SHA denies critical tumour surgery despite full premium payment, leaving patient in pain
The Social Health Authority building in Nairobi.
What you need to know:
- For Akinyi, a house help whose income depends on her physical ability to work, waiting was not an option.
- The tumour was causing pain and interfering with her daily activities.
When Millicent Akinyi was wheeled into Naivasha Sub-County Referral Hospital for tumour removal surgery that morning, her employer had every reason to expect smooth processing. After all, he had paid her full annual Social Health Authority (SHA) premium, believing it would cover the medical emergency.
But sometimes, the system has other plans.
Ms Akinyi, who works as a house help, had been diagnosed with hypochondriac lipoma—a benign tumour made of fat cells. She was booked for surgery at the hospital, and her employer had completed all the necessary preparations, confident that the insurance coverage would handle the costs.
That confidence was quickly shattered.
After filling out the surgical services pre-authorisation form and submitting it to the SHA offices located at the hospital, her employer received news that would expose a troubling gap in Kenya's healthcare coverage system.
"The SHA office told us the tumour had not reached the threshold to be covered," explains Akinyi's employer, frustration evident in his voice. "For it to be covered, it must measure 3 by 3cm. Millicent's tumour was 2 by 2cm."
One centimetre. The difference between coverage and catastrophic out-of-pocket expenses came down to a single centimetre.
"I don't understand why we would do all the paperwork and submit to SHA, then we are told that the tumour was not big enough to be covered by SHA," he continues. "Should we wait for people to be bedridden or to be fatally ill for them to be covered? Why the demand for the full annual payment if they cannot cover such illnesses?"
Impossible choice
The employer revealed that before the pre-authorisation of the surgery, they were instructed to pay the full annual premium payment, which he did, only to be told that the tumour was still small for SHA to cover.
The revelation left both employer and patient facing an impossible choice: wait for the tumour to grow larger and potentially more dangerous, or pay out of pocket for immediate treatment.
"A single centimetre difference is what was used to determine whether my house girl gets treatment or not," he says. "Do we have to wait for our case to be serious before they could pay?"
For Akinyi, whose income depends on her physical ability to work, waiting was not an option. The tumour was causing pain and interfering with her daily activities. Despite the financial strain, her employer made the difficult decision to pay cash for the surgery.
But that decision unveiled an even more troubling discovery.
What the employer discovered next defies all logic about how healthcare pricing should work. From receipts seen by the Nation, the procedure carried dramatically different price tags depending on the payment method.
According to the doctors' SHA pre-authorisation, the procedure was capped at Sh33,500. However, when paying cash, the total surgery cost came to Sh7,200.
"When paying cash, the total surgery cost came to Sh7,200. However, what was initially approved had SHA approved the surgery, the same procedure would have been capped at Sh33,500, nearly five times more expensive," the employer explains.
"What are the discrepancies for? What is not happening?" he demands.
This pricing disparity raises serious questions about whether SHA is being systematically overcharged by healthcare providers, with hospitals potentially inflating costs for insured patients whilst offering more reasonable rates for cash payments.
"I had to pay cash because the tumour was growing and the girl was in so much pain," the employer adds. "Why would SHA wait for patients' conditions to worsen for them to qualify for coverage? I thought early intervention is often more effective and less costly than treating advanced conditions."
Found guilty
The pricing irregularities Akinyi's case exposed are part of a wider pattern that has caught the government's attention. Health CS Aden Duale mentioned that at least 31 private health facilities have been closed after being found guilty of converting outpatient to inpatient claims.
The facilities had been found guilty of defrauding the SHA by converting outpatient claims to inpatient claims. The facilities were closed in an ongoing crackdown targeting unscrupulous activities draining the SHA's resources.
He said that facilities converting outpatient claims to inpatient claims will be closed down without hesitation. Health workers colluding with facilities to admit patients unnecessarily will face disciplinary action, with both parties held personally responsible for any resulting fraud.
"Doctors sharing pre-authorisation codes to defraud the SHA fund will face prosecution," he said. "Facilities admitting non-existent patients beyond their capacity will be brought to book, and facilities charging both SHA and patients in cash simultaneously will be reported through the call centre, with patients encouraged to speak out against such malpractices."
Akinyi's experience reflects wider problems with SHA implementation, where rigid rules are creating barriers to necessary care. For low-income Kenyans, these barriers represent more than inconvenience—they can mean the difference between receiving timely treatment and death.
"I still don't know the logic used behind telling us that the tumour was still small to be covered by SHA," the employer wonders. "Is this how Kenyans are going to be left on their own to die silently, yet they struggle to pay the annual premium?"
As Millicent Akinyi recovers from her surgery—paid for out of her employer's pocket rather than the insurance system designed to protect her—her case stands as a stark reminder that healthcare coverage is only as good as the system that delivers it.
