Service Level Agreement
As part of signing up for Alafia by Reliance HMO Health or the Tranquillity by Reliance HMO, 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 HMOealth plans.
These shall jointly be referred to as the “Parties” and individually as a “Party”
WHEREAS:
1.0 Now it is therefore agreed as follows:
| 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 HMO” 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 HMO or Tranquillity by Reliance HMO 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 | “Care Balance” means the prepaid healthcare credit funded by the Enrollee for use exclusively on eligible services within Reliance HMO’s network. It is maintained exclusively within the Reliance platform and may only be applied toward eligible healthcare expenses under the Tranquility Plan. It is non-transferable, non-withdrawable, discretionary and not to be regarded as a deposit, bank account, electronic money or cash equivalent and does not confer any right of redemption or Refund except as provided in this Agreement. |
| 1.1.6 | “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:
Confidential Information shall not include information which:
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| 1.1.7 | “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. |
| 1.1.8 | “Covered services” means the scope or extent of services to be provided by Reliance HMO under the Alafia by Reliance HMO brand and Tranquility by Reliance HMO 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. |
| 1.1.9 | “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. |
| 1.1.10 | “Effective Date” shall have the meaning ascribed to it under clause 8.1 of this Agreement. |
| 1.1.11 | “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:
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| 1.1.12 | “Enrollee” means the individual who is designated to receive healthcare services under a selected plan, (Alafia or Tranquility by Reliance HMO) whether such person is the Buyer or a third-party beneficiary identified by the Buyer. |
| 1.1.13 | “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. |
| 1.1.14 | “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. |
| 1.1.15 | “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. |
| 1.1.16 | “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. |
| 1.1.17 | “Out-of-Area Services” means healthcare services that are provided by a Provider outside the Enrollee’s Service Area. |
| 1.1.18 | “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. |
| 1.1.19 | “Out-Of-Network Services” means healthcare services provided to an enrollee by an Out-Of-Network Provider or Non-Plan Provider. |
| 1.1.20 | “Pending Deduction” means a provisional record of a service-related charge not yet deducted from the Care Balance, which does not constitute a negative balance or a liability. |
| 1.1.21 | “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. |
| 1.1.22 | “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. |
| 1.1.23 | “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. |
| 1.1.24 | “Reliance HMO” or “Reliance” means Reliance HMO Limited inclusive of its successors-in-title and assigns. |
| 1.1.25 | “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). |
| 1.1.26 | “Refund” means a discretionary reversal of unused Care Balance credits initiated solely by Reliance in limited exception-based circumstances. |
| 1.1.27 | “Service Area” means the Federal Republic of Nigeria. |
| 1.1.28 | “Term” shall have the meaning ascribed to it under clause 8.1 of this Agreement. |
| 1.1.29 | “Tranquility plan” refers to the brand under which Reliance HMO Limited delivers healthcare services pursuant to this Agreement. |
| 1.1.30 | “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. |
| 1.1.31 | “Upgrade of Plans”: If there are any changes in the plans selected by the Enrol |
| 1.1.32 | “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. |
| 1.1.33 | “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. |
2.1 The Buyer hereby engages Reliance HMO to provide the Covered Services to the Enrollees under the Alafia by Reliance HMOealth brand, or Tranquility by Reliance HMO, 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 HMOealth brand and Tranquility by Reliance HMO.
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.
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.
3.3.1 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.
3.4.1 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 Refund under the Tranquility Plan are governed by Section 3.9.4 of this agreement.
3.4.6 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.
3.4.7 Reimbursements without valid authorization from Reliance HMO shall not be paid.
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.
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.
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 denials.
Services requiring pre-authorization include but are not limited to:
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 Admission and 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.
Charges for Primary Care services (including but not limited to telemedicine, prescriptions, and general consultations) shall be deducted from the Enrollee’s Care Balance after the service has been rendered. The exact deduction amount will not be displayed to the Enrollee until processing is complete, which may occur on the same day or weeks later, as determined by Reliance HMO’s TPA workflows.
Charges for Secondary Care services (including but not limited to specialist consultations, diagnostics, and procedures) shall be deducted from the Enrollee’s Care Balance immediately upon authorization. If the Enrollee cancels the service prior to delivery, the deducted amount shall be refunded to the Care Balance within 5 (five) business days.
It is important to note that where a Service is rendered before charges are confirmed, a ‘Pending Deduction’ may be displayed. This does not constitute a loan or obligation and is adjusted only against future Care Balance top-ups.
The Refund shall be governed by the below:
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.
5.1 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.
6.1 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.
7.1 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.
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.
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.
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.
9.1 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.
9.8 Reliance shall not be liable for any expectation that Care Balance is equivalent to or convertible into money or any assumption of liquidity, financial return or transferability associated with the Care Balance.
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.
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:
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.
In relation to the Tranquility Plan, any disputes concerning the Care Balance or delayed Refunds shall first be reported via the “Contact Us” page. Reliance will review and resolve disputes within 5–10 business days of receiving full documentation. This provision shall not override the general dispute resolution procedure set out in Clause 10 of this Agreement.
The Care Balance is a non-transferable healthcare credit facility provided solely to enable access to prepaid healthcare services available within the Reliance network. It does not represent funds held on behalf of Enrollees, nor does it confer any entitlement to cash or monetary redemption outside the context of covered healthcare services.
Reliance does not hold, manage or safeguard Enrollee funds and shall not be deemed a bank, trustee, escrow agent or financial intermediary in respect of any amounts credited to the Care Balance. No fiduciary or custodial relationship is created between Reliance and the Enrollee through the operation of the Care Balance.
Refunds of unused Care Balance credits may be initiated at Reliance’s sole discretion and are subject to internal review and verification. Any such Refund, where applicable, will be processed only in respect of unused service credits and not as a withdrawal or return of money. Enrollees acknowledge that Refunds are not guaranteed, not claimable as of right and may be subject to timing, eligibility or compliance checks.
Enrollees further agree that the Care Balance may not be assigned, pledged, exchanged for cash or consideration or transferred to third parties and that no interest, yield or other financial benefit shall accrue in connection with any unused credit.
12.1 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.
Each Party acknowledges that it is (as applicable)
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:
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.
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.
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.
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.
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.
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.
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.
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.
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.
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 |
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), including, but not limited to, Care Balance-related services such as third-party payment processing fees, currency conversion charges, and non-healthcare transactions 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:
|
| 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:
|
| 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:
|
| Custodial care | The following types of care and associated costs are excluded from coverage under this policy unless otherwise stated in Schedule A:
|
| 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:
|
| Experimental, unorthodox or trado-medical care | The following types of care and associated costs are excluded from coverage under this policy:
|
| Eye Care | The following eye care services and any associated costs are excluded from coverage under this policy:
|
| Audiology | The following hearing-related services, investigations, and treatments are excluded from coverage under this policy:
|
| 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:
|
| Professional and Amateur Sports and High-Risk Recreational Activities | The following bodily injuries and associated costs are excluded from coverage under this policy:
|
| Illnesses of unknown cause | The following conditions and associated costs are excluded from coverage under this policy unless otherwise stated in Schedule A:
|
| Injuries related to intoxication or fights and physical brawls. | The following injuries and associated costs are excluded from coverage under this policy:
|
| Obstetrics | The following obstetric services and associated costs are excluded from coverage under this policy unless otherwise indicated in Schedule A:
|
| 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:
|
| 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:
|
| 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:
For a treatment, service, or supply to be considered Medically Necessary, it must meet the following criteria:
In determining whether a service or supply is appropriate under the circumstances, Reliance HMO will consider:
|
| Miscellaneous Exclusions | The following services and associated costs are excluded from coverage under this policy unless explicitly stated otherwise in Schedule A:
|
