Does HMO cover surgery in Nigeria? What plans pay for, what they leave out, and what to ask

Step by step

1. 1

   Find your benefit schedule

   Get the full list of benefits and exclusions for your plan from your HMO or your employer's HR team.

2. 2

   Ask the seven questions

   Ask your HMO in writing whether it pays for this operation, its limit, any waiting period, which hospitals, and what you will pay yourself.

3. 3

   Get a written quote from the hospital

   Ask the hospital for the full price, so you can see the gap between it and what the HMO will pay.

4. 4

   Wait for the authorisation code

   Do not agree an admission date for a planned operation until the HMO has approved it, or until you have decided to pay yourself.

5. 5

   Keep every message

   Keep the HMO's approval, the code and the hospital's quote together. They settle most arguments later.

The kinds of plan people in Nigeria have

Most people with health insurance in Nigeria have one of three kinds of plan. The first is the national scheme run under the National Health Insurance Authority (NHIA), often through an employer, with an HMO managing your care. The second is a private plan bought from an HMO, by your employer or by you. The third is a state scheme, such as Ilera Eko in Lagos, run by LASHMA.

All of them have rules about what they pay for. The NHIA itself says its programmes do not cover all ailments: there are exclusions and partial exclusions, and enrollees can only use NHIA-accredited facilities. Private plans each have their own list of benefits, exclusions and hospitals.

Plan tiers and surgery limits

HMO plans are usually sold in tiers. Cheaper plans tend to pay for clinic visits, common drugs and minor procedures, and may pay for little or no major surgery. Higher plans add more operations, but often only up to a set limit per person. In January 2025, Nairametrics reported that one HMO's retail plans capped major surgery at ₦750,000 or ₦1,000,000 per person, depending on the plan. If your operation costs more than your limit, you pay the rest.

Read your own plan's benefit schedule, not a summary on a flyer. The schedule is the document that decides what is paid.

Common reasons an HMO says no

When an HMO refuses or pays only part, it is usually for one of these reasons:

• The operation is on the plan's exclusion list. Cosmetic operations are commonly excluded, even when done for comfort or pain
• You have not yet completed the plan's waiting period for surgery
• The plan's limit for surgery, or for the year, is already used up
• The hospital is not on your HMO's list of providers
• Nobody asked the HMO for approval before a planned operation
• The plan has lapsed because a premium was not paid
• The condition started before you joined, and the plan treats it differently

Prior authorisation: the approval you need before admission

For a planned operation, the hospital or your doctor sends your HMO the diagnosis and the planned operation and asks for approval. If the HMO agrees, it issues an authorisation code. The code is what tells the hospital the HMO will pay its part. Some HMOs approve only part of the cost, and approvals can expire, so check the date if your operation moves.

In an emergency, go to hospital first. The hospital should contact your HMO as soon as it can, and you or your family should call the HMO too.

Co-pays and top-ups

A co-pay is a share of the cost your plan expects you to pay yourself. A top-up is the difference between what your HMO approves and what the operation costs, for example when the bill is above your plan's limit, or the HMO pays for open surgery and you choose keyhole. Ask the hospital and the HMO for both figures in writing, so you know exactly what is yours to pay.

Questions to ask your HMO, in writing

Call or email your HMO with your enrollee number and ask:

• Does my plan pay for this operation? Please give me the name of the benefit it falls under
• Is there a limit for surgery on my plan, and how much of it have I used this year?
• Do I have a waiting period, and has it ended?
• Which hospitals can I use for this operation?
• What do you need from the hospital to approve it, and how long does approval take?
• Will you pay for the surgeon, anaesthetist, theatre, stay, blood and drugs, or only some of these?
• What will I pay myself, as a co-pay or a top-up?

Using your HMO when you ask Mezo for a quote

When you ask Mezo for a surgery quote, you can choose to pay through your HMO and tell us which HMO it is. Your coordinator checks with you what your plan may pay before anything is booked. Mezo cannot promise that your HMO will pay for an operation at a Mezo centre: that depends on your plan and on your HMO.

On an HMO quote, the deposit is your own part. Mezo then asks your HMO to authorise the rest, and your date is agreed after the HMO answers. If the HMO authorises less than it was asked for, the difference is yours to pay on your quote page. If it says no, its part becomes yours. Either way, you know before the day, not at discharge.

Common questions