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By Ngozi Nwoke
Employees of companies running group health insurance in Lagos have expressed mixed experiences with their Health Maintenance Organisations (HMO), ranging from quick approvals, to substandard medicines, lack of transparency, long delays and out-of-pocket payments.
The subscribers stressed that the disputes between providers and HMOs often leave them stranded at the point of care. They also say Nigeria’s health insurance coverage is growing, but trust and efficiency issues are not being resolved at the same pace.
Tolu Agbaje, a marketer at Isolo, Lagos, said she faced challenges during treatment for malaria.
She urged companies that run HMO services to demand greater transparency from providers, particularly by making drug lists and coverage details available to staff before hospital visits.
She noted that after waiting three hours for approval from the HMO provider, she was told by the hospital that two prescribed drugs were not covered and had to pay ₦18,000 out of pocket because they were not on formulary. She also added that she expected lab tests to be fully covered, but they were not.
She pointed out transparency as one thing to make the HMO better, while recommending that patients are allowed to see the drug list before getting to the hospital to avoid them being stranded if the drugs are not included in the package.
Godstone Wechie, a father, also recounted a difficult case involving his 13-year-old daughter. Despite the confirmation from the HR of the company he works for, still paid out of his pocket.
“My daughter needed an emergency scan. The hospital said HMO approval was pending. We waited close to five hours. We eventually paid ₦75,000 to save time. The MRI was not covered in the package. Only basic X-ray, but we would have saved time if the package explicitly stated that.
“My satisfaction with the HMO the company uses is 3/10. I need faster approvals and a real emergency line that works. The worrisome part is that the law guarding against these poor services hasn’t yet translated to maximum action at the point of our need.”
In contrast to the unpleasant reports of other patients not stated, Mirabel Nwabuisi, a customer service representative, described a smooth experience.
“I used my HMO for antenatal. Approval came in 20 minutes. No issues. Everything for pregnancy was covered. I never paid out of my pocket. They should just add dental care among the services. That’s all I want.
“People have dental needs, and it is one of the basic health services that should be included in standard HMO packages to make coverage more complete for subscribers. “Most people complain about the poor services by some HMOs, but the relieving part is that Nigeria finally has a law that enforces quality health insurance service.”
Similarly, Confidence Nelson stated: “Honestly, my experience with the HMO I use has been really good. Approval for consultations and lab tests usually comes in fast, so I don’t spend the whole day waiting at the hospital.
“The customer care line is responsive too. Whenever I have a question about treatments my plan covers, they explain it clearly. Having an HMO means I don’t have to worry about sudden medical bills. It’s been reliable, and I’m glad my company subscribed to it.”
Most Nigerians enrolled under the HMO also decry delayed payments, poor service delivery, and lack of clarity as some of the major challenges facing the health insurance system.
Some hospitals allege that HMOs owe them millions in unpaid claims. According to enrollees, the debt has forced some hospitals to put HMO patients on a separate queue or reject them entirely during emergencies.
The National Health Insurance Authority, (NHIA), itself acknowledged it had to address provider payment delays as part of its 2024-2025 reforms.
Enrollees also complained of long waits for treatment approval. Some of them report waiting hours for approval codes. Others report that they are told a drug isn’t on the HMO list or that a scan needs further approval.
Many HMO users said they do not fully understand what their plan covers. They ask if physiotherapy and antenatal scans are included in their plan.
The Health Maintenance Organisations (HMO), acts as a gatekeeper, where companies register with a primary provider, get referrals, and the HMO approves treatments to its staff, while the role of the National Health Insurance Authority (NHIA) is to regulate, accredit, sanction, and protect enrolees.
Under the NHIA model, healthcare payments under the new insurance model are handled by HMOs through two main channels.
The employer or individual pays a premium to an HMO. The HMO then pays healthcare providers using either capitation, which is a fixed amount paid per enrolee every month, regardless of whether the person falls sick, or a fee-for-service payment made for each specific service rendered.
Sharing his insight, Group Head of Human Resources at Chisco Group, Ezekiel Yusuf, raised concerns over delays and poor communication in the HMO system used by the company’s staff.
Speaking on the challenges, Yusuf said: “The biggest complaints we get are around delays in approval codes. Staff sometimes wait 30-60 minutes at the hospital, and others are told certain drugs or scans need further approval. It creates frustration, especially during emergencies.”
He also confirmed cases where staff were denied immediate care. “We’ve had a few cases. Mostly it’s been for drugs, not on the formulary list or when a provider said the enrolment wasn’t yet active. In two cases, staff had to pay out-of-pocket first, and we helped them follow up with the HMO for reimbursement. It’s not frequent, but even one case is too many.”
Despite the issues, Yusuf said the HMO still provides value to employees. “Overall, the HMO we use delivers value because staff can access care without large out-of-pocket costs. But we need improvements, especially for emergencies and lab tests. A clear and easy list of what each plan covers. The staff should know their benefits before they get to the hospital. If those are fixed, the model will work a lot better for both employees and employers.”
HMOs, on their part, revealed that premiums from companies come in late and that fraud by patients and providers also drives up costs. With 22 million enrolled and 83 HMOs licensed, the infrastructure exists.
Some HMOs said they are caught in the middle, citing major issues. They maintained that their mandate is to ensure access, manage risk, and work with NHIA to enforce standards. With mobile apps, telemedicine, and digital claims, they noted that the system is modernising gradually.
A Lagos-based health insurance provider disclosed that late payments and rising medical costs are key factors straining the delivery of HMO services.
Janet Etteh, Managing Director of Glend-Crest HMO services in Allen, Lagos, said the challenges make it difficult for providers to sustain care for enrollees.
“First is late premium payments by companies, which delays our ability to pay hospitals and restock drugs. We are also dealing with fraud, inflated claims, and patients visiting multiple providers for the same condition within a short period. The rising cost of drugs and diagnostics, which outpaces premium increases, means we are spending more to treat patients than what we receive from HMOs.”
According to Etteh, the delays patients face in getting approvals from HMOs are largely due to internal verification processes.
“When a request comes in, we have to confirm the enrollee’s eligibility, check if the service is covered under the plan, and get clinical review and authorisation from the HMO’s medical desk. If the company premiums are unpaid, or if the documentation from the hospital is incomplete, the approval gets held up, and that is what causes the waiting time for patients at the point of care.”
Chika Nzeribe, an Abuja-based independent Health Policy Analyst, said, “We have the law. Now, what we need is enforcement. NHIA must publish a transparent dashboard of HMO performance, claims paid, complaints, and approval times. Nigerians should be able to choose HMOs based on data.
“Public education is missing. 90 per cent of Nigerians still pay out-of-pocket because they don’t trust the system. Some call the HMO scheme a scam. We need technology to link HMOs, hospitals, and NHIA in real time to rule out every distrust, and we must protect providers from payment delays.”
In 2022, the National Health Insurance Authority Act repealed the old NHIS and gave the NHIA wider powers to enforce, regulate, and expand coverage. The idea was simple: HMOs pay hospitals upfront, and let Nigerians walk into clinics without digging into their pockets.
Five years on, the NHIA DG, Kelechi Ohiri, announced that health insurance enrolment has climbed to 22.03 million Nigerians, a 35 per cent year-on-year increase. Lagos alone has 1.18 million residents enrolled under private HMOs, the highest in Nigeria. NHIA also says 83 NHIA-accredited HMOs are operating in the country.
He announced this milestone at the Annual General Meeting of the Nigerian Association of Insurance and Pension Editors in Lagos, noting that the sharp 35 per cent year-on-year growth reflects a growing nationwide acceptance of health insurance and the Federal Government’s resolve to provide affordable healthcare to all Nigerians.
Speaking on the shift from planning to action, Ohiri stated that the agency had transitioned from mere policy formulation to delivering measurable operational improvements across the country in line with the federal health sector reform agenda.
He said, “Nigeria has a policy. Nigeria has legislation. The decisive variable is now implementation, consistent, rigorous, and accountable execution that converts political commitment into healthcare access for real Nigerians.
“The progress recorded so far demonstrates that sustained collaboration among the Federal Government, states, healthcare providers, Health Maintenance Organisations, employers, and development partners is beginning to translate reform into tangible results for citizens.
“The NHIA has simultaneously launched an aggressive push for consumer protection, resulting in an 87 per cent complaint resolution rate that successfully settled 3,878 disputes, concluded 95 per cent of cases within prescribed timelines, refunded over N14.2m to aggrieved enrollees, and issued sanctions to non-compliant facilities.
“To further eliminate negligence and ensure health insurance translates into timely care, the regulatory body has introduced rigid service standards, including a mandatory one-hour treatment commencement expectation for any enrolled patient requiring urgent emergency medical attention.
“The authority also rolled out massive funding upgrades for healthcare providers to enable clinics and hospitals to cope with the influx of patients, implementing a 93 per cent increase in capitation payments to help facilities invest in personnel and equipment, alongside a 378 per cent increase in fee-for-service reimbursements to ensure fair compensation for complex medical treatments.”
The NHIA says it has responded by sanctioning non-compliant HMOs and providers and improving its complaints process. The Authority stated that over 80 per cent of issues were addressed in 2024.
It noted that the two payment models are designed to ensure hospitals are funded upfront while giving enrollees access to care without out-of-pocket payments at the point of service, while also warning users about fake HMOs and ghost hospitals, and assuring that it is tightening accreditation standards to curb the problem.
In 2024-2025, NHIA announced tariff increases to fix payment problems: capitation raised by 93 per cent and fee-for-service by 378 per cent. It also introduced a one-hour deadline for issuing care authorisation codes to curb delays and promised predictable healthcare costs, wider access, and less out-of-pocket spending.
