Under the health insurance scheme, you pay or your company pays the Health Maintenance Organization (HMO) on your behalf to manage your health. By paying monthly or quarterly or yearly premiums to the HMO, when you are sick, you do not have to pay the doctor out of your pocket. The HMO pays the doctor to treat you and members of your family depending on the plan that covers you. This scheme has rules and regulations, rights and privileges. It is important that you understand the rules and regulations of and your rights and privileges in the scheme to enable you know what you are entitled to at all times.
A lot of the patients (enrolees) are not getting their due and they do not know that they are not getting their entitlements because they do not know what is due to them under the scheme. Please know your rights and demand them from both your hospitals (providers) and your HMOs.
1. It is your right to understand fully your benefits as contained in the plan under which you are covered by the HMO.
2. It is your right to choose your Health Maintenance Organisation (HMO).
3. It is your right to be received promptly and treated in a friendly and efficient manner by your hospital.
4. It is your right to ask and be sure that your HMO is paying your hospital as and when due.
5. It is your right to know who your HMO officers are and to talk with them frequently and to demand explanation to the things you do not understand about the scheme.
6. It is your right to choose your provider (Hospital). If your hospital of choice is not on the list of providers and up to 25% of the employees are interested in your particular hospital, that hospital should be listed for your company.
7. It is also your right to decide if you want to change your hospital. In this instance, it is still your right to choose your new hospital. Nobody has the right to transfer you from one hospital to the other without your permission. Therefore, no HMO has the right to post you from your hospital of choice to any other one you have not chosen by yourself. It is your right to change your old hospital to another one if you are dissatisfied with the old hospital. No HMO has the right to stop you from using a hospital you are still satisfied with. The only condition you will be compelled to leave your hospital maintained through an HMO is if there has been a valid and proper execution of contract termination between the HMO and the hospital. In this case still, you exercise your right of choice for another hospital.
8. It is your right to have your medical bills in your hospital paid by your HMO to ensure your hospital is able to continue to treat you.
9. If your medical bills are not being paid as at when due, it is your right to demand explanations from the HMO and to demand compliance.
10. It is your right to be treated well at all times by your hospital of choice.
11. It is your right to be happy with your HMO and with your hospital.
NOTE: The AGPMPN offers you free information, counselling and legal aid in all matters concerning your health insurance.
Health insurance is good when it is run well. A successful health insurance should leave the patients happy, leave the providers happy and leave the HMOs happy. To achieve this, the three partners must be committed to the scheme and there must be mutual respect, transparency and accountability.
Association of General and Private Medical Practitioners of Nigeria (AGPMPN)