HandWaving
0700-7354-2623
login
Alafia

Alafia Service Level Agreement

Service Level Agreement

As part of signing up for Alafia by Reliance Health you agree to this Service Level Agreement effective from the day you
sign up for the duration of activity of your plan.

This serves as an agreement

BETWEEN

RELIANCE HMO LIMITED, a Health Maintenance Organization incorporated and registered under the laws of the Federal Republic of Nigeria having its place of business at 32, Lanre Awolokun Street, Gbagada Phase II GRA, Lagos, Nigeria. (hereinafter referred to as “Reliance” or “Reliance HMO” which expression shall wherever the context so permits or admits include its successors-in-title and assigns) of the one part.

AND

the buyer (person purchasing the plan) and enrollee (individual using the plan) of Alafia by Reliance Health plans.

These shall jointly be referred to as the “Parties” and individually as a “Party”

WHEREAS:

  1. The Parties and Reliance HMO have agreed upon the provision of health and medical services for the benefit of the parties herein referred to upon the terms and conditions hereinafter appearing.
  2. The Buyer seeks to procure a health insurance plan from Reliance HMO, either for personal coverage or for the benefit of a third-party beneficiary (the “Enrollee”).
  3. The Parties have agreed to enter into this Agreement to establish the terms and conditions governing the provision of health and medical services to the Enrollee pursuant to the selected plan.

 

1.0

Now it is therefore agreed as follows:
1.1 Definitions
1.1.1 “This Agreement” means this Service Level Agreement and any schedules or annexures attached thereto as may be amended and substituted by the Parties from time to time;
1.1.2 “Alafia by Reliance Health” refers to the brand under which Reliance HMO Limited delivers healthcare services pursuant to this Agreement.
1.1.3 “Approved affiliate(s)” means other registered entities affiliated or connected to Reliance HMO through which Alafia by Reliance Health provides the medical services and meets its obligations herein stipulated which affiliates have been prior approved by the Buyer or Enrollee.
1.1.4 “Buyer” means the individual procuring a health insurance plan from Reliance HMO, either for personal coverage or on behalf of an Enrollee.
1.1.5 “Confidential Information” means any and all information, whether written, electronic, oral, or in any other form, disclosed by one party (‘Disclosing Party’) to the other party (‘Receiving Party’) in connection with this Agreement, that is marked as confidential, or which, by its nature or content, should reasonably be understood by the Receiving Party to be confidential. This includes, but is not
limited to:
(i) Healthcare Data, including any personal health information, medical records, diagnoses, treatment history, prescriptions, laboratory results, claims information, and any other health-related data disclosed in connection with the services provided under this
Agreement;
(ii) Customer Information, including personal data of the Buyer or Enrollee, contact details, and any related financial or account information;
(iii) Business and Proprietary Information, including trade secrets, business plans, financial data, proprietary technology, software, designs, formulas, marketing strategies, and
technical specifications; and
(iv) Customer Information, including personal data of the Buyer or Enrollee, contact details, and any related financial or account information;

Confidential Information shall not include information which:
(i) is or becomes publicly available through no fault of the Receiving Party;
(ii) is lawfully obtained from a third party without breach of any obligation of confidentiality;
(iii) is independently developed by the Receiving Party without reference to the Disclosing Party’s Confidential Information; or
(iv) is required to be disclosed by law, court order, or regulatory authority, provided that the Receiving Party gives the Disclosing Party prompt written notice of such requirement and cooperates in any effort to obtain confidential treatment of the information.
1.1.6 “Cover Limit” The overall cover limit refers to the maximum annual reimbursement by RELIANCE HMO to cater for the care and treatment of the Enrollee. These limits are plan specific as stated in this Agreement or any other related coverage documentation. Specific monetary or benefit limits may apply for specific services such as optical, dental, surgical procedures, cancer care. Some services are capped or restricted based on length of stay or number of procedures dispensed.
1.1.7 “Covered services” means the scope or extent of services to be provided by Reliance HMO under the Alafia by Reliance Health brand pursuant hereto and specified in Schedule ‘A’ annexed hereto and made an integral part of this Agreement by this reference. For the avoidance of doubt, Reliance HMO reserves the sole authority to interpret the Covered Services, in accordance with industry standards.
1.1.8 “Critical or Life Threatening” means a medical condition that poses a significant risk of imminent death or serious, irreversible harm to an individual, necessitating immediate medical intervention to prevent a fatal outcome or severe, long-term impairment.
1.1.9 “Effective Date” shall have the meaning ascribed to it under clause 8.1 of this Agreement.
1.1.10 “Emergency Condition” means a medical condition that manifests itself by symptoms of sufficient severity or seriousness, including severe pain, such that a prudent non-medical person with an average knowledge of health and medical care could reasonably expect the absence of immediate medical attention to result
in:
(a) Placing the Enrollee’s health in serious jeopardy; or
(b) Serious impairment of vital bodily functions.
1.1.11 Enrollee” means the individual who is designated to receive healthcare services under the selected plan, whether such person is the Buyer or a third-party beneficiary identified by the Buyer.
1.1.12 “In-network Provider, Provider or Plan-Provider” means a duly licensed healthcare provider that has entered into an agreement with Reliance HMO to provide healthcare services to the Enrollee under the Medical Scheme, based on eligible network and subject to change.
1.1.13 “Medically Necessary” means health care services that a reasonably prudent physician would deem necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malfunctioning or malformed body or member of an Enrollee. This definition explicitly includes services necessary to prevent harm to vital body organs or processes and excludes services provided for aesthetic purposes or purely elective reasons.
1.1.14 “Medical Scheme” means the health and medical scheme offered, provided and administered by the Reliance HMO for the benefit of the Enrollee in pursuance of the terms to which this Agreement is made.
1.1.15 “Non-Covered Services” means health and medical care services that are not covered services as defined herein in Schedule B and as at the effective date of this Agreement.
1.1.16 “Out-of-Area Services” means healthcare services that are provided by a Provider outside the Enrollee’s Service Area.
1.1.17 “Out-Of-Network Provider” means a healthcare provider not accessible to the enrollee. This includes providers not accessible on the enrollee’s tier and providers not related to or affiliated to RELIANCE HMO under the Medical Scheme.
1.1.18 “Out-Of-Network Services” means healthcare services provided to an enrollee by an Out-Of-Network Provider or Non-Plan Provider.
1.1.19 “Pre-existing medical conditions” means any injury, illness, disease, or other physical, medical, mental or nervous condition, disorder or ailment that, with reasonable medical certainty, existed at the time of application or at any time prior to the effective date of the insurance, whether or not previously manifested or symptomatic, diagnosed, treated or disclosed prior to the effective date, including any subsequent, chronic or recurring complications or consequences related thereto or arising there from. This includes the existence of Lumps, Masses, Past Surgeries, and/or complications, proposed surgeries, Hypertension, Diabetes, Asthma, Sickle cell Disease, Multiple Sclerosis, Epilepsy, Blood disorders and others. The health plans have made provision to effectively manage pre-existing conditions, provided that such conditions do not fall under the stated exclusions of this policy.
1.1.20 “Premium” means the agreed consideration paid by the Buyer to RELIANCE HMO per Enrollee per annum for all Covered Services rendered under the Medical Scheme, except the Excluded Services which shall be paid for separately under TPA when authorized by the Buyer. The Premium is subject to annual review upon plan renewal and may be adjusted based on factors including, but not limited to, overall plan utilization and changes in market conditions.
1.1.21 “Quality Assurance” means the process designed and/or adopted by Reliance HMO to monitor and evaluate quality and appropriateness of care, pursue opportunities to improve care and resolve identified problems in the quality and delivery of care under the medical scheme generally and in furtherance of this Agreement.
1.1.22 “Reliance HMO” or “Reliance” means Reliance HMO Limited inclusive of its successors-in-title and assigns.
1.1.23 “Reimbursable” means the amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service. This amount payable as reimbursement is Usual, Customary and Reasonable (UCR).
1.1.24 “Service Area” means the Federal Republic of Nigeria.
1.1.24 “Service Area” means the Federal Republic of Nigeria.
1.1.25 “Term” shall have the meaning ascribed to it under clause 8.1 of this Agreement.
1.1.26 “TPA” means Third Party Administration. It is a system of managing healthcare in which a third party
(here RELIANCE HMO), ‘The Administrator’, is contracted to manage provider networks and medical claims
for the Enrollee to desired scope of cover.
1.1.27 “Upgrade of Plans”: If there are any changes in the plans selected by the Enrollee, these changes will only be effected within the first one month of the policy year. Once this period has elapsed, there will be no more upgrades for the Enrollee till the next policy year. Upgrades request would be accepted or rejected by RELIANCE HMO based on her policy on the minimum number of Enrollees that must be on each plan for any upgrade request.
1.1.28 “Utilization review” means the evaluation exercise by which Reliance HMO or a duly appointed and authorized agent on its behalf determines on a prospective, concurrent and/or a retrospective basis the medical appropriateness of the covered services provided to the Enrollee.
1.1.29 “Waiting Period” means the period of uninterrupted plan coverage that must pass before an Enrollee becomes eligible to access specific benefit categories. The waiting period begins upon the Enrollee’s successful registration and remains in effect for the duration specified for each applicable benefit. During this time, the Enrollee must maintain continuous coverage under the plan to qualify for the benefits subject to the waiting period.

2.0

Engagement
2.1 The Buyer hereby engages Reliance HMO to provide the Covered Services to the Enrollees under the Alafia by Reliance Health brand, and RELIANCE HMO hereby agrees to make such services available to the Buyer or designated Enrollee, subject to the terms and conditions set forth in this Agreement.
2.2 For the avoidance of doubt, the services contemplated herein shall be provided by Reliance HMO under the Alafia by Reliance Health brand.

3.0

Delivery of Services
3.1 Covered services:
3.1.1 Reliance HMO shall provide, or arrange for the provision of, the Covered Services as specified in Schedule A, which is incorporated herein by reference. Reliance HMO reserves the right to amend the scope of Covered Services from time to time, subject to reasonable notice to the Buyer.
3.1.2 The Covered Services shall be provided in accordance with the generally accepted clinical and legal standards consistent with medical ethics and practices applicable in Nigeria.
3.2 Verification of beneficiaries
Except in the case of emergency, Reliance HMO shall at all times utilize mechanisms including but not limited to soft copy identification cards on enrolees’ phones, hard copy identification cards, online services, telephone calls or messaging, which are part of the system of Reliance HMO to confirm an Enrollee’s eligibility to benefit hereunder prior to rendering any Covered Service.
3.3 Non-provision of non-covered services
3.3.1 Reliance HMO shall not be obligated to provide any services that are expressly excluded under Schedule B or that fall outside the scope of the selected plan.
3.3.2 Reliance HMO may only, at its sole discretion, offer or provide non-covered service(s) in an emergency condition, life-threatening condition or situation, or where a TPA services agreement for a particular condition has been mutually concluded. In such a situation, the Enrollee shall be liable for all costs arising therefrom and Reliance HMO shall as much as practicable obtain the prior consent of the Enrollee or where it is impracticable to obtain the prior consent of the Enrollee, inform the Enrollee within 48 (Forty-Eight) hours of commencing or rendering such non-covered service(s) and the Enrollee shall be liable for any costs arising therefrom notwithstanding that prior consent was not obtained.
3.3.3 Where a service not covered by the medical scheme or plan is desired by an enrollee, Reliance HMO may undertake to arrange a discounted rate for this service(s). Reliance HMO shall be refunded the full cost incurred in the provision of this service plus 20% of the full cost of service as administrative fee. This service is only rendered at the instance of the Enrollee. This service would also be recommended when the limits of coverage for such aforementioned services have been exceeded.
3.4 Reimbursements
3.4.1 3.4.1 An Enrollee shall obtain Reliance HMO’s prior written approval before accessing care outside our provider network (except in emergency cases), after approval is given, a reimbursement link is sent to the Enrollee to fill details such as evidence of payment (bills, prescription, doctor’s report and receipt), account details after which reimbursement is processed within 7 (Seven) -14 (Fourteen) business days of submission. Provided that Reliance HMO shall not be obliged to process any reimbursement on a day other than a business day.
3.4.2 An enrollee is entitled to a refund where:
3.4.2.1 In the case of an Emergency Condition, he/she receives Out-of-Network Services; or
3.4.2.2 He/She is out of the service area and receives Out-of-Area Services, having being authorized by Reliance HMO before accessing such care.
3.4.2.3 Where he/she is made to pay for a Covered Service by his/her In-Network Provider.
3.4.3 In any of the above instances, the Enrollee will be required to explain the situation to RELIANCE HMO in writing, enclosing a valid medical report, duly signed by the doctor in charge at the Provider’s facility. Provided that the Parties agree that RELIANCE HMO may request further information and documents from the Enrollee, and RELIANCE HMO shall not be under any obligation to commence processing the reimbursement until it receives the information and/or document from the Enrollee.
3.4.4 In all cases, RELIANCE HMO shall agree to the limit of payment covered by such out-of-network services, such limit shall be determined based on the cost RELIANCE HMO would have paid a Provider; once approved, Reliance HMO shall reimburse the Enrollee for approved payment.
3.4.5 Referrals to secondary or tertiary facilities due to complications or specialist treatment will be reimbursed based on the amount it would have cost Reliance HMO to pay an In-network Provider under the plan purchased.In cases where no facility within the network is available near the Enrollee, the Enrollee will be reimbursed up to the limit of the plan purchased. Prior approval must be obtained from the Reliance HMO Care Coordination (RCC) team, accompanied by referral letters, medical reports, and proof of payment. For the avoidance of doubt, Reimbursement for specialist consultations outside the network is limited to what Reliance HMO would have paid for an in-network provider.
3.4.4 Reimbursements without valid authorization from Reliance HMO shall not be paid.
3.5 Age Limits for Enrollees
Reliance HMO plans have specific age limits for Enrollees. The principal Enrollee shall not be older than eighty-five (85) years at the time of enrollment. Unless otherwise negotiated and explicitly stated in the quote and contract, this standard age limit applies. Reliance HMO reserves the right to deny coverage for previously undisclosed age exceptions.Furthermore, Reliance HMO may request documentation, including government-issued identification, to verify the age of the principal Enrollee. Any discrepancies in the information provided may result in the termination of coverage.
3.6 Limitations on Out-of-Network Services
Reliance HMO provides coverage for accidents and emergencies both within and outside the network, in accordance with applicable regulations. Documentation must be provided to demonstrate the medical necessity and emergency status before reimbursement is granted for out-of-network care.In the case of emergencies, Reliance HMO will reimburse 100% of the cost of stabilization. If treatment continues beyond the first 24 hours, reimbursement will be based on the tariff of a hospital accessible under the Enrollee’s plan. All emergency care is subject to the overall plan benefit limit
3.7 Pre-Authorization and Referrals
All enrollees must comply with the pre-authorization and referral processes for specific treatments or services, as defined by Reliance HMO. Any failure to obtain the necessary pre-authorization or referral prior to treatment may result in the denial of care. The Enrollee acknowledges and accepts responsibility for ensuring compliance with this process to avoid unnecessary care denialsServices requiring pre-authorization include but are not limited to:Specialist ConsultationsPrescribed Medications (Acute and OTC Medications)Prescribed Medications for Chronic IllnessTelemedicine Consultations

Accident and Emergency Care

Inpatient Services

Accommodation for Relative During Critical Care Admission

Basic Lab Tests (Haematology, Chemistry and Microbiology)

Basic Diagnostic Imaging and Procedures

Advanced Laboratory Investigations

Advanced Diagnostic Imaging and Procedures

Surgery and Anaesthesia

Intensive Care Unit

Optical Care, Lenses and Frames

Dental Care

Behavioural/Mental Health Support

Weekly Gym Access

Spa Facials or Body Massage

Antenatal Care & Delivery

Routine Newborn Care (First 29 Days)

Fertility and Reproductive Health Tests

Basic Immunizations

Expanded Immunizations

Family Planning

Emergency Air Ambulance Service

Neonatal Intensive Care and Incubators

Occupational and Speech Therapy

Physiotherapy Care

Durable Medical Equipment

Dialysis

Cancer Care

After Demise Compensation

Wellness Checks

Reimbursed Benefits
3.8 Benefits Category Coverage
Refers to the classification of medical services and items covered under the Reliance HMO plan. It is essential for Enrollees to understand these categories, as they define which services are covered and the specific limits that apply to each category. Examples of benefit categories include: Specialist Consultations, Prescribed Medications (Acute and OTC Medications), Prescribed Medications for Chronic Illness, Telemedicine Consultations, Accident and Emergency Care, Inpatient Services,Accommodation for Relative During Critical Care Admissionand others, all of which are detailed in the table of benefits.For categories with specific limits, any care related to that category will be subject to the designated limit for that category alone, rather than the general plan limits. This means that all services including consultations, emergency treatments, inpatient hospitalizations, surgeries, diagnostics, and any other care related to a specific category (e.g., dental care, surgery or maternity services) will be covered exclusively under the limit assigned to that category. For example, all dental-related services, including consultations, diagnostics, hospitalizations and procedures, will count toward the dental care limit, not the general plan limit. Similarly, hospitalizations and surgeries related to a particular category (e.g., maternity, surgery) will be subject to that category’s specific limit

4.0

Payment of Premium
4.1 Reliance HMO shall be entitled to the Premium to be paid by the Buyer, as consideration for the provision of Covered Services.
4.2 Where the Buyer fails to pay the Premium on or before the subscription end date,, Reliance HMO shall be at liberty to grant the Buyer a grace period of 7 (seven) days within which the outstanding payment must be made. During this grace period, the Buyer shall be restricted from accessing healthcare services under the HMO plan until payment is received.
4.3 If the Buyer fails to make payment within the 7 (seven) days grace period, all graduated benefits under the plan shall be forfeited, and Reliance HMO shall have the right to terminate coverage. Any care or services accessed during the period of restriction or after termination shall be ineligible for reimbursement and shall remain the sole financial responsibility of the Enrollee.

5.0

Obligations of Reliance HMO
5.1 Reliance HMO covenants for the benefit of and hereby agrees with the Enrollee as follows:
5.1.1 That Reliance HMO and each and every of its physicians, medical staff and all personnel shall be duly trained, knowledgeable, licensed and registered as may be required under any applicable law or regulation to perform and carry out the duties performed and carried out by such physician, medical staff or personnel in pursuance of this agreement and the said physicians, medical staff etc. will continue to be qualified to perform and carry out the said duties and render the services contemplated hereby.
5.1.2 That it would employ and use equipment, methods, procedures and processes of highest professional standards in performing its obligations under this Agreement.
5.1.3 That a list of approved Providers will be made available and furnished to the Enrollee which list shall be deemed annexed hereto (whether or not so annexed) and form an integral part of this Agreement. The Enrollee shall be duly informed of any modification to this list before the effective date of such modification, as this may be required from time to time in the course of running the Medical Scheme. The Enrollee shall have a right of choice among the list of approved Providers.
5.1.4 That it represents and warrants that it shall and does have the full legal power and authority to bind its physicians and medical staff and personnel and the approved affiliates and their physicians and medical staff and personnel to the terms and provisions hereof.
5.1.5 That Reliance HMO shall use its best endeavor to ensure that it and each of its physicians and medical staff and personnel shall not differentiate or discriminate in the provision of the Covered Services or meet their obligation hereto as a result of race, color, nationality, origin, ancestry, religion, sex, marital status, sexual orientation, income, health, status or age.
5.1.6 That Reliance HMO reserves the right to include and/or exclude partner hospitals for reasons of medical incompetence or otherwise, from time to time. All this, Reliance HMO shall do, bearing in mind its commitment to service excellence.
5.1.7 That the covered services shall be provided on a 24 (Twenty-Four)-hour per day, 7 (Seven)-day per week, 365(6) (Three Hundred and Sixty-Five or Sixty-Six)-day per year basis, subject to the subscription duration and the activation of any graduated benefits, where applicable
5.1.8 That it shall carry out quality assurance and utilization review processes and inform the Enrollee of its findings.

6.0

Obligations of the Buyer and Enrollee
6.1 The Buyer and Enrollee (as applicable) hereby agrees with Reliance HMO as follows:
6.1.1 That Reliance HMO shall be entitled to the Premium, calculated as the total sum of the Premiums applicable to each Enrollee under the subscribed plan(s) by the Buyer (as applicable). The aggregate Premium shall be determined based on the number of Enrolees and shall be payable in accordance with the selected payment schedule, which may be monthly, quarterly, or annually, as applicable.
6.1.2 That the Premium is net of all applicable taxes, charges and out-of-pocket expenses (if any).
6.1.3 That the Enrolee shall pay the Premium within the time stipulated in this Agreement. The scheme operates on a “no premium, no cover” basis.
6.1.4 Reliance HMO reserves the right to suspend or deactivate any Enrollee account where there is strong suspicion of fraud. In cases where the issue is not resolved within 30 days, Reliance HMO may take independent action, including suspension of the account until the matter is satisfactorily addressed. Additionally, in the event of fraud that is deemed systemic or affects multiple Enrollees, Reliance HMO reserves the right to terminate the Agreement, in addition to any actions taken with respect to individual Enrollee accounts
6.1.5 It shall ensure that all communications with Reliance HMO, are conducted in a professional and respectful manner. The Enrollee agrees not to engage in any form of disparagement or abusive behaviour towards Reliance HMO staff, whether verbally, in writing, or through any other medium.Additionally, Reliance HMO expects all Enrollees to treat staff and members of the Provider network with respect. Verbal, physical, or any form of abusive behaviour towards Reliance HMO staff or Providers will not be tolerated. In cases of such behaviour, Reliance HMO reserves the right to issue warnings, suspend services, or take other appropriate actions, including termination of the contract in cases of repeated or severe misconduct.

7.0

Confidentiality and Data Protection
7.1 Reliance HMO shall maintain the confidentiality of all confidential data, information, and records obtained, created, or collected in connection with the Enrollee during the performance of this Agreement. Reliance HMO shall not disclose such confidential information to any third party, including but not limited to external vendors, without the prior written consent of the Enrollee, except where disclosure is required by law or a statutory obligation. Reliance HMO shall implement appropriate technical and organizational measures to prevent unauthorized access or disclosure.
7.2 Reliance HMO shall indemnify the Enrollee for any loss, damage, cost or expense suffered or incurred by it for any breach of the provisions of clause 7.1 by Reliance HMO.
7.3 The In-Network Provider shall remain responsible to the relevant authorities for any breach of confidence or other obligations imposed by the Hippocratic Oath, any Rules of Professional Conducts and generally accepted clinical/legal standards consistent with best practices in medical ethics applicable
internationally.
7.4 Each Party undertakes to comply with all applicable data protection laws and regulations, including but not limited to the Nigeria Data Protection Regulation 2019 (NDPR), the Nigeria Data Protection Act 2023
(NDPA) and any successor legislation.
7.5 The Parties agree that the processing of personal data under this Agreement shall be governed by a separate Data Processing Agreement (DPA). The DPA will outline in detail the roles, obligations, and responsibilities of each Party concerning the collection, processing, sharing, and protection of
personal data.
7.6 Enrollee consent is required before the processing or sharing of any sensitive personal data, including medical information. The Parties agree not to disclose enrollee medical data to third parties, including clients, friends and family, without such consent, except as required by law.
7.7 Each Party agrees to implement appropriate security measures to protect personal data and to notify the other Party in the event of a data breach, as further detailed in the accompanying DPA
7.8 Both Parties agree to respect the rights of data subjects, including their right to access, rectify, or erase their personal data. These rights and the obligations of each Party shall be detailed in the DPA.
7.9 Reliance HMO acknowledges its legal obligation to comply with applicable public health laws and regulations in Nigeria. Accordingly, Reliance HMO may be required to report certain contagious or notifiable diseases to public health authorities, even without the Enrollee’s consent, where such reporting is mandated by law.Where Reliance HMO becomes aware of an Enrollee with a contagious disease, it shall:
7.9.1 Promptly notify the affected Enrollee;
7.9.2 Provide recommendations to the Enrollee, under confidential cover, on appropriate steps to contain, minimize, or eliminate the spread of the disease; and
7.9.3 Limit any disclosures to public health authorities strictly to the extent required by law and ensure all other personal health information remains confidential.
7.10 Reliance HMO reaffirms its commitment to protecting all personal and health information of Enrollees in compliance with this Agreement and applicable laws, including the Nigeria Data Protection Regulations 2019 (NDPR), Nigeria Data Protection Act 2023 (NDPA) and the National Health Act. All disclosures shall be limited, proportionate, and compliant with legal obligations.

8.0

Effective date, term, renewal and termination
8.1 Effective date
Notwithstanding the date written above, this Agreement shall commence on the (the “Effective Date”) and shall subsist for a period of twelve (12) months unless terminated pursuant hereto (the “Term”). Following the expiration of the current Term, the Parties agree that this Agreement shall automatically renew upon the successful payment of the Premium for the following year.
8.2 Termination for cause
In the event that either Party fails to observe or perform any material covenant, term, or provision of this Agreement applicable to such party, the non-defaulting party shall provide written notice to the defaulting party specifying the nature of such default. If Reliance HMO discovers any irregularities in relation to the Plan, the Plan shall be immediately suspended, and the Enrollee shall be notified accordingly. A review period of thirty (30) days shall be granted for the irregularities to be addressed and resolved. If the defaulting party fails to remedy the irregularities within this period, Reliance HMO shall have the right to terminate the Plan upon written notice.Upon termination, both Parties shall immediately return all Confidential Information and comply with any outstanding obligations. Termination shall not affect any rights or liabilities accrued prior to termination.Reliance HMO reserves the right to terminate this Agreement immediately in the event of non-compliance with established fraud prevention policies or if the Enrollees fail to take reasonable steps to prevent waste, fraud, or abuse. In such instances, Reliance HMO shall have the authority to seek recovery of any amounts associated with fraudulent activities from the Enrollees, including but not limited to costs incurred as a result of fraudulent claims, losses due to improper billing, or any related financial damages.
8.3 Effect of termination
This Agreement shall remain in full force and effect during the period between the date notice of termination is given and the effective date of such termination. As of the date of termination of this Agreement, this Agreement shall be of no further force and effect and each party shall be discharged from all rights, duties and obligations under this agreement except that the Enrolee shall remain liable for covered services then being rendered by Reliance HMO to the Enrollee until the episode of illness then being treated is completed and the obligation of Enrollee for covered services rendered pursuant to this agreement discharged. Any termination of this Agreement (however occasioned) shall not affect any accrued rights or liabilities of any of the parties nor shall it affect the coming into force or the continuance in force of any provision hereof which is expressly or by implication intended to come into or continue in force on or after such termination.In the event that a prepaid payment is made for the premium, upon termination by either party, the Enrollee shall be issued any outstanding sums as refund in excess of all received claims paid already at termination date, including 20% of all IBNRs (Incurred But Not Recorded), on the initial claims received and paid already as at termination date.

9.0

Limitation of Liability and Indemnity
9.1 The Enrollee acknowledges that Reliance HMO shall not be liable for any act or omission of an In-Network Provider or third-party providing services under this Agreement. Reliance HMO shall use its best efforts to ensure that all providers within its network meet the required professional standards; however, any liability arising from medical malpractice or negligence shall rest with the Provider, and Reliance HMO shall not bear responsibility for the same.
9.2 In no event shall Reliance HMO be liable for any indirect, incidental, special, consequential, punitive, or exemplary damages, including but not limited to loss of profits, loss of goodwill, loss of business opportunity, or anticipated savings.
9.3 Notwithstanding anything to the contrary in this Agreement, the total aggregate liability of Reliance HMO, whether in contract, tort (including negligence), or otherwise arising out of or in connection with this Agreement, shall not exceed the total amount of premiums paid by the Enrollee to Reliance HMO during the twelve (12) months immediately preceding the event giving rise to such liability.
9.4 Reliance HMO shall not be liable for any failure or delay in performing its obligations under this Agreement to the extent such failure or delay is caused by events beyond its reasonable control, including but not limited to acts of God, war, civil unrest, strikes, epidemics, pandemics, or government actions.
9.5 The limitations set forth in this clause shall survive the termination or expiration of this Agreement and shall apply to any claims made thereafter relating to events that occurred during the term of this Agreement.
9.6 The Enrollee shall indemnify and hold Reliance HMO harmless from any claims, liabilities, losses, or damages arising from or related to any act or omission by the Enrollee in relation to the performance of this Agreement, including but not limited to claims made by the Enrollee for non-covered services or any breach of confidentiality.
9.7 The Enrollee shall not hold Reliance HMO liable for the negligence, malpractice, or misconduct of any in-network provider or third-party administrator, except where such claims arise from the direct fault or willful misconduct of Reliance HMO.

10.0

Governing Law and Dispute resolution

This Agreement shall be governed and construed in accordance with the laws of the Federal Republic of Nigeria and shall be deemed to have been made in Lagos.
10.1 Initial mediation of dispute
In the event of a dispute between the parties to this Agreement, the following procedure shall be used to resolve this dispute prior to either party pursuing other remedies:
i. A meeting shall be held within 14 (fourteen) days of one party notifying the other that a dispute has arisen, at which all parties are present or represented by individuals with full decision making authority regarding the matters in dispute (initial meeting).
ii. If within 30 (thirty) days following the initial meeting, the parties have not resolved the dispute, the dispute shall be referred to mediation in accordance with clause 10.2 hereof.
iii. The Parties agree to negotiate in good faith in the initial meeting.
10.2 Mediation
Either Party may submit any dispute arising out of this Agreement that is not resolved following the processes above to Mediation. The Mediation shall be conducted under the auspices of the Lagos Multi-Door Courthouse (LMDC) in accordance with its rules and procedures as in force at the time of the dispute. The Parties agree that the decision or settlement reached through mediation shall be final and binding on both Parties, and no further appeal or litigation may be pursued thereafter. The costs of mediation shall be shared equally between the Parties unless otherwise agreed.

11.0

Miscellaneous provisions
11.1 Non-interference with medical care
Nothing in this Agreement is intended to create (nor shall be construed or deemed to create) any right of the Enrollee to intervene in any manner in the professional methods or means by which Reliance HMO renders health services to the Enrolee pursuant hereto. Further, nothing herein shall be construed to require Reliance HMO to take any action inconsistent with professional judgment with respect to the medical care and treatment to be rendered the Enrollee in pursuance hereof.
11.2 Anti-Bribery
Each Party acknowledges that it is (as applicable):
i. committed to abide by the applicable laws and regulations prohibiting Bribery; and
ii. has implemented and will maintain within its organization, policies including but not limited to the Compliance and Ethics Guide, that prohibit any such actions by its officers, employees, affiliates, agents, subcontractors, and any other third parties acting on their behalf.

Each Party shall comply with all applicable anti-bribery and anti-corruption laws, statutes, directives and/or regulations including but not limited to the Corrupt Practices and Other Related Offences Act, 2004, the Economic and Financial Crimes Commission (Establishment) Act; the Money Laundering Prohibition Act, 2004 and all other applicable anti-bribery and anti-corruption regulations and codes of practice.

The Parties further represents, warrants and covenants that, in connection with this Agreement:
a. Neither the Parties, nor their officers, employees, affiliates, agents, subcontractors, nor any other third party acting on their behalf, have committed or will commit any bribery of a customer’s officer, employee, affiliate, agent, subcontractor, or any other third party acting on its behalf; and
b. The Parties have implemented and will maintain adequate anti-bribery policies and controls in place to prevent and detect bribery throughout their organization, whether committed by their officers, employees, affiliates, agents, subcontractors or any other third party acting on their behalf.
c. To the extent permitted by the applicable law a Party shall notify the other Party immediately upon becoming aware or upon becoming reasonably suspicious that an activity carried out in connection with this Agreement has contravened or may have contravened this clause or any anti-bribery law or regulation.
d. A Party may at any-time request evidence of the other Party’s compliance with its obligations under this Agreement.
e. A Party may terminate this Agreement with immediate effect upon written notice- as of right and without any judicial authorization – if during the term of this Agreement, the other Party is convicted of an act of bribery or fails to comply with this clause or any anti-bribery law or regulation even if not connected to this Agreement.
f. To the extent permitted by the applicable law, either Party shall indemnify the other, their officers, employees, affiliates, agents, subcontractors, or any other third party acting on behalf of either Party, against any losses, liabilities, damages, costs (including legal fees) and expenses incurred by, or awarded as a result of any breach of this clause.
11.3 Nature of relationship
In the performance of its work, duties and obligations under this Agreement, it is mutually understood and agreed that Reliance HMO and the approved affiliates and their physicians medical staff and personnel are at all times acting and performing as independent contractors offering and rendering medical services and shall not be deemed or construed as agents of one another.
11.4 Additional assurances
The provisions of this Agreement shall be self-operative and shall require no further agreement by the parties except as may be specifically provided in this agreement. However, at the request of either Party, the other Party may execute such additional instruments and take such additional acts as may be reasonably requested in order to effectuate this agreement.
11.5 Assignment
This Agreement shall inure to the benefit of and be binding upon the parties hereto and their respective legal representatives, successors and assigns and neither party may assign this agreement without the prior written consent of the other except that in the event of an assignment to a related entity by ownership, or control or to any successor entity or organization.
11.6 Waiver
No waiver by either Party of any breach or violation of any provision of this agreement shall operate as, or be construed to be a waiver of any subsequent breach of the same or other provisions.
11.7 Notice
Any notice, demand, letter or communication required, permitted or desired to be given hereunder shall be deemed effectively given when personally delivered by electronic mail, hand or courier addressed to the addresses of the parties as herein contained above or their last known address. The parties may by notice in writing change their addresses for delivery of communication.
11.8 Severability
Should any portion of this agreement be judicially determined to be illegal or unenforceable, the remainder of the agreement shall continue in full force and effect, and the parties may renegotiate the terms affected by the severance.
11.9 Entire agreement
This Agreement supersedes any prior agreements, promises, negotiations or representations; either oral or written relating to the subject matter of this agreement and, except as provided herein may not be modified without the express written approval of both parties.
11.10 Force majeure
Neither Party shall be liable for nor deemed to be in default for any delay or failure to perform under this agreement deemed to result, directly or indirectly, from acts of god, civil or military authority, acts of public enemy, war, accidents, fires, explosions, earthquake, flood, failure of transportation, strike or other work interruptions by either party’s employees or any other cause beyond the reasonable control of either Party.
11.11 Survival
Notwithstanding any provisions contained herein to the contrary, the obligations of the Parties under the provisions of clauses 7 and 9 shall survive the determination of this Agreement.

Schedule A: Details of coverage

The benefits table (Schedule A) has been attached to the SLA.

PLAN NAME SERENITY LITE PLAN SERENITY PLAN
ANNUAL BENEFITS LIMITS IN NAIRA (per enrollee) 1,000,000 2,000,000
PREMIUM (per enrollee)
INDIVIDUAL (ANNUAL – 5% DISCOUNT) 342,000 931,000
INDIVIDUAL (QUARTERLY) 90k 245,000
INDIVIDUAL (MONTHLY) 90k followed by 24,500 per month × 11 months; 30k per month after month 12 210,000 followed by 11×70,000 for 1 year; 82,000 per month from month 13 onwards
TERRITORY NIGERIA NIGERIA
HOSPITAL TIER TIER 4 TIER 2, 3 & 4
HOSPITAL WARD/ROOM GENERAL WARD PRIVATE ROOM
ACCOMMODATION & ADMISSION (2 weeks waiting period applies) Covered up to limit of 14 days per year Covered up to limit of 28 days per year
Accommodation for a relative of a patient on ICU or Neonatal Unit Admission Not covered Not covered
GENERAL CONSULTATIONS 100% covered to plan ceiling 100% covered to plan ceiling
SPECIALIST CONSULTATIONS Covered (limit of 8 sessions per year) Covered (limit of 12 sessions per year)
PRESCRIBED MEDICATIONS (Acute & OTC) Covered to a limit of ₦30,000 acute and chronic medication per month Covered to a limit of ₦80,000 acute and chronic medication per month
PRESCRIBED MEDICATIONS for Chronic Illness Covered to a limit of ₦30,000 per month Covered to a limit of ₦80,000 per month
TELEMEDICINE & TELETHERAPY Covered (unlimited consultations) Covered (unlimited consultations)
ACCIDENT & EMERGENCY CARE (2 weeks waiting period) Covered – 2-week waiting period Covered – 2-week waiting period
ROAD AMBULANCE SERVICES (2 weeks waiting period) Covered – limit of 2 rides per annum, 2-week waiting period Covered – limit of 4 rides per annum, 2-week waiting period
INPATIENT SERVICES (2 weeks waiting period) 100% covered to plan ceiling – 2-week waiting period 100% covered to plan ceiling – 2-week waiting period
BASIC LAB TESTS (Hematology, Chemistry & Microbiology) Covered to outpatient sublimit of ₦250,000; covered to ceiling for inpatient Covered to outpatient sublimit of ₦500,000; covered to ceiling for inpatient
BASIC DIAGNOSTIC IMAGING & PROCEDURES Covered to outpatient sublimit of ₦250,000; covered to ceiling for inpatient Covered to outpatient sublimit of ₦500,000; covered to ceiling for inpatient
ADVANCED LAB INVESTIGATIONS / PATHOLOGY (life-threatening cases only) Covered to outpatient sublimit of ₦250,000; covered to ceiling for inpatient Covered to outpatient sublimit of ₦500,000; covered to ceiling for inpatient
ADVANCED DIAGNOSTIC IMAGING & PROCEDURES (life-threatening cases only) Covered to outpatient sublimit of ₦250,000; covered to ceiling for inpatient Covered to outpatient sublimit of ₦500,000; covered to ceiling for inpatient
SURGERY & ANAESTHESIA (3 month waiting period) Covered up to ₦150,000 global surgical limit per year Covered up to ₦500,000 global surgical limit per year
INTENSIVE CARE UNIT (3 month waiting period) Covered up to 24 hours per year (emergency cases only; ₦100,000/day) Covered up to 48 hours per year; ₦100,000/day
BASIC & ADVANCED EYE TESTS Optical ceiling of ₦15,000 annual limit Optical ceiling of ₦30,000 annual limit
OPTICAL LENSES & FRAMES Optical ceiling of ₦15,000 annual limit Optical ceiling of ₦30,000 annual limit
DENTAL CARE (excludes prosthesis & orthodontics) Dental ceiling of ₦25,000 annual limit Dental ceiling of ₦50,000 annual limit
MENTAL & BEHAVIOURAL HEALTH CONSULTATIONS & THERAPY (outpatient only) Covered for outpatient care (8 sessions per year) Covered for outpatient care (12 sessions per year)
WEEKLY GYM ACCESS NOT COVERED COVERED 1 SESSION PER WEEK

 

MATERNITY CARE
ANTENATAL CARE & DELIVERY NOT COVERED NOT COVERED
FERTILITY & REPRODUCTIVE HEALTH COUNSELLING & CONSULTATIONS NOT COVERED NOT COVERED
FERTILITY & REPRODUCTIVE HEALTH TESTS NOT COVERED NOT COVERED
CARE IN A NEONATAL/SPECIAL BABY CARE UNIT NOT COVERED NOT COVERED
CARE FOR BABIES < 29 DAYS NOT ON THE PLAN NOT COVERED NOT COVERED
HOSPITAL & HOME IMMUNIZATIONS
. NPI univalent vaccines (BCG, Hepatitis B, OPV/IPV, Rotavirus, Yellow Fever, Measles, & Vitamin A) Adult immunizations covered under outpatient annual ₦250,000 limit (Hepatitis B, Yellow Fever & Meningitis only) Adult immunizations covered under outpatient annual ₦500,000 limit (Hepatitis B, Yellow Fever & Meningitis only)
. Trivalent (DPT, MMR) & Tetravalent (DPT & IPV)
. Pentavalent (DPT, Hepatitis B & Hib) & Hexavalent (DPT, Hepatitis B, Hib & IPV)
. Non-NPI univalent vaccines – Pneumococcal, Chicken Pox, Meningitis, & HPV
FAMILY PLANNING
. Copper T Intrauterine Device NOT COVERED NOT COVERED
. Injectables (Depo Provera, Noristerat) NOT COVERED NOT COVERED
. Contraceptive pills NOT COVERED NOT COVERED
. Intradermal implants NOT COVERED NOT COVERED
. Surgical methods are covered up to the surgery limit (vasectomy & tubal ligation) NOT COVERED NOT COVERED
WELLNESS SERVICES & ANNUAL HEALTH CHECK FOR 15 YEARS AND ABOVE (3 months waiting period)
BMI check, general physical exam & blood pressure check – once per year COVERED COVERED
PCV, urinalysis, blood sugar & fasting/random lipid panel – once per year COVERED COVERED
Annual visual acuity check (using Snellen chart) – once per year COVERED COVERED
Mammography (for women ≥ 40 years) – once every two years NOT COVERED COVERED
Fecal occult blood test for colon cancer ≥ 40 years – once per year NOT COVERED COVERED
PSA check (for men ≥ 40 years) – once per year NOT COVERED COVERED
Cognitive & memory screening for the elderly (65+ years) – once per year NOT COVERED COVERED
HIV antibody & Hepatitis B antigen/antibody & Hepatitis C antibody screening – once per lifetime NOT COVERED COVERED
Chest X-ray – once per year NOT COVERED NOT COVERED
Pap smear – once per year NOT COVERED NOT COVERED
Liver & kidney function tests – once per year NOT COVERED NOT COVERED
Blood group & genotype – once per lifetime NOT COVERED NOT COVERED
On-site health checks, health talks/education forums or wellness fairs – twice per year NOT COVERED NOT COVERED
PHYSICAL/SPEECH THERAPY SESSIONS Covered under 8 specialty consultation per year limit Covered under 12 specialty consultation per year limit
8 SESSIONS PER YEAR
PHYSIOTHERAPY CARE Covered under 8 specialty consultation per year limit Covered under 12 specialty consultation per year limit
DURABLE MEDICAL EQUIPMENT NOT COVERED Covered with prescription & medical justification to ₦50,000 limit, 3-month waiting period
CONGENITAL, Autoimmune, Sickle Cell, Cancer & Chronic Kidney Disease (1-year waiting period) Covered under applicable limits after 1-year waiting period Covered under applicable limits after 1-year waiting period
DIALYSIS Covered under applicable limits after 1-year waiting period Covered under applicable limits after 1-year waiting period
AFTER DEMISE COMPENSATION NOT COVERED Covered after 1-year waiting period (up to ₦100,000 limit)

 

OTHER BENEFITS
HOME VISITS BY DOCTORS & NURSES NOT COVERED NOT COVERED
OCCUPATIONAL HEALTH SCREENING NOT COVERED NOT COVERED
EMERGENCY AIR AMBULANCE SERVICE NOT COVERED NOT COVERED
REIMBURSEMENT FOR OUT-OF-COUNTRY EMERGENCIES NOT COVERED NOT COVERED
REIMBURSEMENT FOR DELIVERY ABROAD NOT COVERED NOT COVERED
PERMANENT & TOTAL DISABILITY ARISING FROM ACCIDENTS NOT COVERED NOT COVERED
EMPLOYEE ASSISTANCE PROGRAMS NOT COVERED NOT COVERED

Schedule B: Policy exclusions (non-covered services)

Exclusions and limits apply to all costs associated with benefits, diagnoses, or services that are not covered under this policy. “Services” include all drugs, equipment, devices, treatments, therapeutic procedures, and diagnostic procedures required to treat the excluded or limited benefit category or diagnosis.

If a benefit category, service, or diagnosis is not covered, all related services necessary for its treatment will also be excluded, even if those services would otherwise be covered under different circumstances. Non-covered services can still be accessed through our approved providers via our TPA (Third-Party Administrator) service platform.

Except otherwise specifically stated, any services or benefits not listed in (Schedule A) are automatically excluded from coverage under this policy in addition to the following:

Medical examinations, services and supplies. The following medical examinations services and supplies are excluded from coverage under this policy unless otherwise stated in schedule A, including but not limited to:

  • Educational or Licensing Examinations
  • Employment-Related Examinations
  • Medical examinations conducted for the purposes of obtaining, maintaining, or certifying fitness for employment, including any tests, screenings, or related procedures required by employers or potential employers.
  • Medical examinations required as part of admission into schools, compliance with school obligations, or as a condition for obtaining professional licenses, certifications, or insurance coverage.
  • Non-Covered Durable Medical Equipment
  • Preventive and Non-Essential Services: Services unrelated to medical improvement or patient care.
  • Provision, rental, or repair of durable medical equipment, prosthetics, orthotics, hearing aids, or similar devices unless explicitly listed as covered under Schedule A of this policy.
  • Advanced surgeries
Advanced surgeries The following advanced surgical procedures and any associated costs are excluded from coverage under this policy unless otherwise stated in Schedule A, including but not limited to:

  • Cardiac and Cardiothoracic Surgeries: Surgical interventions involving the heart, major blood vessels, or chest cavity.
  • Foetal Surgeries: Any surgical procedures performed on a foetus in utero.
  • Liver Surgeries: Surgical procedures involving the liver, including but not limited to resections and other complex interventions.
  • Neurosurgeries: Surgical procedures involving the brain, spinal cord, or peripheral nerves.
  • Organ Transplants: Transplantation of organs or tissues, including but not limited to heart, liver, kidney, lung, pancreas, and bone marrow transplants.
  • Shunt Operations: Procedures involving the placement, adjustment, or removal of shunts, including those for cerebrospinal fluid drainage.
  • Subspecialist Surgeries and Procedures: Surgeries or medical procedures performed by surgical subspecialists This is including but not limited to joint replacements and other similar high-risk procedures which may require tertiary, critical care or otherwise specialized postoperative care.
Cosmetic Services The following cosmetic services and any associated costs are excluded from coverage under this policy unless otherwise stated in Schedule A, including but not limited to:

  • Artificial Limbs: Provision, replacement, or maintenance of prosthetic limbs, except where explicitly listed as covered under this policy.
  • Cosmetic Surgery: Surgical procedures performed primarily to enhance or alter physical appearance without medical necessity. Medical necessity is defined as procedures required to treat a condition or illness that directly improves medical outcomes, such as survival, or preservation of functionality, of vital organs.
  • Dental Aesthetics: Procedures such as the provision of dentures, advanced conservative restorations, orthodontic treatments, or any associated cosmetic dental services.
  • Hair Treatments: Services for alopecia, baldness, or wigs.
  • Orthodontic and Related Treatments: Any dental or maxillofacial treatments primarily for aesthetic purposes.
  • Personal Comfort Items: Non-essential items that may be claimed as part of care provision including Television or entertainment, beauty services, etc.
Custodial care The following types of care and associated costs are excluded from coverage under this policy unless otherwise stated in Schedule A:

  • Custodial Care: Non-medical care provided to assist with activities of daily living (ADLs), such as bathing, dressing, feeding, toileting, mobility, or other personal care tasks, regardless of whether such care is provided by licensed personnel or family members. This includes care that does not require the supervision of medical professionals or is not intended to treat or improve a specific medical condition.
  • Home Care: Care provided at home primarily for convenience, comfort, or maintenance, including but not limited to homemaker services, companionship, or general supervision. This exclusion applies regardless of whether such care is recommended by a healthcare provider or involves periodic visits by medical personnel.
Cosmetic Dental care The following cosmetic dental services and any associated costs are excluded from coverage under this policy unless otherwise stated in Schedule A, including but not limited to:

  • Associated Supplies and Procedures: Any materials, tools, or follow-up treatments related to cosmetic dental enhancements.
  • Cosmetic Dental Surgeries: Surgical procedures performed to enhance the appearance of teeth, gums, or jawline, including but not limited to gum contouring, tooth reshaping, or other non-medically necessary interventions.
  • Dental Appliances: Provision, replacement, or repair of dental appliances used primarily for cosmetic purposes, such as veneers, crowns, or bridges not required for medical necessity.
  • Dental Implants: Placement, maintenance, or replacement of dental implants or any associated supplies and procedures conducted for aesthetic enhancement.
Experimental, unorthodox or trado-medical care The following types of care and associated costs are excluded from coverage under this policy:

  • Alternative Medicine: Including but not limited to acupuncture, aromatherapy, homeopathy, and herbal remedies.
  • Experimental or Unproven Treatments: Any medical, surgical, or therapeutic procedures, devices or drugs that are not scientifically validated or officially recognized by the relevant regulatory or professional medical bodies as effective and standard care.
  • Traditional Bone-Setting: Treatment of bone fractures or musculoskeletal conditions in traditional bone-setting facilities or by practitioners not recognized within the framework of orthodox medicine.
  • Trado-Medical Practices: Treatments, remedies, or procedures rooted in traditional, cultural, or herbal medicine that lack endorsement or recognition within orthodox medical practice.
Eye Care The following eye care services and any associated costs are excluded from coverage under this policy:

  • Cosmetic or Convenience Treatments: Procedures performed primarily for cosmetic or convenience purposes, including but not limited to laser vision correction (e.g., LASIK, PRK) or other refractive surgeries that are not medically necessary to treat an underlying eye disease or condition.
  • Non-Covered Treatments: Any eye care treatments, procedures, or associated costs not explicitly listed as covered in Schedule A of this policy, which describes the specific benefits included under this plan.
Audiology The following hearing-related services, investigations, and treatments are excluded from coverage under this policy:

  • Hearing Assessments: Tests such as pure tone audiometry, tympanometry, otoacoustic emissions, or any similar diagnostic procedures not explicitly listed as covered under Schedule A.
  • Non-Covered Treatments: Any ear-related treatments, procedures, or associated costs not specifically mentioned in Schedule A of this policy, which outlines the covered benefits.
Force majeure The following conditions and associated costs are excluded from coverage under this policy due to force majeure events, including but not limited to:

  • Epidemics and Pandemics: Events arising from outbreaks of infectious diseases, including epidemics, pestilence and pandemics, that impact the general population.
  • Natural Disasters: Injuries caused by earthquakes and, weather related fire, drought, flooding, heatwaves, landslides etc.
  • Other Force Majeure Events: Any other unforeseeable events beyond the control of the parties involved, such as natural disasters, terrorism, or governmental actions, which disrupt normal operations and services.
  • War, Terrorism and Civil Strife: Injuries or damages sustained because of participation in acts of war, riots, terrorism, strikes, civil unrest, or any form of civil strife.
Professional and Amateur Sports and High-Risk Recreational Activities The following bodily injuries and associated costs are excluded from coverage under this policy:

  • Professional and Amateur Sports: Injuries arising from participation in professional or amateur sports, or any sports where the individual is compensated for their involvement or where participation is for competitive purposes.
  • High-Risk Activities: Bodily injuries resulting from participation in high-risk recreational activities, including but not limited to mountaineering, aviation, hand gliding and parachuting, horse racing, motor racing.
Illnesses of unknown cause The following conditions and associated costs are excluded from coverage under this policy unless otherwise stated in Schedule A:

  • Diseases of Unknown Cause: Any illnesses, diseases, or medical conditions where the underlying cause is undetermined or unknown, and no conclusive diagnosis can be made based on available medical evidence.
  • All autoimmune conditions.
Injuries related to intoxication or fights and physical brawls. The following injuries and associated costs are excluded from coverage under this policy:

  • Drug Addiction: Treatment for drug addiction or rehabilitation services for substance abuse disorders.
  • Fights and Physical Brawls: Injuries sustained while engaging in or as a result of participation in fights, physical brawls, or violent altercations.
  • Injuries Resulting from Criminal Activities: Injuries or disabilities caused while engaging in or attempting to engage in illegal activities, including but not limited to theft, assault, or any criminal action.
  • Intoxication: Injuries or disablement caused wholly or partly by the influence of intoxicating liquor, illegal drugs, or other substances (excluding those prescribed by a licensed medical practitioner).
  • Self-Inflicted Injuries: Injuries resulting from attempted suicide, self-harm, or other willfully inflicted injuries.
Obstetrics The following obstetric services and associated costs are excluded from coverage under this policy unless otherwise indicated in Schedule A:

  • Excessive Pregnancies: Ante-natal care and delivery services for pregnancies in excess of allowable number of plan dependents, whether the offspring are born under the scheme or not. This applies once the insurance quota of allowed dependent quota has been reached. Any additional dependent will attract an additional premium to be charged by Reliance HMO prior to coverage.
  • Fetal Anomaly Scans: Any costs related to fetal anomaly scans, including screenings or diagnostics, are excluded.
  • Molecular Diagnostics and In-Utero Testing: All costs related to molecular diagnostics of parent or foetus or genetic testing performed in utero are excluded.
  • Newborns coverage: RELIANCE HMO shall not cover or pay for any treatment incurred by or for any new-born that is not registered after 6weeks of birth.
  • Non-Covered Individuals: Antenatal and delivery services for individuals other than the principal insured or covered legal spouse of the principal insured. RELIANCE HMO shall not cover or pay for any treatment incurred by or for any new-born in the first 6 weeks of life delivered to persons who are not covered or enrolled under this policy. We only provide automatic cover for specified services, as listed in the benefit schedule, to new-borns in the first 6 weeks of life delivered to Principal Enrollees or Spouses covered by this policy.
Mental Health and Behavioural Services The following mental health services and associated costs are excluded from coverage under this policy unless explicitly specified in Schedule A:

  • Inpatient Mental Health Treatment: Inpatient care or hospitalization for mental health conditions is excluded unless specifically covered under the policy.
  • Medication for Psychiatric Conditions: The cost of medications prescribed for the treatment of psychiatric or behavioural conditions is excluded unless otherwise explicated stated under the policy benefits in Schedule A.
  • Suicide or Self-Inflicted Injuries: Medical treatment for injuries sustained from attempted suicide, deliberate self-harm, or other wilfully inflicted injuries.
  • Treatment for Addiction and Intoxication: Services related to the treatment of substance abuse disorders, including addiction to drugs or alcohol.
  • Treatment for injuries or conditions resulting from intoxication or substance use is also excluded.
Excluded Conditions and Treatments The following conditions and associated costs are excluded from coverage under this policy unless otherwise stated in Schedule A, including but not limited to:

  • Age-Related Conditions: Excludes conditions primarily caused by aging, including but not limited to Alzheimer’s disease and cognitive impairments.
  • Autoimmune Diseases: Exclusions include but are not limited to conditions such as lupus, rheumatoid arthritis, and celiac disease.
  • Congenital Abnormalities: Treatment for congenital abnormalities or birth defects is excluded, except for life-threatening cases.
  • Gender-Affirmation and Sterility Treatments: Consultations, Surgeries, treatments, or medications related to gender affirmation or gender transition.
  • Growth Hormone Therapy: Treatments or medications for growth hormone deficiencies or hormonal therapies unless otherwise specified.
  • Illnesses of Unknown Cause: Coverage is excluded for illnesses without a conclusive diagnosis or determined cause.
  • Newborn Treatment: Excludes treatment for newborns of non-covered mothers. No coverage is provided for newborns not registered within six (6) weeks of birth.
  • Obesity Treatments: Surgical and non-surgical treatments for obesity (including morbid obesity) and weight control programs are excluded. Specifically, the use of GLP-1 agonist drugs for weight management or obesity treatment is excluded unless explicitly covered under Schedule A.
  • Sexual Dysfunction and Virility Enhancing Drugs: Consultations, treatments, and medications related to sexual dysfunction or performance enhancement.
  • Smoking Cessation Programs: Treatments, supplies, and therapies aimed at quitting smoking or nicotine addiction.
  • Treatments for sterility, infertility, or related conditions, including sexual dysfunction, are not covered unless otherwise stated in Schedule A.
  • Work-Related Accidents: Injuries or conditions arising from workplace accidents are excluded as per applicable laws.
Overseas treatment All medical expenses incurred for treatments, procedures, or services provided outside the country of Nigeria, except as otherwise outlined and covered in Schedule A.
Treatment, service or supplies considered not to be medically necessary. The following services, treatments, or supplies are excluded from coverage under this policy, even if prescribed, recommended, or approved by the attending physician or dentist:

  • Unproven Treatments: Not validated by regulatory bodies.
  • Alternative Medicine: Including acupuncture, homeopathy, and herbal remedies.
  • Experimental Devices and Drugs.

For a treatment, service, or supply to be considered Medically Necessary, it must meet the following criteria:

  • Effectiveness: The service or supply must be likely to produce a significant positive outcome, and no more likely to produce a negative outcome than any alternative service or supply, both in relation to the specific sickness or injury and the person’s overall health condition.
  • Diagnostic Procedures: A diagnostic procedure must be indicated by the person’s health status and should be likely to provide information that could influence the course of treatment, and no more likely to result in a negative outcome than any alternative diagnostic procedure.
  • Cost Considerations: The diagnosis, care, and treatment must not be more costly (considering all related health expenses) than any alternative service or supply that meets the above criteria.

In determining whether a service or supply is appropriate under the circumstances, Reliance HMO will consider:

  • Information relating to the affected person’s health status;
  • Reports from peer-reviewed medical literature;
  • Guidelines published by nationally recognized healthcare organizations that include supporting scientific data;
  • Opinions from health professionals in the relevant medical specialty; and
  • Any other relevant information brought to Reliance HMO’s attention.
  • The following services or supplies will never be considered Medically Necessary:
  • Non-Technical Services: Services that do not require the technical skills of a medical, mental health, or dental professional.
  • Personal Comfort or Convenience: Services provided mainly for the personal comfort or convenience of the individual, their caregivers, family members, healthcare providers, or healthcare facilities.
  • Inpatient Services Not Required: Services provided solely because the person is an inpatient on any day when their sickness or injury could safely and adequately be diagnosed or treated while not confined to a healthcare facility.
  • Inappropriate Setting: Services furnished solely because of the setting (e.g., inpatient care) when the service could safely and adequately be furnished in a physician’s or dentist’s office, or in a less costly setting.
Miscellaneous Exclusions The following services and associated costs are excluded from coverage under this policy unless explicitly stated otherwise in Schedule A:

  • Excluded Populations: Coverage is not provided for adults over the age of 65 or dependent children above the age of 24, unless explicitly stated as covered under the policy agreement in Schedule A.
  • Injuries Sustained During Criminal Actions: Coverage is excluded for injuries resulting from participation in or as a consequence of criminal actions by the insured individual.
  • Molecular Diagnostics: Molecular diagnostics, including genetic, genomic, and other molecular testing, is excluded from coverage under this plan.
  • Search and Rescue Operations: Expenses related to search and rescue activities for individuals lost in remote areas are excluded.
  • Solicitation of Specific Treatments or Drugs: Any treatment or medication specifically requested by the enrollee but not deemed medically necessary or appropriate by the attending physician is excluded.
  • Unapproved Inpatient Treatment: Inpatient care obtained without documented prior authorization from Reliance HMO is excluded. Queries and concessions must be granted prior to care delivery for coverage.
  • Unlisted Benefits: Any benefit or service not explicitly included in the list of covered services is excluded.