Resolution Insurance – Coverage Details

1. Insurance Overview

Resolution Insurance (formerly “Resolution Health”) is a licensed general insurer in Kenya providing medical insurance among other classes of business.

They offer both inpatient and outpatient health insurance plans for individuals, families, groups, and companies — including flexible benefit packages depending on the plan chosen.

2. What Resolution Covers Under Its Health Plans

Inpatient (Hospitalisation & Related Care)

• Hospital admissions (ward/bed, surgery, theatre, general/surgical care) — covered under “Value” or “Harmony” (or higher) plans.

• Maternity (normal delivery, C-section where applicable) for principal member/spouse when maternity benefit is included.

• Newborn baby illness cover (when mother’s maternity benefit is active).

• Chronic illnesses / declared pre-existing & congenital conditions (under sub-limit) in certain plans.

• In emergencies: ambulance/evacuation and emergency admissions are covered under many plans.

• Organ transplant — covered under higher-tier plans (in some Value/Harmony variants) if selected.

Outpatient (Consultations, Diagnostics, Medicines, Follow-ups)

(Only if outpatient benefit is included in plan)

Included services often are:

• GP & specialist consultations

• Diagnostic exams: lab tests, x-rays, scans, imaging, other investigations (with prior authorisation for MRI/CT/chemotherapy/haemodialysis)

• Prescribed medicines and treatments from outpatient visits

• Antenatal & postnatal care, baby check-ups and immunisation (for children) under certain outpatient subplans.

• Minor trauma treatment, injections, procedures done in consultation rooms, and routine outpatient care.

Optional Add-on Benefits

Depending on the plan, Resolution offers:

• Dental cover (extractions, fillings, x-rays, scaling, etc.) under dental sub-plan.

• Optical cover (routine eye exams, prescription glasses/lenses, lens/frame replacement) under optical sub-plan.

• Personal accident cover — benefit for accidents for insured persons

• Funeral / last-expense benefit (a payout to beneficiaries upon death of insured).

• Daily cash benefit (hospital cash) for hospital admissions: after 3 days of admission up to maximum 180 days. Payout per day varies depending on plan (e.g. some plans payout KSh 500 / 1,000 / 2,000 per night).

• Worldwide travel / emergency evacuation cover under certain limits — including overseas emergency cover if required.

3. Coverage Limits & Plan Tiers

Resolution divides its inpatient cover into tiers/plans. Example annual limits under some plans: KSh 500,000, 1,000,000, 2,000,000, 5,000,000 depending on plan selected.

In outpatient plans (if included), annual benefit limits vary by plan — e.g. Plan 35, 50, 75, 100, 150 (depending on choice) which defines how much yearly outpatient coverage you get.

Sub-limits apply for some benefits: e.g. chronic/pre-existing conditions, psychiatric/mental health, dental/optical, and some other special-care categories.

4. Pre-Authorization / Approval Requirements

• Major treatments (e.g. surgeries, hospital admissions, maternity, organ transplant) often require prior authorisation from Resolution Insurance before admission — regardless of plan tier.

• For certain diagnostics or high-cost procedures (e.g. MRI, CT scan, haemodialysis, chemotherapy, radiotherapy) prior authorisation is required under outpatient plans.

• To access outpatient HIV services, members must visit approved Comprehensive Care Clinics (CCCs) under Resolution’s network.

5. Co-Pay / Co-Insurance & Waiting Periods

• Outpatient visits may require a co-payment when using certain high-tier hospitals/clinics in their network (e.g. some premium hospitals). 

• For declared pre-existing conditions under outpatient cover, there may be sub-limits (i.e. benefits only up to a portion/sub-limit of the outpatient limit).

• Waiting periods often apply before certain benefits (especially pre-existing, congenital, or chronic conditions) become active — check plan schedule upon subscription.

6. How to Use Resolution Cover at a Hospital

1. Confirm the hospital/clinic is on Resolution Insurance’s approved provider list (either “Enhanced” or “Standard” medical provider list) before treatment.

2. Present your Resolution membership card / policy number and valid ID (for principal and dependants) at hospital reception/registration.

3. For planned admissions or major procedures: obtain prior authorisation from Resolution before admission — contact their medical desk.

4. After treatment, the hospital bills Resolution (for in-network facilities) or you submit claims as per your policy (if using out-of-network or cash-back style cover) depending on plan terms.

7. Required Documents / Eligibility

• Valid government-issued ID (for principal and dependants)

• Resolution membership card or proof of coverage

• For maternity: prenatal documentation or membership declaration as required by policy

• For planned admissions: authorisation form or prior approval note from Resolution

• For outpatient visits: approval may be required for certain services (e.g. scans, long-term medications, chronic illness management) especially under pre-existing condition coverage

8. Common Exclusions & Limitations

Depending on plan and tier:

• Cosmetic or elective (non-medically necessary) procedures may be excluded or have restrictions

• Alternative/unverified treatments (non-allopathic, non-standard, experimental) may not be covered

• Dental/optical benefits are optional add-ons — may not be included by default

• Coverage limits and sub-limits apply — once benefit limit is reached, you may pay out-of-pocket

• Some high-cost benefits (e.g. transplants, overseas treatment, chronic illness claims) may require special underwriting and may have sub-limits or additional terms

9. Value-Added / Unique Features & Additional Covers

• Daily cash benefit “hospital cash” — cash payout per night for admitted members after 3 days of admission (for up to 180 days) under certain plans.

• Funeral / Last-Expense Benefit — a lump-sum payout to beneficiaries in the event of death under some cover options.

• Personal Accident Cover — included under many plans; useful for accidents (especially outside hospital) and emergency coverage.

• Emergency Evacuation / Worldwide Emergency Cover — for emergencies requiring evacuation or overseas treatment (on eligible plans).

• Flexible Plan Options and Benefit Tiers — members can choose a plan that fits their budget and needs: from basic inpatient-only cover, to full inpatient + outpatient + add-ons.

10. Risk / Recent Context — What to Know / Verify

⚠️ In recent years, there have been reports that some health facilities stopped honouring Resolution’s medical cover (especially after restructuring), so it’s wise to confirm that your hospital is still on their provider list before treatment. 

⚠️ Because of past financial and regulatory challenges, ensure your policy is active and premiums up to date.

11. Disclaimer

This summary is based on publicly available Resolution Insurance health-plan brochures and policy guides. Actual coverage, benefit limits, eligibility, waiting periods, and requirements depend on the specific plan and agreement you have with Resolution. Always verify coverage details directly with Resolution Insurance before seeking care.