Steps to File a Health Insurance Claim in Nigeria Without Delays or Denials

You walked into the hospital with a valid health insurance card, expecting everything to go smoothly. But instead, you’re told your HMO hasn’t approved the treatment, or worse—your claim has been denied. It’s frustrating, confusing, and in many cases, preventable. Filing a health insurance claim in Nigeria doesn’t have to be a nightmare. Once you know how the process works and the steps involved, you’ll avoid delays, miscommunication, and out-of-pocket surprises.

If you want to make sure your next claim gets approved without drama, keep reading. What you’re about to learn could save you time, stress, and money.

What Is a Health Insurance Claim in the Nigerian Context?

A health insurance claim is a formal request made by a hospital or insured person to an HMO, asking them to pay for medical services received. It confirms that the treatment falls within the coverage agreed upon in the policy, and the HMO is expected to cover the cost as per the plan’s terms.

In most cases, the hospital files the claim directly. But there are times when you’ll have to make a direct claim yourself—especially if you pay upfront due to an emergency or visit a non-accredited hospital. Either way, the process follows a series of steps, and missing any of them can result in denial or long delays.

Start With a Valid Insurance Plan and Know What It Covers

Before you even think about filing a claim, your insurance plan must be active. This means:

• Your premium has been paid
• You’ve served any required waiting period
• You’re visiting a hospital that is within your HMO’s accredited network (unless it’s an emergency or you’ve been referred)

You should also know what your plan covers and what it doesn’t. This will help you avoid requesting reimbursement for excluded services. For example, if your plan doesn’t include dental or cosmetic procedures, those will likely be denied if claimed.

Step One: Visit Your Primary Provider (Or Approved Hospital)

When you feel unwell or need medical care, your first point of call should be your registered primary provider—the hospital you selected when enrolling with your HMO. If your plan allows walk-in services at multiple hospitals, you can go to any accredited partner facility. Once you arrive, present your HMO card or digital ID, and ensure the hospital verifies your eligibility. The hospital will open a treatment file for you and proceed with medical evaluation. At this point, the hospital notifies your HMO electronically or via their backend platform, requesting treatment authorization—especially if the service involves admission, surgery, or diagnostic tests.

Step Two: Pre-Authorization (If Required)

Not all treatments need pre-approval, but many do—especially high-cost procedures. This step involves your hospital sending a pre-authorization request to your HMO. The HMO then reviews the request to:

• Confirm if your plan covers the treatment
• Check if you’re eligible for it
• Approve or decline the request based on policy terms

If approved, the hospital gets a go-ahead to treat you and later submit a claim. If the HMO denies the request, they must state why—sometimes it’s due to plan limitations, expired coverage, or lack of referrals. To avoid delays at this stage, always ask your doctor or hospital admin to follow up with your HMO for fast approval. Some approvals are done within hours, while others may take a day or more.

Step Three: Receiving Treatment and Documentation

After approval (if needed), you will receive the treatment. It could be outpatient consultation, lab work, admission, surgery, or emergency care. While you’re receiving care, the hospital records everything—services rendered, medicines given, doctor’s notes, and test results.

This documentation is vital because it supports the claim they’ll send to your HMO. If the documents are incomplete or inconsistent, your claim may be rejected. That’s why it helps to keep copies or at least get a discharge summary or invoice, especially if you suspect your provider may not follow up properly.

Step Four: Hospital Submits the Claim

After treatment, the hospital sends a claim form and supporting documents to your HMO. This claim usually includes:

• The patient’s details (name, HMO number, plan type)
• Description of treatment provided
• Dates of service
• Costs incurred (though you won’t pay it yourself)
• Doctor’s diagnosis and recommendations
• Any referral notes or lab results

The HMO will review these documents to determine if the treatment is covered, medically necessary, and delivered at an approved facility.

Step Five: Claim Review and Payment by the HMO

Once the claim is received, your HMO’s claims department will assess it for accuracy and eligibility. If everything checks out, the HMO pays the hospital directly. This is known as a cashless claim. This part of the process is where many issues arise. If your plan doesn’t cover the exact treatment, if the claim form is missing information, or if the HMO suspects fraud, the claim might be denied or delayed. You, the patient, may not even be informed unless you follow up. That’s why it’s smart to ask your hospital for a copy of the submitted claim or track the status through your HMO’s mobile app or customer support line.

Filing a Direct Claim: When You Pay First and Get Reimbursed

In emergencies, or when you get treatment at a hospital not on your HMO list, you might have to pay from your pocket. In such cases, you’re allowed to file a direct claim for reimbursement. Here’s how that works:

• You must notify your HMO within 24 to 48 hours of receiving treatment
• Get an official hospital receipt and invoice (clearly stamped and signed)
• Ask for a medical report or discharge summary
• Fill out your HMO’s claim reimbursement form (usually downloadable online)
• Submit the completed form along with the documents to your HMO via email or office drop-off

Most HMOs will process the reimbursement within 7 to 21 working days—if the claim is valid.

Avoid These Common Claim Mistakes

Many Nigerians miss out on insurance benefits due to avoidable errors during the claims process. Here’s what you should always watch out for:

• Visiting unapproved hospitals without emergency referral
• Getting treated for a service not covered under your plan
• Submitting incomplete or fake receipts
• Delaying claim submission beyond the allowed timeframe
• Not following proper referral protocols

These mistakes don’t just get your claim rejected—they can even lead to policy suspension or blacklisting with your provider.

How to Follow Up on a Delayed or Rejected Claim

If your claim is taking too long or you’ve received a rejection message, don’t just leave it. Contact your HMO through all available channels—calls, WhatsApp, email, or in-person visit. Request for details and ask for a written explanation. In cases where you believe you’ve been unfairly denied, escalate to the National Health Insurance Authority (NHIA) by submitting a formal complaint. They will investigate the matter and can enforce accountability on HMOs or hospitals acting improperly.

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