braces) under my dental insurance?

Many standalone dental policies include orthodontics coverage, but it's often subject to a lifetime limit (KES 200,000-400,000) and higher percentage out-of-pocket (50-60%). Family or comprehensive plans may offer better orthodontic benefits. Check your specific policy.

Is LASIK eye surgery covered under optical insurance?

LASIK coverage varies significantly. Some policies exclude it entirely, others offer partial coverage (50-70%) up to a limit of KES 100,000-200,000. Premium policies are more likely to include it. Ask your insurer specifically about refractive surgery coverage.

What if I lose my glasses or contact lenses? Are replacements covered?

Most optical insurance policies do NOT cover lost or damaged eyewear. They cover the cost of obtaining new glasses/lenses within your annual allowance only once per period (usually every 2 years). Purchase protective cases and replacement insurance separately if needed.

Does dental insurance cover implants fully or partially?

Dental implants are typically covered at 50-60% (major coverage category) with the patient paying 40-50% out-of-pocket. However, some policies have annual or lifetime limits on implant coverage (e.g., 1-2 implants per lifetime). Verify your policy.

Are gum disease treatments covered?

Yes, gum disease treatments like scaling, root planing, and surgical gum grafting are covered as basic or major restorative care (70-80% for non-surgical, 50-60% for surgical). Prevention care (prophylaxis cleaning) is often 100% covered to encourage early treatment.

If I change insurance companies, will waiting periods apply again?

Yes, typically new waiting periods apply when you switch insurers. However, some insurers may waive or reduce waiting periods if you provide proof of continuous previous coverage. Ask your new insurer about waiting period waiver options.

Can I get dental and optical coverage if I already have a medical condition?

Yes. Dental and optical insurance are typically separate from medical insurance and don't have the same health underwriting. You can usually get dental and optical coverage regardless of medical conditions, though pre-existing dental/eye conditions may have waiting periods.

Is emergency dental care covered fully?

Emergency dental care (acute pain, broken tooth, infection) is usually covered immediately at your plan's coverage percentage, even during waiting periods, as it's considered a medical emergency. Non-emergency treatment planned after the emergency may require waiting periods.

What documents do I need to claim dental or optical benefits?

Typically required: insurance card/certificate, ID/passport, itemized receipts and invoices from the provider, treatment prescriptions or referrals, pre-authorization approval (if applicable), and completed claim forms from your insurer. Keep all original documents and copies.