“What do you mean I am not covered? Mr. JB retorted angrily. I have been paying for health insurance (through salary deductions) for the past 10 years and I have never visited the hospital. This is my first time here and you’re telling me I’m not covered for the service? I will sue you!”

In Nigeria, we tend to add a bit of flavor to our dealings, often turning on its head, concepts that have pretty much worked seamlessly the world over. I have decided to use Mr. JB’s story to illustrate how health insurance typically works in the Nigerian setting.

Most beneficiaries consider their health insurance premium deductions a waste of money since they never actually “use” their health insurance.

Mr. JB works for a responsible corporate entity that provides health insurance for all its workers through a private Health Maintenance Organization (HMO). The company deducts a small percentage monthly, from staff salaries and makes up the rest in order to meet up with the premium payments to the HMO. Now, most beneficiaries consider these deductions a waste of money since they never actually get to “use” their health insurance and typically go ballistic whenever they attempt to access healthcare through their insurer and get turned down for any number of reasons.

The problem however is a lack of understanding of how health insurance plans work. Unknown to many, what most health insurance beneficiaries buy into are a set of benefits, specially curated for the plan that they (or their employers) have purchased. The HMO uses a number of metrics to determine what benefits to include in any given plan and the appropriate price to set as the premium (cost of purchase) for that plan.

What is a Plan Benefit?

Plan benefits work like your cable TV subscription. Most cable TV providers have several bouquets (packages) that vary in price and in turn have a different combination of channels that are accessible on the subscription.

Think of benefits as the various services available for the individual (also known as the beneficiary) who has purchased a health plan. For example, one of the services that a dental practice offers is routine scaling & polishing and this would be defined under a plan as part of the “Dental Benefit”.

The easiest way to explain what plan benefits are and how they work is to compare it with a cable TV subscription. Most providers have several bouquets (packages) that vary in price and in turn have a different combination of channels that are accessible on the subscription. Some bouquets may have certain sports or movie channels while others may not. Most people would typically ask for the content of these packages and become aware of what channels they can access in order to manage their expectations and this is how plan benefits work as well.

Now back to our dental benefit example, a particular kind of dental surgery may be required by the beneficiary which is not listed under the dental benefit and as such cannot be accessed by the beneficiary through his/her health insurance. The lack of information of what is included and what is excluded from the plan benefit is the major cause of near fistfights at most healthcare providers since they have to turn down the beneficiary once they can confirm that the requested service is not covered and as such will not be paid for by the HMO

What are Mr. JB’s Options?

It is quite understandable, how a person could be frustrated when the required care is denied on the basis of a service not covered under the plan benefits but all hope is not lost. Mr. JB could use any of the following options

1. Carry on with the fistfight, throw tables and chairs at the hospital admin staff, thereby injuring one or more of them. This will lead to his arrest and charge for assault, attempted murder and any other thing the hospital’s lawyers can think of to put him in jail for a very long time ?
2. Talk to his HMO and give any required commitments (if it is within his power) to upgrade his plan to one that has the required benefit. The hospital (or provider) will likely need authorization from the HMO to render the required service.
3. Find out if any of the services to be provided are covered under the current plan and pay out-of-pocket for the ones that are not covered. He should also work towards upgrading to a higher plan eventually.

A lot of the HMOs do not do a good job of educating their clients on the covered vs not covered benefits on the purchased plans

What the HMOs can do

A lot of the HMOs do not do a good job of educating their clients on the covered vs not covered benefits on the purchased plans and as such it starts to look suspicious when the beneficiary gets to hear this for the first time at the point of accessing medical care. Health technology providers now have intuitive self-service solutions that can list all of the details of the beneficiary’s plan either through online portals or mobile apps which in turn can help reduce the cases where beneficiaries can claim ignorance of the covered services.

In conclusion…

Access to health care using health insurance does not have to deteriorate into a boxing match if all the stakeholders invest a bit of time in getting educated on the best ways to share (and receive) information. Health care providers, on the other hand, can set a minimum standard of requiring self-service portals from their HMO partners in order to help them access and share information regarding a beneficiary’s covered service in a transparent way.