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What is an HMO?
A Health Maintenance Organisation (HMO) is a
company that provides health cover for a regular fee — usually paid
yearly. Instead of paying cash every time you visit a hospital, your
HMO pays the hospital directly from the pool of premiums it collects
from members.
Each HMO has a network of hospitals it has
agreements with. When you fall ill, you visit any hospital in that
network, show your membership card, and receive treatment paying
little or nothing at the point of care.
💡 Big networks matter — Hygeia has 2,000+ facilities, Reliance and
AXA around 1,000–1,500. Before buying, check that hospitals near you
are in the plan's network.
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Understanding waiting periods
A waiting period is the time between when your cover starts and when
certain benefits become claimable. They exist for one reason:
to stop people from buying insurance only when they're
already sick.
Without waiting periods, someone could discover they need surgery
next week, buy a ₦40,000 plan today, and claim a ₦800,000 operation
immediately. Premiums would collapse — the pool only works when
healthy people are in it too. Waiting periods keep cover affordable
for everyone.
| Benefit | Typical wait |
|---|
| GP visits & consultations | From day one |
| Emergency care | From day one |
| Surgery | 6–12 months |
| Dental & optical | 6–12 months |
| Maternity | 9–12 months |
⚠️ If you're already pregnant when you enrol, maternity is not
covered — the baby is covered from birth, but the delivery isn't.
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Individual vs Family plans
An individual plan covers one person. Prices are
quoted per person, and each member gets their own annual limit.
A family plan covers you, your spouse, and usually
up to 4 children under one policy. Because insurers price the whole
household together — young, healthy kids offset older adults —
family plans typically cost
40–60% less than buying separate individual plans
for everyone.
Rule of thumb: two or more people, go family. A
couple alone can also buy a "couple" variant on some plans.
💡 Example: WellHealth covers a couple + 4 kids for ₦80,500/yr —
about ₦13,400 per person. Separate individual plans for six would
cost 2–3× more.
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What is an annual limit — and how much do you need?
Your annual limit is the maximum the HMO will pay
out for you in a year. Entry plans start around ₦200k–₦500k; mid
tiers reach ₦1M–₦2M; premium plans go higher or unlimited.
A single surgery can cost ₦500k–₦2M in a private hospital, so a
₦200k limit runs out fast if anything serious happens.
If surgery cover matters to you, aim for at least ₦1M.
Quick math for value: divide the annual limit by the price. A
₦98,000 plan with a ₦1M limit gives you 10× cover per naira — that's
a good deal in this market.
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What's NOT covered?
Every plan has standard exclusions. The usual ones in Nigeria:
Cosmetic surgery, fertility treatments (IVF), self-inflicted
injuries, drug abuse-related care, and — on most plans —
pre-existing conditions for the first year
(disclosed conditions are often excluded permanently; ask before you
buy).
⚠️ Always ask "what is excluded on this plan?" in writing before
paying. A good broker (that's our job) gets you the exclusion list
upfront.
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Why your claim was rejected (and how to avoid it)
Most rejections in Nigeria boil down to five avoidable reasons:
1. Non-disclosure. You didn't mention a condition
you had before buying. Insurers use this to void the claim — even
unrelated ones. Avoid it: disclose everything at enrolment;
let your broker find a plan that accepts it.
2. Waiting period hadn't elapsed. You claimed
surgery in month 3 on a 6-month wait. Avoid it: know your
plan's wait table before you need it.
3. Out-of-network hospital. You treated at a
hospital your HMO has no agreement with. Avoid it: confirm
the hospital is in your plan's network before admission — one
WhatsApp message to your handler.
4. The treatment is excluded. Cosmetic surgery,
IVF, or an undisclosed pre-existing condition. Avoid it:
read the exclusion list before paying, not after.
5. Lapsed policy. Premium wasn't renewed, so cover
ended before the claim. Avoid it: Cova reminds you before
renewal — never miss it.
💡 With Cova, your handler checks all five before the claim is
filed — most "rejections" never reach the insurer in the first
place.
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How do claims work with Cova?
Traditional HMO claims mean forms, phone trees, and follow-up calls.
With Cova you message your named handler on WhatsApp,
they file and chase the claim with the HMO for you, and we hold
insurers to a 72-hour claim SLA.
For hospital visits on your plan's network, you usually don't claim
at all — you present your card and walk in. Claims matter for
exceptions, reimbursements, and non-network emergencies.
