Health Insurance in Nigeria: What You Should Know

A social media post about Health Maintenance Organisations (HMOs) has stirred up debate among Nigerians and healthcare workers about health insurance.

The post, shared on X on 2 August by a user named @106_36_52, who claims to be a doctor, criticized a family for visiting a hospital after church under their HMO plan.
“I give the federal government 24 hours to ban this thing called HMO in Nigeria. Full family, straight from church with matching Ankara. Third set only today. God abeg,” he wrote.

As of 12 August, the post had more than 1.9 million views and was shared by several blogs, leading to mixed reactions from Nigerians and healthcare professionals.
While some questioned why healthcare workers should care about how often insured patients use their plans, others pointed out that the reactions did not consider the financial and administrative pressures faced by healthcare providers and HMOs.

In this article, we look at how health insurance works in Nigeria, the duties of patients, healthcare providers, and HMOs, and what the law says about their responsibilities.

How health insurance works

One major misunderstanding from the debate is that HMO patients receive free treatment. Patients may not pay hospitals directly at the time of service, but it does not mean the services are free or that doctors work for free.

Health insurance relies on pooling money to pay for healthcare when members need it. The National Health Insurance Authority (NHIA) describes social health insurance as a system where contributions are combined to provide a set package of healthcare services.
Pelumi Akinboade, a senior executive officer and insurance nurse, said HMOs handle important tasks in this system, such as enrolment, claims management, authorization, quality assurance, and coordination between patients and healthcare providers.

He explained that healthcare providers are paid through methods like capitation and fee-for-service, which depend on the type of care provided.
“Patients may not bear the bulk of their care costs out of pocket, as their respective insurance companies pay their healthcare providers directly through capitation and fee-for-service,” Mr Akinboade told PREMIUM TIMES.

Using an insurance plan does not mean a patient is asking a doctor to treat them for free. They are accessing services financed through an insurance arrangement.

Doctors’ frustration

However, the viral post also shows another aspect of the system. It is easy to see a doctor’s complaint as anger towards HMO patients. Healthcare providers rely on HMOs to pay for services they have already provided. Problems with payments or authorizations can impact how facilities deliver care.

Mr Akinboade noted issues like delayed payments, administrative hurdles, limited coverage, and disputes between providers and HMOs can cause delays or denials of care.
The NHIA Act 2022 outlines penalties for failing to make payments to healthcare providers on time and for not settling claims in the specified timeframe.

The federal government has also acknowledged the financial pressure on healthcare providers. When announcing new payment rates under the national health insurance scheme, the NHIA revealed capitation fees increased by over 90 percent, while fee-for-service payments rose by 378 percent.

The Coordinating Minister of Health and Social Welfare, Muhammad Pate, said this adjustment aimed to lessen the financial burden on healthcare providers and enhance services for enrollees.

So while a patient using their insurance should not be blamed for a provider’s frustration, the financial issues of healthcare facilities cannot be ignored.

The law and disputes

Section 47 of the NHIA Act 2022 states that disputes among parties under the Act should first go to the Authority for mediation. The Act identifies HMOs, healthcare providers, contributors, and the Authority as parties involved in such disputes.

Section 48 makes it an offense to fail to pay healthcare providers within the specified period, to settle claims on time, or to provide care to registered enrollees.
This means the law recognizes that there can be disputes over payments, claims, and access to care in the health insurance system. The tension seen online between patients, healthcare providers, and HMOs is not just about patients “overusing” their insurance.

It also raises questions about whether each party is fulfilling their obligations.
Patients are expected to understand their health plans and follow the right procedures, while healthcare providers and HMOs have responsibilities under the regulations governing health insurance in Nigeria.

Patients with insurance have rights.
Mr Akinboade said healthcare providers must see this distinction. Hospitals should have trained staff who understand health insurance and can guide patients properly through the process.
He rejected the notion that insured patients should receive lower quality care because they are not paying directly at the time of treatment.
“Insurance patients are not secondary patients. They own the right to quality healthcare services,” he said.

This view aligns with the NHIA’s statement on enrollee rights. The Authority says Nigerians covered under its programs have the right to easy access to quality healthcare without hindrance and to be treated with respect and dignity.

This distinction is especially important in Nigeria, where health insurance coverage is low, and families bear a large share of healthcare costs.
A 2025 Nigeria Health Systems and Services Profile published through the African Health Observatory Platform, with World Health Organisation (WHO) involvement, reported that out-of-pocket spending made up more than 75 percent of total health spending and estimated that only about five percent of Nigerians had health insurance, prepayment, or other risk-pooling systems.

In this kind of system, health insurance aims to protect families from the financial impact of illness.

Patients also have responsibilities.
Mr Akinboade said they need to understand the health insurance package they signed up for.
Different plans have various benefits, exclusions, and limitations. So, enrollees need to know the services covered by their plans, the facilities available to them, and the procedures for referrals and authorizations.

Patients should also know how to report issues when care is delayed or denied. Mr Akinboade suggested that enrollees keep the contact details of their HMO’s customer service or quality assurance unit and escalate complaints when necessary.

So, health insurance is not just a card shown at a hospital. It is an arrangement that creates responsibilities for patients, healthcare providers, and HMOs.

What needs to change

Making the system better will need action from everyone, Mr Akinboade said. He added that HMOs should process claims and pay healthcare providers on time while ensuring that referrals and authorizations do not create unnecessary hurdles to care.

Healthcare providers need trained insurance desk officers who understand the terms of different plans and can communicate them clearly to patients.
Regulators must enforce existing rules and impose penalties when organizations fail to meet their obligations.

Meanwhile, patients must understand their benefits, exclusions, and responsibilities and use complaint mechanisms when they face problems.

The NHIA Act provides a way to resolve disputes between HMOs, healthcare providers, contributors, and the Authority, including mediation.