What Does Health Insurance Cover in Nigeria?

Health insurance has become more important than ever in Nigeria. With rising medical costs, poor access to public hospitals, and the financial pressure of paying for treatment out of pocket, more people are turning to health insurance as a safety net. But many Nigerians still have questions—especially about what exactly health insurance covers. Does it include surgeries? What about childbirth? Will it cover malaria treatment or just big hospital procedures? These are valid concerns. Getting a policy is one thing; knowing what you’re paying for is another. This article looks into the types of services typically included in a Nigerian health insurance plan so you don’t end up surprised when you need it most.

The Basics of Health Insurance Coverage

In Nigeria, health insurance is offered by both public schemes and private companies. The most popular public scheme is the National Health Insurance Authority (NHIA, formerly NHIS), while the private side includes Health Maintenance Organizations (HMOs) like AXA Mansard, Hygeia, Avon, and Reliance. Though coverage varies across providers, most standard health insurance plans in Nigeria are structured to include three main areas:

• Outpatient services (care without hospital admission)
• Inpatient services (hospital admission and surgeries)
• Emergency and preventive care

How much of each you get depends on your plan level and the provider you choose.

What Is Typically Covered Under Most Plans?

1. Consultations with Doctors

This is the most basic service included in any plan. You’ll be able to see general practitioners and sometimes specialists (depending on your plan) without paying cash every time. Visits to the doctor for malaria, infections, fever, and body pain are usually included.

2. Laboratory Tests 

Basic diagnostic tests are often covered, such as blood tests, urine tests, malaria screening, pregnancy tests, and typhoid diagnostics. If you go in for a consultation and the doctor recommends tests, your plan should cover it if it’s on the approved list.

3. Prescribed Medications

Most health insurance plans will cover medications for common conditions, but only those listed in the insurer’s approved drug list (called a drug formulary). If the doctor prescribes something outside that list, you’ll need to pay for it.

4. Hospital Admissions

If you need to be admitted for treatment, a good health insurance plan should cover it. This may include bed charges, feeding, doctor visits during admission, and medications. However, the number of admission days allowed per year might be limited based on your plan.

5. Surgeries and Procedures

Many plans cover minor surgeries like appendectomy, hernia repairs, and C-sections. However, not every plan covers major or complex surgeries. Basic plans may exclude procedures that involve specialists or require expensive consumables.

6. Maternity Services

Some plans include antenatal care, childbirth (normal delivery or C-section), postnatal checkups, and baby immunizations. But not all plans have maternity coverage by default—you often need to select a family plan or add maternity as a separate feature.

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7. Immunizations and Child Health

Vaccines and routine child healthcare are typically part of family insurance plans. This includes immunization schedules recommended for infants and toddlers, as well as consultations for fever, colds, and infections.

8. Emergency Care

Emergencies such as accidents, asthma attacks, or sudden illnesses are usually covered under private and government health plans. Ambulance services, however, are rarely included unless you’re on a high-tier plan.

9. Preventive Services

Preventive care is gaining attention in Nigerian insurance policies. Many HMOs now cover basic health screenings such as blood pressure checks, blood sugar, cholesterol, and weight management.

What Is Usually Not Covered?

Knowing what isn’t covered can be just as important as knowing what is. Here are some of the things that health insurance in Nigeria often excludes:

• Treatments for cosmetic or aesthetic purposes (e.g., skin lightening, plastic surgery)
• Dental care beyond simple cleaning and extractions
• Mental health services in most basic plans
• Fertility treatments like IVF
• Organ transplants
• Expensive brand-name drugs when cheaper generic versions exist
• Chronic condition complications not declared during registration
• Non-approved medical facilities or specialists not listed in your plan’s network

It’s important to read your policy document or speak with your HMO representative to be clear on what isn’t covered before emergencies arise.

Coverage Under the National Health Insurance Authority (NHIA)

The government-backed NHIA offers a more basic health insurance structure. Though it may not provide as wide a range of services as some private HMOs, it still includes:

• General outpatient care
• Family planning
• Eye and dental care (limited)
• Hospitalization (to a degree)
• Immunization
• Antenatal and maternity care

NHIA plans often cover civil servants and employees of companies that register under the scheme. It also partners with state governments to provide health insurance for rural and urban dwellers through community-based health programs.

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Private Plans Offer More Flexibility

While government schemes provide basic coverage, private HMOs offer a wider range of services—though at higher costs. You can pick from basic, mid-level, or premium plans. As you move up the ladder, your coverage improves.

Premium plans may include:

• Full specialist care
• CT scans and MRI
• Dental surgeries
• Chronic disease management
• Advanced maternity services
• Referral treatments in private or specialized hospitals

That said, if your budget is limited, starting with a basic private plan is still better than having no coverage at all. You can always upgrade later when your income improves.

What You Should Ask Before Enrolling

If you’re about to choose a health insurance plan, these questions can save you headaches later:

• What hospitals and clinics are part of the plan’s network?
• Are medications included? If yes, which ones?
• How many hospital visits are allowed per year?
• Is there maternity coverage included in the plan?
• Are tests like scans and X-rays covered?
• How fast is the response during emergencies?
• What procedures or services are not covered at all?

The more information you gather ahead of time, the fewer surprises you’ll encounter when you need care.

Tips to Make the Most of Your Plan

Once you sign up, keep track of your entitlements. Visit hospitals only within the provider’s approved list. If you’re referred to a specialist or lab for tests, get authorization from your HMO first to avoid rejection.

Also, always carry your HMO card or digital ID during hospital visits. Without it, hospitals may refuse service or delay treatment.

If you’re confused about any part of your plan—whether it’s benefits, renewal, or usage—don’t hesitate to reach out to your insurer’s customer care.

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