SLA for small business

Service Level Agreement 

As part of signing up for Small Business 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:   Your company incorporated under the laws of the Federal Republic of Nigeria, (hereinafter referred to as “the company”) which expression shall wherever the context so permits or admits include its successors-in-title and assigns) of the one part     And:    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 No 18, Jimoh Oladeinde Street, Gbagada, Lagos, Nigeria. (hereinafter referred to as "Reliance" which expression shall wherever the context so permits or admits include its successors-in-title and assigns) of the other part.     

Whereas: 

 

1. The company offers to provide medical benefits to its insured employees/members of staff.  

1. Reliance HMO is a registered Health Maintenance Organization which provides health insurance services.  

1. The company and Reliance HMO have agreed upon the provision of health and medical services for the benefit of the members of staff of the company pursuant to the company’s scheme herein referred to upon the terms and conditions hereinafter appearing. 

 

1. Now therefore it is agreed as follows: 

 

1. Definitions: 

 

1. “This agreement” means this Service Level Agreement and any schedules attached thereto as amended and substituted from time to time; 

 

1. “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 company. 

 

1.  “Beneficiaries” or “enrollees” means the members of staff of the company and defined spouse and dependents approved by the company as eligible to benefit under the medical scheme and the words “beneficiaries” and “enrollees” shall be used interchangeably in this agreement. 

 

1.  “The company” inclusive of its successors-in-title and assigns. 

 

1. “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. 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. “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. “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 

1. Serious impairment of bodily functions or 

1. Serious dysfunction of any bodily organ or part. 

 

1. “The medical scheme” means the health and medical scheme offered, provided and administered by the company for the benefit of the members of its staff in pursuance of which this agreement is made. 

 

1. In-network Provider or Plan-Provider means a duly licensed healthcare provider that has entered into an agreement with the HMO to provide healthcare services to a Plan Member under the Medical Scheme. 

 

1. “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. “Non-covered services” means health and medical care services that are not covered services as defined herein and as at the effective date of this Agreement. 

 

1. “Out-of-Area Services” mean healthcare services that are provided by a Provider outside the enrollee’s service area. 

 

1. “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. “Out-Of-Network Services” means healthcare services provided to an enrollee by an Out-Of-Network Provider or Non-Plan Provider. 

   

1. “Period of cover for New-borns”: All new-borns from parents on family plans (not yet registered under any plan) are automatically covered for the first 6 weeks. Thereafter premium must be paid for cover to continue. 

 

1. “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. However, RELIANCE HMO reserves the right not to treat such anytime it deems it so, if the condition had not been declared at inception.   

1. “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 company/individuals, according to the client’s desired scope of cover. 

 

1. “Premium” means the agreed annual consideration paid by the Company 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 Company. 

 

1. “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. “Reliance HMO” means Reliance HMO Limited inclusive of its successors-in-title and assigns. 

 

1. “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. “Relationship Manager” means an employee of the HMO assigned to the Company for seamless operation. 

 

1. “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. “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. “Waiting Period” means the period when underwriting takes place. This begins with the intending enrollee filling our client data form, RELIANCE HMO doing the necessary documentation and making the healthcare providers’ facilities accessible to the enrolees within 10 minutes of completion of registration online, or 2 weeks of completion of our non-online/hard copy forms. 

   

1. Engagement 

 

1. The company hereby agrees to retain the services of Reliance HMO to offer and make available the Covered Services to the beneficiaries as herein defined and Reliance HMO hereby agrees to offer the Covered Services to the company 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 company to Reliance HMO as herein stipulated. Upgrade of plans shall be entertained only within 1 month of commencement of the scheme. 

 

1. Delivery of services 

 

1. Covered services 

 

1. Reliance HMO shall provide or through approved affiliates arrange for the provision to beneficiaries those covered services that are identified or stipulated in Schedule ‘A’ attached hereto.   The list of covered services may be modified, deleted, substituted or added thereto as may be mutually agreed by the parties hereto. The covered services for each beneficiary are limited to the benefits available on the plans purchased. 

 

1. Such modification shall be in a form as near to as possible to the form of schedule ‘A’ aforesaid endorsed thereon with the effective date of modification and signed for and on behalf of the parties hereto and made pursuant to these presents.    

 

1. All covered services shall be provided in accordance with the generally accepted clinical and legal standards consistent with medical ethics and practices applicable in Nigeria. 

 

1.   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.   

1.   Non-provision of non-covered services 

 

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. 

 

1. Reliance HMO may only 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 company shall be liable for all costs arising therefrom and Reliance HMO shall as much as practicable obtain the prior consent of the company or where it is impracticable to obtain the prior consent of the company, inform the company within 48 hours of commencing or rendering such non-covered service (s) and the company shall be liable for any costs arising therefrom notwithstanding that prior consent was not obtained. 

 

1. Where a service not covered by the medical scheme or plan is desired by an enrollee or the company 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 company. This service would also be recommended when the limits of coverage for such aforementioned services have been exceeded. 

 

1. Reimbursements 

1. An enrollee shall notify RELIANCE HMO before accessing care outside our provider network, 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 24-48 hours of submission.  

 

1. 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; or as a result of an emergency or enrollee’s unawareness of In-Network Provider in an out of services area, or if for any reason he/she is made to pay to an In-Network Provider; or  3.4.2.3 Where he/she is made to pay for a Covered Service by his/her In-Network Provider.   

1. 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.  

 

1. In all cases, RELIANCE HMO decides what is reimbursable; usually what it would have cost RELIANCE HMO to pay at a plan Provider. 

 

1. Reimbursements without a proper authorization from RELIANCE HMO shall not be paid 

  4.0. Payment of Premium     4.1. 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 any of our four plans. The parties agree that this premium is subject to annual review which shall be communicated to the company in writing by Reliance HMO and agreed between the parties prior to the commencement of any renewed term. The reviewed premium shall be determined by factors such as frequency of utilization of the services, hospital tariff, etc.    4.2 Reliance HMO Health Insurance Policy is a prepaid scheme and as such, payments of premium are expected to be paid by the company no later than 15 days into the commencement of the term, and in the case of a renewed term, no later than 15 days prior to the commencement of the renewed term. The company understands that Reliance HMO operates on a “no premium, no cover” basis.    4.3. Where the company fails to pay the premium within the stipulated time, Reliance HMO shall be at liberty to grant the company a further grace period of 15 (fifteen) days within which time the company must pay the outstanding premium.     4.4. In the event that the company 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.     4.5. Where the company intends to add any employee as a beneficiary under the medical scheme during the term of this agreement or any renewed term, the company 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.     

1. Obligations of Reliance HMO 

  5.1 Reliance HMO covenants for the benefit of and hereby agrees with the company as follows:   

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. 

 

1. That it would employ and use equipment, methods, procedures and processes of highest professional standards in performing its obligations under this agreement. 

 

1. That a list of approved Providers will be made available and furnished to the company and the beneficiaries which list shall be deemed annexed hereto whether or not so annexed and form an integral part of this agreement. The company 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 company and the beneficiaries shall have a right of choice among the list of approved Providers. 

 

1. 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. 

 

1. 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. 

 

1. 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. 

 

1. That it will comply with the policies and procedures established by the company for its medical scheme for the beneficiaries provided notice thereof has been given to Reliance HMO and that the policies and procedures do not contravene the spirit of the medical scheme and the provisions of any applicable law. 

 

1. That the covered services shall be provided on a 24-hour per day, 7-day per week, 365(6)-day per year basis. 

 

1. That it will collaborate and cooperate with the company in the exercise of the quality assurance and utilization review processes to be undertaken by the company or on its behalf and help to facilitate such processes. 

 

1. That it shall carry out Quality Assurance and Utilization Review processes and inform the company of its findings.  

 

1. That it will promptly notify an affected enrollee first, and inform the latter of the need to inform the company 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 company 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, RHMO has no right to divulge such confidential information, except when deemed to be in public interest to do so. 

 

1. That it will produce and make available to all enrollees, Reliance HMO identification cards that give them access to care. 

 

1. Obligations of the company 

  6.1 The company hereby agrees with Reliance HMO as follows:   

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. The list of beneficiaries by this reference is deemed annexed hereto and forms an integral part of this agreement whether or not actually annexed to this agreement. 

 

1. That it shall notify Reliance HMO in writing of all its policies, procedures, rules, regulations and schedules that the company considers material to the performance of this agreement as well as any amendments thereto. 

 

1. 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 any of our four plans. This fee shall be multiplied by the total number of beneficiaries under each plans purchased, and will be payable according to the payment frequency selected on our website.   

 

1. That the premium stated above IS NET OF ALL CHARGES. 

 

1. That the company shall pay the premium within the time stipulated in this agreement. The scheme operates on a “no premium, no cover” basis. 

 

1. That Reliance HMO identity card of all staff who leaves the employment of the company 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 company that the concerned staff is no longer in its employment. To ensure such cards are disabled at the appropriate time, updates on those being added to, or leaving the scheme, should be made available to Reliance HMO regularly. Where company is unable to retrieve hard copy cards, a list of exited staff should still be sent to RELIANCE HMO regularly so such enrollees can be disabled as appropriate.  

 

1. 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. 

 

1. 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. 

   

1. 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 Hospital (a grievance), the Company shall promptly notify the HMO in writing of the grievance. Each Party shall indemnify and hold the other harmless from and against any and all claims, liabilities, suits, costs, attorney’s fees and other expenses arising from or related to its action or omissions, other than claims caused wholly by the negligence or willful misconduct of the other Party. 

  7.0 Records and confidentiality    7.1     All confidential data, information and records obtained, created or collected by Reliance HMO relating to the beneficiaries and/or the company in the course of the performance of this agreement shall be kept confidential and secret by Reliance HMO and not made available to third parties for any reason whatsoever, save with the consent of the beneficiary and the company as the case may be or pursuant to any legal or statutory requirement.  7.2  Reliance HMO shall fully indemnify the company for any loss, damage, cost or expense suffered or incurred by the company 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    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 Extension and Renewal  8.2.1 Not later than 90 (ninety) days prior to the expiration of this agreement by normal effluxion of time, the parties hereto shall jointly review the performance of this agreement and mutually decide whether or not to extend the tenure of the agreement for 1 (one) more year or such other time as may be agreed by the parties and subject to such amendments or modifications as they shall mutually agree.    8.2.2   Such renewal or extension of this agreement shall be made in writing by an agreement duly executed by or on behalf of the parties which agreement except if otherwise expressly stated shall be supplemental to this agreement.  The supplemental agreement shall where necessary incorporate such schedules and annexures recognized or contemplated by this agreement to give full effect to this agreement and the supplemental agreement.    8.2.3   In the event that the parties are unable to reach a mutually acceptable agreement for the renewal and extension of this agreement by the expiry date, then the agreement shall automatically lapse and terminate except expressly renewed or extended even for a temporary renewal period.    8.3 Termination for cause  In the event that either party shall fail to keep, observe or perform any covenant, term or provision of this agreement, applicable to such party, the other party shall give the defaulting party notice that specifies the nature of such default.  If the defaulting party shall have failed to cure or remedy such default within 30 (thirty) days after the giving of such notice, the non-defaulting party may terminate this agreement upon a thirty (30)-day notice to the defaulting party.    8.4 Voluntary termination  Either party may terminate this agreement with or without cause upon 30 (thirty) days written notice to the other party.    8.5 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 company 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 company 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 Reliance HMO, the company 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 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.  9.1 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:   

1. 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). 

 

1. If within 30 (thirty) days following the initial meeting, the parties have not resolved the dispute, the dispute shall be referred to arbitration in accordance with clause 9.2 hereof.  

 

1. The parties agree to negotiate in good faith in the initial meeting. 

  9.2 Binding arbitration 

9. i. 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 final and binding arbitration.

 

1. The parties hereby agree that the dispute shall be settled by a sole arbitrator in accordance with the provisions of the valid and prevailing Arbitration and Conciliation Act, or any applicable statute for the time being in force.

  iii Where the Parties are unable to agree on a choice of arbitrator, any Party may apply to the Chairman of the Chartered Institute of Arbitrators, Nigeria and the decision of the Chairman shall be final and binding on the Parties.    iv The place and seat of the arbitration shall be Lagos, Nigeria and the language of the arbitral proceedings shall be English.    10.0 Miscellaneous provisions   

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 company 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.   

1.     Anti-Bribery 

  Each Party acknowledges that it is:  

1. committed to abide by the applicable laws and regulations prohibiting Bribery; and 

1. 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.  10.3 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.     10.4 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.    10.5 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.    10.6 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.    10.7 Notice  Any notice, demand, letter or communication required, permitted or desired to be given hereunder shall be deemed effectively given when personally delivered by 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.     10.8 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.    10.9 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.    10.10 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.    10.11 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.    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:   

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  Provision of artificial limbs
Custodial care	Home care
Dental care	Including, but not limited to dental appliances, implants and 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	Treatment of glaucoma, retinal detachment, cataract extraction or any treatment not specifically mentioned in the benefit cover.  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	Ante-natal care and Delivery services for pregnancies in excess of four, whether the offspring thereof were born under the scheme or not; provided the insurance quota of principal, spouse and four biological children has been filled. Additional child shall attract a premium to be charged by Reliance HMO.  Antenatal & Delivery services for enrollees other than principal insured (if female) or spouse (if male).
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 of newborns of non-covered mothers	RELIANCE HMO shall not cover or pay for any treatment incurred by or for any new-born in the first 6 weeks of life delivered to mothers not covered or enrolled under this policy. We only provide automatic cover for specified services, as listed in the benefit schedule, to new-borns in the first 6 weeks of life delivered to Principal Enrollees or Spouses covered by this policy.
Treatment of newborns not registered after 6 weeks of birth	RELIANCE HMO shall not cover or pay for any treatment incurred by or for any new-born that is not registered after 6weeks of birth.
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  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.  Adults above the age of 65 years.   Children above the age of 24 years.  Replacement/Exchange/Swap during a policy year is possible within the first 3 months of the policy year, provided the exit staff had not accessed care within that first 3 months. No refund of the previous premium paid on the exit staff is allowed.     If any staff joins the company at any time within the period of the scheme, a pro-rated premium is paid on the staff, based on the number of months to expiration of the current plan. Aa full premium is then paid for the staff when a new scheme is commenced in the subsequent year.  Any benefit not explicitly stated in the list of covered services.  Injuries sustained as a result of a criminal action.