In a continued effort to uphold service quality and protect the rights of enrollees, the National Health Insurance Authority (NHIA) sanctioned a total of 96 healthcare providers in 2024 for various infractions. The sanctions included 49 healthcare facilities (HCFs) and 47 health maintenance organisations (HMOs) found to have violated the agency’s operational guidelines.
According to NHIA, the disciplinary actions followed thorough investigations into complaints lodged by enrollees under the state and national health insurance schemes. The infractions ranged from service denial to unauthorized charges, signaling the agency’s renewed focus on improving patient experience and accountability in the healthcare system.
Common Complaints and Investigation Outcomes
The 2024 Annual Complaints Report, compiled by NHIA’s Enforcement Department under Acting Director Dr. Abdulhamid Habib Abdullahi, identified the most frequent complaints against HCFs as:
- Unavailability of essential medications
- Denial of insured services
- Unjustified out-of-pocket expenses for covered treatments
- Failure to issue payment narrations
For HMOs, key grievances included:
- Delays or refusals in issuing referral authorization codes
- Late settlement of reconciled payments
- Inadequate quality assurance monitoring in partner facilities
The report was prepared in accordance with Section 17 of the NHIA Act, 2022, which mandates the Authority to establish effective mechanisms for receiving and resolving grievances from scheme participants.
3,507 Complaints Reviewed, Majority Resolved
In total, 3,507 complaints were handled during the reporting period. Of these, 2,929 cases—accounting for 84%—were successfully resolved.
Breakdown of complaints:
- 2,273 filed against healthcare facilities
- 1,232 against HMOs
- 2 against enrollees, submitted by providers
Sanctions and Refunds
Based on investigative outcomes, NHIA issued 84 formal warnings to HCFs. Additionally:
- ₦4.38 million was refunded to 54 enrollees by 39 facilities
- 4 facilities were suspended
- 6 facilities were delisted
For HMOs:
- 35 received warning letters and were instructed to implement corrective measures
- 12 HMOs were ordered to refund ₦748,200 to 15 enrollees
Timely Response and Transparent Procedures
All complaints were processed within the NHIA’s 10 to 25-day standard response window, with an average resolution time of 15 days. For unresolved cases within this timeframe, the NHIA ensured complainants were kept informed as resolution efforts continued.
Grievances were submitted through various channels, including in-person visits, formal letters, emails, phone calls, the NHIA call center, and digital platforms.
The Authority’s Complaint and Grievance Management Protocol provides a structured framework for prompt and fair resolution of issues, including escalation procedures for complex cases.
Leadership Response and Policy Enhancements
Speaking on the development, NHIA Director-General Dr. Kelechi Ohiri emphasized that the complaints resolution process is integral to the agency’s mission of fostering trust, transparency, and improved service delivery in the health insurance sector.
“Enrollees deserve the best care, and we remain committed to ensuring they receive it. These sanctions serve as a firm warning that the NHIA will not tolerate substandard service,” Ohiri said.
He praised providers who continue to deliver quality care, describing them as “worthy partners in the collective effort toward achieving Universal Health Coverage (UHC).”
With the first capitation and fee-for-service increases in 12 years, Dr. Ohiri said providers now have a greater responsibility to enhance patient care.
“We expect more to be done for patients, not less. We must all work together to minimize delays in access to care,” he added.
Referral Code Policy to Prevent Treatment Delays
To address one of the recurring issues—delayed referrals—the NHIA has introduced a new policy mandating that HMOs must issue referral codes within one hour. If no response is received within that timeframe, healthcare providers are directed to begin treatment in line with pre-approved emergency protocols.
Commitment to Quality and President’s Vision
The 2024 report underscores the NHIA’s commitment to transparency, fairness, and continuous improvement, in line with President Bola Ahmed Tinubu’s agenda to make Universal Health Coverage a reality for all Nigerians. The Authority reaffirmed its dedication to creating a level playing field for all stakeholders and improving healthcare access and delivery across the country.
