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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. Reliance HMO is a registered Health Maintenance Organization which provides health insurance services under the Alafia and Alafia by Reliance Health brands
  2. 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.

 

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 “Approved affiliate (s)” means other registered entities affiliated or connected to Reliance HMO through which Reliance HMO provides the medical services and meets its obligations herein stipulated which affiliates have been prior approved by the Parties.
1.1.3 “Beneficiaries” or “Enrollees” means the party enrolled to receive medical care via the plan and the words “beneficiaries”, “beneficiary”. “enrollee” and “enrollees” shall be construed accordingly.
1.1.4 “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, trade secrets, business plans, financial data, customer information, proprietary technology, software, designs, formulas, marketing strategies, technical specifications, and any other information that is not generally available to the public or is disclosed under circumstances suggesting confidentiality. Confidential Information shall not include information which:
1. is or becomes publicly available through no fault of the Receiving Party;
2. is lawfully obtained from a third party without breach of any obligation of confidentiality;
3. is independently developed by the Receiving Party without reference to the Disclosing Party’s Confidential Information; or
4. 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.
1.1.5 “Cover Limit”: The overall cover limit refers to the maximum annual reimbursement by RELIANCE HMO to cater for the care and treatment of the enrollees. These limits are plan specific. 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.
1.1.6 “Covered services” means the scope or extent of services to be provided by Reliance HMO pursuant hereto and specified in Schedule ‘A’ annexed hereto and made an integral part of this Agreement by this reference.
1.1.7 “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:
1. Placing the beneficiaries’ health in serious jeopardy
2. Serious impairment of bodily functions or
3. Serious dysfunction of any bodily organ or part.
1.1.8 “In-network 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 Beneficiaries or Enrollees under the Medical Scheme.
1.1.9 “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 a beneficiary/enrollee.
1.1.10 “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.
1.1.11 “Out-of-Area Services” mean healthcare services that are provided by a Provider outside the enrollee’s service area.
1.1.12 “Out-Of-Network Provider or Non-Plan Provider” means a healthcare provider not related to or affiliated to RELIANCE HMO under the Medical Scheme.
1.1.13 “Out-Of-Network Services” means healthcare services provided to an enrollee by an Out-Of-Network Provider or Non-Plan Provider.
1.1.14 “Period of cover for New-borns”: All new-borns, from parents on family plans (not yet registered under any plan) are covered up to stated limits per plan on the benefits table sold to each client per time.
1.1.15 “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.
1.1.16 “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 employees of a Parties/individuals, according to the client’s desired scope of cover.
1.1.17 “Premium” means the agreed annual consideration paid by the Parties to RELIANCE HMO per enrollee per annum for all Covered Services rendered under the Medical Scheme, as stipulated in the Covered Services Schedule, except the Excluded Services which shall be paid for separately under TPA when authorized by the Parties.
1.1.18 “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.
1.1.19 “Reliance HMO” or “Reliance” means Reliance HMO Limited inclusive of its successors-in-title and assigns.
1.1.20 “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).
1.1.21 “Relationship Manager” means an employee of the HMO assigned to the Parties for seamless operation.
1.1.22 “Upgrade of Plans”: If there are any changes in the plans selected by the enrollees, 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.
1.1.23 “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 beneficiaries/enrollees.
1.1.24 “Waiting Period” means the period when underwriting takes place. This begins with the intending enrollee filling our client data form, RELIANCE HMO preparing the necessary documentation and making the healthcare providers’ facilities accessible to the enrolees within 10 (Ten) minutes of completion of registration online, or 2 (Two) weeks of successful completion of our non-online/hard copy forms.

2.0

Engagement
2.1 The Parties hereby engage Reliance HMO to offer and make available the Covered Services to the Beneficiaries as herein defined and Reliance HMO hereby agrees to provide the Covered Services to the Parties for the purpose aforesaid in consideration of the mutual promises set forth herein and other good and valuable consideration part thereof of which is an annual premium to paid by the Parties to Reliance HMO as herein stipulated. Upgrade of plans shall be entertained only within 1 month of commencement of the Medical Scheme.

3.0

Delivery of Services
3.1 Covered services:
3.1.1 Reliance HMO shall provide or through approved affiliates arrange for the provision to the Beneficiaries the Covered Services as set out in Schedule ‘A’ attached hereto. The Schedule A may be modified, deleted or substituted from time to time by the mutual agreement of the Parties. The Covered Services for each Beneficiary are limited to the benefits available on the plans purchased.
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 enrollees’ phones, hard copy identification cards, online services, telephone calls or messaging, which are part of the system of Reliance HMO to confirm a beneficiary’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 under these presents render or provide to any beneficiary any non-covered services as herein defined. The non-covered services are referred to as exclusions.
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 Third-Party Administration (TPA) services agreement for a particular condition has been mutually concluded. In such a situation, the Parties shall be liable for all costs arising therefrom and Reliance HMO shall as much as practicable obtain the prior consent of the Parties or where it is impracticable to obtain the prior consent of the Parties, inform the Parties within 48 (Forty-Eight) hours of commencing or rendering such non-covered service(s) and the Parties 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 or the Parties requests treatment for a staff not yet registered on the medical scheme or one whose policy has expired, 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 Parties. This service would also be recommended when the limits of coverage for such aforementioned services have been exceeded.
3.4 Reimbursements
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 24 (Twenty-Four)-48 (Forty-Eight) hours 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 plan provider; once approved Reliance HMO shall reimburse the enrollee for approved payment.
3.4.5 Reimbursements without a proper authorization from RELIANCE HMO shall not be paid.

4.0

Payment of Premium
4.1 Reliance HMO shall be entitled to an annual premium to be paid by the Parties, which is the sum total of all the premiums for each beneficiary on each of the subscribed plans.
4.2 Reliance HMO Health Insurance Policy is a prepaid scheme and as such, payments of premium are expected to be paid by the Parties not later than 15 (Fifteen) days into the commencement of the term, and in the case of a renewed term, no later than 7 (Seven) days prior to the commencement of the renewed term. The Parties understands that Reliance HMO operates on a “no premium, no cover” basis.
4.3 Where the Parties fails to pay the premium within the stipulated time, Reliance HMO shall be at liberty to grant the Parties a further grace period of 15 (fifteen) days within which time the Parties must pay the outstanding premium.
4.4 In the event that the Parties fails to pay the outstanding premium within the stipulated time, Reliance HMO may in its discretion, suspend the provisions of the services until the outstanding premium is paid.
4.4 Where the Parties intends to add any employee as a beneficiary under the Medical Scheme during the term of this Agreement or any renewed term, the Parties shall pay Reliance HMO the agreed prorated premium applicable to such employee in advance, for the employee to be enrolled by Reliance HMO as a beneficiary.

5.0

Obligations of Reliance HMO
5.1 Reliance HMO covenants for the benefit of and hereby agrees with the Parties 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 Parties and the beneficiaries which list shall be deemed annexed hereto whether or not so annexed and form an integral part of this agreement. The Parties shall be duly informed of any modification to this list before the effective date of such modification since this may be required from time to time in the course of running the medical scheme. The Parties and the beneficiaries 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 competence or otherwise, from time to time. All this, Reliance HMO shall do, bearing in mind its commitment to service excellence.
5.1.7 That Reliance HMO will comply with the policies and procedures established by the Parties for its medical scheme for the beneficiaries provided a prior written notice thereof has been given to Reliance HMO and accepted by Reliance HMO in writing and that the policies and procedures do not contravene the spirit of the Medical Scheme and the provisions of any applicable law.
5.1.8 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.
5.1.9 That it shall carry out quality assurance and utilization review processes and inform the Parties of its findings.
5.1.10 That it will promptly notify an affected enrollee first and inform the latter of the need to inform the Parties where it has such information, under confidential cover, about any of the enrollees with a contagious disease or the existence of such contagious disease and advice the Parties with steps and action to be taken in relation thereto to contain minimize and eliminate the spread of such disease. In the event that the enrollee refuses to divulge such information, Reliance HMO has no right to divulge such confidential information, except when deemed to be in public interest to do so.
5.1.11 That it will produce and make available to all enrollees, Reliance HMO identification cards, either soft copy or hard copy, that give them access to care14 (fourteen) days of receipt of enrolment documents and information.

6.0

Obligations of the Parties
6.1 The Parties hereby agrees with Reliance HMO as follows:
6.1.1 That it shall duly and promptly furnish Reliance HMO with a list of the beneficiaries entitled to receive Covered Services under this Agreement and promptly update the said list as and when necessary with written notification to Reliance HMO. The list of beneficiaries by this reference is deemed an integral part of this Agreement whether or not actually annexed to this agreement.
6.1.2 That it shall notify Reliance HMO in writing of all its policies, procedures, rules, regulations and schedules that the Parties considers material to the performance of this agreement as well as any amendments thereto.
6.1.3 That Reliance HMO shall be entitled to an annual premium, which is the sum total of all the premiums for each beneficiary on each of the subscribed plans. This fee shall be multiplied by the total number of beneficiaries under each plans subscribed, and will be payable on an agreed payment frequency of quarterly or annually based on the selection of the parties
6.1.4 That the premium stated above IS NET OF ALL CHARGES.
6.1.5 That the Parties shall pay the premium within the time stipulated in this agreement. The scheme operates on a “no premium, no cover” basis.
6.1.6 That Reliance HMO identity card of all staff who leaves the employment of the Parties shall be retrieved and returned to Reliance HMO, if hard copy. Soft copy ID cards would be disabled by Reliance HMO’s internal IT Systems upon being informed by the Parties that the concerned staff is no longer in its employment. To ensure such cards are disabled at the appropriate time, formal updates on those being added to, or leaving the scheme, should be made available by the Parties to Reliance HMO regularly. Where the Parties is unable to retrieve hard copy cards, a list of exited staff should still be sent to RELIANCE HMO immediately upon exit so such enrollees can be disabled as appropriate.
6.1.7 That in contemplation of this agreement it shall perform all such necessary administrative, accounting, enrollment and other functions relating to beneficiary eligibility, determination, claims review data collation and evaluation that will facilitate the performance of this agreement.
6.1.8 That it shall replace, at its own cost, any Reliance HMO hard copy identity card that it wishes to be supplied to an enrollee who had earlier been given one.
6.1.9 Where a Beneficiary has suffered personal or bodily loss or damage including but not limited to bodily injury, sickness, disease, or death, as a result of an act or omission of alleged negligence, misconduct or breach of duty (whether professional or otherwise) on the part of an In-Network Provider/ Hospital (a grievance), the Parties shall promptly notify the In-Network Provider and Reliance HMO in writing of the grievance and the In-Network Provider shall indemnify and hold the Parties harmless from and against any and all claims, liabilities, suits, costs and attorney’s fees.

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 beneficiaries and/or the Parties 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 beneficiary and/or the Parties, 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 Parties for any loss, damage, cost or expense suffered or incurred by the Parties 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.

8.0

Effective date, term, renewal and termination
8.1 Effective date
Notwithstanding the date written above, the effective date and tenure of this agreement is twelve (12) months beginning from the date you sign up for the plan (the “Effective Date”) through to the period your plan ceases to be defined as active and the agreement shall commence on the effective date and extend for its tenure unless terminated pursuant hereto.
8.2 Termination for cause
RelianceHMO also holds the right to terminate the contract at any time after adequate notice of 48 hours due to but not limited to fraud, waste, abuse, violation of terms of this agreement. 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.
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 Parties shall remain liable for covered services then being rendered by Reliance HMO to beneficiaries until the episode of illness then being treated is completed and the obligation of Parties 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 Parties 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 Parties 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 Parties 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 Parties 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 Parties in relation to the performance of this Agreement, including but not limited to claims made by beneficiaries for non-covered services or any breach of confidentiality.
9.7 The Parties shall further indemnify Reliance HMO against any claims or lawsuits arising from 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 7 (seven) 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 9.2 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 in clauses 9.1 (i), (ii), and (iii) 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 Parties to intervene in any manner in the professional methods or means by which Reliance HMO renders health services to beneficiaries 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 beneficiaries in pursuance hereof.
11.2 Anti-Bribery
Each Party acknowledges that it is:
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:
i. 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
ii. 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.
iii. 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.
iv. A Party may at any-time request evidence of the other Party’s compliance with its obligations under this Agreement.
v. 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.
vi. 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 clause 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 SERENITY
ANNUAL BENEFITS LIMITS IN NAIRA (per enrollee) 1,000,000 2,000,000
TERRITORY NIGERIA NIGERIA
HOSPITAL TIER TIER 4 TIER 2, 3 & 4
HOSPTIAL 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 MEDICATIONS) COVERED TO A LIMIT OF #30,000 ACUTE AND CHRONIC MEDICATION LIMIT PER MONTH COVERED TO A LIMIT OF #80,000 ACUTE AND CHRONIC MEDICATION LIMIT PER MONTH
PRESCRIBED MEDICATIONS FOR CHRONIC ILLNESS COVERED TO A LIMIT OF #30,000 ACUTE AND CHRONIC MEDICATION LIMIT PER MONTH COVERED TO A LIMIT OF #80,000 ACUTE AND CHRONIC MEDICATION LIMIT PER MONTH
TELEMEDICINE & TELETHERAPY COVERED (UNLIMITED CONSULTATIONS) COVERED (UNLIMITED CONSULTATIONS)
ACCIDENT AND EMERGENCY CARE (2 weeks waiting period applies) COVERED – 2 week waiting period COVERED – 2 week waiting period
ROAD AMBULANCE SERVICES (2 weeks waiting period applies) COVERED LIMIT OF 2 RIDES PER ANNUM, 2 week waiting perieod COVERED LIMIT OF 4 RIDES PER YEAR – 2 week waiting period
INPATIENT SERVICES (2 week waiting period applies) 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 PLAN OUTPATIENT ANNUAL SUBLIMIT OF #250,000; COVERED TO CEILING FOR INPATIENT COVERED TO PLAN OUTPATIENT ANNUAL SUBCEILING OF #500,000; COVERED TO CEILING FOR INPATIENT
BASIC DIAGNOSTIC IMAGING & PROCEDURES COVERED TO PLAN OUTPATIENT ANNUAL SUBLIMIT OF #250,000; COVERED TO CEILING FOR INPATIENT COVERED TO PLAN OUTPATIENT ANNUAL SUBCEILING OF #500,000; COVERED TO CEILING FOR INPATIENT
ADVANCED LABORATORY INVESTIGATIONS/PATHOLOGY (Life threatening cases only) COVERED TO PLAN OUTPATIENT ANNUAL SUBLIMIT OF #250,000; COVERED TO CEILING FOR INPATIENT COVERED TO PLAN OUTPATIENT ANNUAL SUBCEILING OF #500,000; COVERED TO CEILING FOR INPATIENT
ADVANCED DIAGNOSTIC IMAGING & PROCEDURES (Life threatening cases only) COVERED TO PLAN OUTPATIENT ANNUAL SUBLIMIT OF #250,000; COVERED TO CEILING FOR INPATIENT COVERED TO PLAN OUTPATIENT ANNUAL SUBCEILING 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 FOR UP TO 24 HOURS LIMIT PER YEAR (Emergency cases only; 100,000 per day limit) COVERED FOR UP TO 48 HOURS LIMIT PER YEAR; 100,000 per day limit
BASIC & ADVANCED EYE TESTS OPTICAL CEILING OF #15,000 ANNUAL LIMIT OPTICAL CEILING OF #30,000 ANNUAL LIMIT
OPTICAL LENSES AND FRAMES OPTICAL CEILING OF #15,000 ANNUAL LIMIT OPTICAL CEILING OF #30,000 ANNUAL LIMIT
DENTAL CARE (exclude dental prosthesis and orthodontic care incuding dentures, braces, and implants) DENTAL CEILING OF #25,000 ANNUAL LIMIT DENTAL CEILING OF #50,000 ANNUAL LIMIT
MENTAL & BEHAVIOURAL HEALTH CONSULTATIONS AND 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
SPA FACIALS OR BODY MASSAGE NOT COVERED NOT COVERED
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 vaccies (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 #500,000 ANNUAL 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
. Injectibles (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 examination, & blood pressure check – once per year COVERED COVERED
PCV, urinalysis, blood sugar & fasting or 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 of age) – once every two years COVERED COVERED
Fecal Occult Blood Test for Colon Cancer ≥ 40 years of age – once per year NOT COVERED COVERED
PSA Check (For Men ≥ 40 years of age) – once per year NOT COVERED COVERED
Cognitive & memory screening for the elderly (65 years and above) – once per year NOT COVERED COVERED
HIV antibody & hepatitis B antigen and antibody & hepatits C antibody screening – once per lifetime of plan 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 forum 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 AND 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 NAIRA 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)

These exclusions apply to all benefits/services covered. Services refer to all drugs, equipment, devices, treatment, therapeutic or diagnostic procedures required for treating an enrollee.

Please note that where an ailment is not covered, all services required to treat such will be excluded even if they would have otherwise been covered. All non-covered services can be accessed through us with our approved Providers on our TPA service platform.

Except otherwise specifically stated, the policy shall exclude the following:

Service Exclusions
Medical examinations, services and supplies.
  • Medical examinations for the purposes of obtaining and maintaining employment.
  • Medical examinations for the purposes of admission into schools, as a fulfillment of obligation required by schools from time to time, licensing and/or insurance
  • Including, but not limited to provision of hearing aids.
Advanced surgeries
  • Including, but not limited to Fetal surgeries, Neuro surgeries, surgeries of the heart and/or liver, Organ transplant (including bone marrow transplant), shunt operations and cardiothoracic surgeries
Cosmetic services
  • Including, but not limited to cosmetic surgery, dentures, advanced conservative restorations, orthodontic and associated treatment, cosmetic dermatological consultations, procedures and medications
  • Provision of artificial limbs
Custodial care
  • Home care
Dental care
  • Including, but not limited to dental appliances, implants and consumable supplies arising from procedures like surgeries.
Experimental, unorthodox or trado-medical care
  • Including, but not limited to treatment of bone fractures in traditional bone setting homes
  • Any treatment that is not officially recognized by orthodox medicine.
Eye treatment
  • Laser eye surgeries
Force majeure
  • Including, but not limited to Conditions relating to epidemics, Injuries arising from participating in wars, riots, strike and/or civil strife.
Professional sports and high risk sports
  • Bodily injuries arising from partaking in professional sports, including, but not limited to mountaineering where ropes and glides are used, aviation (except when patient is travelling solely as a passenger), Hand gliding and parachuting, horse racing, car and motorbike racing.
Illnesses of unknown cause
  • All diseases arising from unknown causes are excluded.
Injuries related to intoxication or fights and physical brawls.
  • Injuries while under the influence of or disablement due wholly or partly to the effect of intoxicating liquor or drugs other than those prescribed by a medical practitioner;
  • treatment of drug addiction, attempted suicide and/or willfully inflicted injuries.
Obstetrics
  • This plan excludes coverage for all maternity care including but not limited to antenatal care and delivery, fertility and reproductive health counseling, fertility and reproductive health tests, care in a neonatal / special units and care for newborn babies as well as childhood immunizations.
Children
  • This plan excludes coverage for all paediatric care including but not limited to care in a neonatal / special units, care for newborn babies as well as childhood immunizations.
Overseas treatment
  • All medical expenses incurred outside Nigeria.
Treatment, service or supplies considered not to be medically necessary. This applies even if they are prescribed, recommended, or approved by the person’s attending Physician or dentist.

In order for a treatment, service or supply to be considered Medically necessary, the service or supply must:

  • be care or treatment which is likely to produce a significant positive outcome as and no more likely to produce a negative outcome than any alternative service or supply both as to the Sickness or Injury involved and the person’s overall health condition
  • be a diagnostic procedure which is indicated by the health status of the person and be as likely to result in information that could affect the course of treatment as and no more likely to produce a negative outcome than any alternative service or supply both as to the sickness or injury involved and the person’s overall health condition; and
  • as to diagnosis, care and treatment, be not costlier (taking into account all health expenses incurred in connection with the treatment, service or supply), than any alternative service or supply to meet the above tests.

In determining if a service or supply is appropriate under the circumstances, Reliance HMO will take into consideration: information relating to the affected person’s health status; reports in peer reviewed medical literature; reports and guidelines published by nationally recognized health care organizations that include supporting scientific data; the opinion of health professionals in the generally recognized health specialty involved; and any other relevant information brought to Reliance HMO ‘s attention.

In no event will the following services or supplies be considered to be Medically Necessary:

  • those that do not require the technical skills of a medical, a mental health, or a dental professional; or
  • those furnished mainly for the personal comfort or convenience of the person, any person who cares for him or her, or any persons who is part of his or her family, any healthcare provider, or healthcare facility; or
  • those furnished solely because the person is an inpatient on any day on which the person’s Sickness or Injury could safely, and adequately, be diagnosed or treated while not confined; or those furnished solely because of the setting, if the service or supply could safely and adequately be furnished in a Physician’s or a dentist’s office or other less costly setting.
Work-related accidents
  • According to the prescribed law.
Search and rescue
  • RELIANCE HMO shall not cover or pay for search and rescue operations if an enrollee is lost in a remote area.
Treatment for sexual dysfunction
  • RELIANCE HMO shall not pay for appointments and treatments for sexual dysfunction, as well as virility enhancing drugs.
Miscellaneous
  • Solicitation by enrollee of a specific treatment and/or drug where the attending physician has not deemed it appropriate to provide such.
  • Congenital abnormalities/Birth defects are not covered
  • Complications (or further treatment) arising from treatment of ailments not covered by the scheme or treatment received from hospitals not on the network where prior authorization had not been obtained from Reliance HMO, in cases that do not qualify as emergencies.
  • Any benefit not explicitly stated in the list of covered services.
  • Injuries sustained as a result of a criminal action.
  • The plan is available to enrollees up to a maximum age of 85 years.
  • All life threatening conditions must be established by a certified medical doctor, additional documentation may be required to established medical need
  • There is a two week waiting period for inpatient admissions, accidents and emergencies
  • Surgeries, durable medical equipment, wellness screenings and critical care services will only be covered after a 3 month waiting period after commencement of the scheme
  • After demise compensation as well as certain diagnoses and complication of those diagnoses will be subject to 1 year waiting period prior to coverage eligibility, these include chronic and end-stage kidney disease, all cancers/oncological conditions, congenital illness, autoimmune conditions and benign hematological conditions (including sickle cell disease)
  • please carefully review and note all plan limits and exclusions
  • Replacement/Exchange/Swap of covered enrollee during a policy is not allowed under any circumstances
  • Penalties and resetting of waiting periods will apply for plans with coverage interruption during the coverage period to cover unpaid premiums
  • Additional fees may apply for changing plan level and coverage during the year of premium coverage
  • For categories of care that are subject to prior authorization and approvals (specialist consultations, medications, laboratory test and radiology, inpatient admissions, dialysis, dental care, optical care, surgical procedures) – parties are responsible for the payment for any care incurred that was not approved. Specialist consultations require referrals from GP prior to approval.
  • We may request additional medical documentation to establish the medical necessity prior to approval.
  • For example, Reliance Health retail plans are for individuals and families but are not ideal for organized bodies like companies or cooperatives.
  • RH reserves the right to decline claims associated with fraud, waste and abuse. RH plans are also not to be marketed by third parties including existing enrollees or hospitals.
  • Enrollees suspected to engage in fraud, waste and abuse of our plans will be penalized with termination with cause, declined approvals, legal actions to recover losses.
  • KYC Requirements: Parties agree to provide KYC data on request to verify identity upon request. Failure to do so should give us the right to suspend and deactivate the suspected account and terminate with cause.
  • ID fraud – plan covers the individual only and sharing the plan across multiple individuals will be penalized with termination with cause, declined approvals, legal actions to recover losses.
  • No rebates for unused coverage or services on the retail plan.
  • Premiums may be increased based on enrollee’s utilization at the end of the annual term of the contract
  • Contract renews annually unless terminated by either party.
  • Right to Audit: Reliance HMO has the right to audit to ensure compliance with the terms of the agreement, especially in cases of suspected fraud or irregularities.
  • Provider Network Changes: Reliance HMO holds the right to modify the provider network at its discretion. The client will be appropriately notified of such changes within 30 days of such a change.