For millions of Nigerians enrolled in health insurance, possessing an insurance card is only the beginning of the journey. The real test comes when medical attention is needed and the subscriber must find out whether the promised coverage translates into timely treatment.
With Nigeria’s healthcare system facing persistent pressure from inadequate infrastructure and manpower shortages, understanding the rights attached to health insurance has become increasingly important.
The National Health Insurance Authority (NHIA) has introduced measures aimed at reducing delays in treatment authorisation by Health Maintenance Organisations (HMOs), following complaints from enrollees over delayed approvals, denied services and unexpected charges.
One of the most significant changes is the requirement for HMOs to process treatment authorisation requests within one hour of receiving them from healthcare providers.
The rule became operational on April 1, 2025, following concerns that prolonged approval processes were creating barriers to healthcare access.
For the more than 22 million Nigerians covered by health insurance, the requirement means subscribers can reasonably expect greater clarity and speed when treatment requires HMO approval.
However, knowing the one-hour rule exists does not mean every treatment is automatically covered. Subscribers still need to understand the terms and limitations of their individual health plans.
When treatment approval takes too long
One of the common frustrations for insured patients occurs when a doctor recommends treatment but the hospital says it must first obtain approval from the patient’s HMO.
While some approvals may be processed quickly, others can result in patients or relatives spending considerable time contacting both the hospital and insurer.
Under the NHIA’s operational guidelines, HMOs are expected to issue treatment authorisation codes within the prescribed one-hour period after receiving requests from healthcare providers.
Healthcare facilities also have responsibilities. They are expected to submit authorisation requests promptly, meaning delays cannot automatically be attributed to the HMO.
Both HMOs and providers are required to maintain records of authorisation requests and responses. Where an HMO has a legitimate reason to decline a request, the reason should be communicated instead of leaving the patient waiting without an explanation.
For subscribers, the timing of the request can therefore become important.
A patient who is told that approval is pending should find out when the hospital submitted the request and, where necessary, document the time.
The NHIA has encouraged enrollees to report delays or other barriers to accessing care where authorisation requests exceed the one-hour limit.
Emergencies are different
Insurance procedures should not unnecessarily stand between a patient and emergency medical care.
The NHIA’s position allows emergency treatment to commence without prior authorisation, with the necessary insurance code obtained subsequently within the applicable timeframe.
For patients and families, the practical message is straightforward: seek urgent medical attention when faced with an emergency while allowing the hospital and HMO to complete the required administrative process.
Insurance paperwork should not become a reason for avoidable delays in emergency treatment.
Complaints can lead to action
The NHIA’s 2025 complaints figures provide an indication of the types of problems encountered by subscribers and the regulator’s response.
The Authority reported resolving 3,878 complaints during the year, representing an 87 per cent resolution rate. Of those resolved cases, 62 per cent were concluded within 48 hours, while 95 per cent were settled within the prescribed 21-day period.
The regulator also escalated 240 cases for enforcement review and issued 368 warning letters as part of its compliance efforts.
Nine healthcare facilities were suspended over significant breaches of NHIA operational guidelines.
Regulatory intervention also resulted in more than N14 million being refunded to affected enrollees through cases involving HMOs and healthcare providers.
For subscribers, the figures demonstrate the importance of documenting disputes rather than simply accepting an unsatisfactory response.
Receipts, prescriptions, referrals, authorisation requests, correspondence with an HMO and records showing when approval was sought can all become useful if a dispute has to be escalated.
Where an HMO says a service is not covered, the subscriber can ask for an explanation. If a provider demands payment, the patient should establish exactly what the charge represents.
However, a refusal to pay for a treatment is not automatically a breach of a subscriber’s rights.
Health insurance plans contain defined benefits, exclusions and, in some cases, partial exclusions. The important question is whether the treatment falls within the relevant plan and whether the HMO and healthcare provider have followed the applicable procedures.
An insurance card does not cover everything
A common misconception is that an insurance card guarantees payment for every medical expense.
That is not the case.
Subscribers need to understand the specific benefits attached to their plans, including covered treatments and medicines, applicable co-payments, procedures requiring prior approval and services that are excluded.
They should also establish whether referrals are required before consulting specialists and which hospitals and other healthcare providers are included in their network.
The NHIA has stated that beneficiaries under its programmes generally do not need to make cash payments for covered treatment, although a 10 per cent co-payment for drugs may apply under the relevant programme.
Knowing these conditions before illness occurs can prevent unnecessary disputes at the hospital.
The hospital on your card matters
The relationship between an insured patient and the healthcare system involves more than the HMO.
The healthcare provider is ultimately responsible for delivering the treatment, while the NHIA provides regulatory oversight.
Consequently, the list of hospitals and facilities available under a particular insurance plan is an important consideration for subscribers.
People should verify that their preferred hospital is accredited and included in their plan’s provider network.
This can be particularly important for families seeking specific facilities for maternity services, paediatric care, specialist treatment or emergency services.
A plan may appear affordable or attractive until a subscriber discovers that a preferred or nearby hospital is outside its network.
What happens when a provider asks for payment?
Subscribers should not automatically assume that every charge is illegal, nor should they accept every demand without asking questions.
The first step is to establish whether the service is covered.
The subscriber should also determine whether the amount represents an authorised co-payment, payment for a medicine outside the approved list, an excluded procedure or another service outside the benefit package.
If the explanation is unclear or appears inconsistent with the terms of the plan, the subscriber should contact the HMO and retain evidence of the transaction.
Where the dispute remains unresolved, the matter can be taken through the NHIA’s complaints process.
The Authority says complaints can be lodged through NHIA offices, HMOs or its call centre, with contact details and information on state and zonal offices available through its official channels.
The NHIA Act 2022 established the Authority as the regulator of the health insurance system and provides mechanisms for addressing complaints involving enrollees.
Coverage is growing
The debate over HMO performance is unfolding as health insurance coverage continues to expand.
By the first quarter of 2026, health insurance coverage had reached 22,025,342 people, according to government figures.
That represents significant growth from the 16.2 million people recorded in the fourth quarter of 2023, an increase of roughly 35 per cent.
The expansion, however, brings another challenge: ensuring that increased enrolment translates into better access to quality healthcare.
A growing number of Nigerians carrying insurance cards will have limited impact if patients continue to encounter unnecessary approval delays, providers refuse insured patients or HMOs fail to respond promptly.
Consequently, provider accreditation, complaints management, enforcement and efficient payment arrangements are becoming as important as increasing enrolment.
Coverage must translate into protection
The success of health insurance cannot be measured solely by the number of people registered.
The more important test is financial protection.
Effective insurance should reduce the likelihood that illness will force households to sell assets, take expensive loans or delay essential treatment because they cannot immediately raise the required money.
This objective is central to the NHIA’s mandate to expand universal health coverage and improve financial access to quality healthcare under the NHIA Act 2022.
Government financing initiatives are also being used to support vulnerable Nigerians. In June 2026, the Federal Government approved an additional N32.88 billion second-quarter disbursement under the Basic Health Care Provision Fund.
Government figures also showed that 2,450,204 beneficiaries had been covered and verified with National Identification Numbers under the relevant BHCPF arrangement as of the first quarter of 2026.
Informal workers remain a major gap
Expanding insurance coverage beyond formally employed Nigerians remains one of the sector’s major challenges.
Workers in structured employment often have contributions deducted through organised payroll systems. Traders, artisans, farmers and small-business operators may not have comparable arrangements.
The NHIA therefore has programmes covering formal-sector workers, organised private-sector employees, vulnerable groups, individuals and families, alongside private health plans.
But expanding these programmes will require more than enrolment drives.
Subscribers must understand how referrals work, which services require authorisation, where they can receive treatment and what their plans exclude.
Without that knowledge, people may remain vulnerable to confusion and unexpected costs even after obtaining insurance.
Five things every subscriber should know
Before the next hospital visit, every HMO subscriber should be able to answer five basic questions:
What does my plan cover? Read the benefit package rather than relying on assumptions.
Which hospitals can I use? Confirm that your preferred facility is within the approved network.
Which treatments require authorisation? Understand when an HMO approval is necessary.
What am I expected to pay? Know the applicable co-payments and excluded services.
Where can I complain? Keep your HMO’s customer-service details and information on NHIA complaint channels.
These details can make a significant difference when treatment is needed urgently.
What to do when an HMO delays approval
If a hospital says it is waiting for HMO authorisation, the subscriber should first ask when the request was submitted.
The patient should then confirm with the HMO that the request was received and record the time.
If the one-hour period has elapsed, the subscriber can request an explanation and, where the matter remains unresolved, report the delay to the NHIA.
In emergencies, patients should prioritise receiving appropriate medical attention while the hospital and HMO resolve the administrative requirements.
The bigger challenge
Stronger regulation can improve the system, but effective health insurance requires cooperation across the entire chain.
HMOs must respond within the prescribed timelines. Healthcare providers must submit requests promptly and deliver services covered by their agreements. Subscribers must understand their plans and preserve evidence when disputes occur.
The regulator, meanwhile, must continue to monitor compliance and take action where necessary.
The NHIA’s 2025 figures suggest that complaints are increasingly being used as a mechanism for regulatory intervention rather than simply as individual grievances.
For Nigerians, the implication is clear: an HMO’s response does not necessarily have to be the final word where a legitimate dispute remains unresolved.
As insurance coverage moves beyond 22 million Nigerians, the next measure of progress should not simply be how many people possess health insurance.
It should be whether those people can actually use their coverage when illness strikes.
For subscribers, that begins with understanding the fine print.
Know the benefits. Know the provider network. Know the authorisation rules. Keep records. And know where to seek redress.
An insurance card may open the door to healthcare, but understanding the rights attached to it is what helps ensure the door does not remain closed when treatment is needed.
