Understanding Health Insurance


What is health insurance?

Health insurance is a type of insurance coverage that pays for your medical services, either in part or in full.

How does it work?

When you buy a health plan, you agree to pay a certain rate or premium to your health insurance company. In return, your HMO agrees to pay your medical bills, provided they are covered by your health plan.

Why should I get a Health Plan?

Medical treatment and screening can quickly get very expensive. A health plan not only helps you manage the cost of receiving medical care—whether routine or unplanned, local or international—but also creates an affordable avenue to access high quality medical services.

What is an HMO?

HMO is an acronym that stands for health maintenance organisation. An HMO provides or arranges managed care for health insurance, self-funded healthcare benefit plans, individuals and other entities, and acts as a liaison with healthcare providers (hospitals, doctors, etc.) on a prepaid basis.

I currently have a Health Plan through my employer. What happens if I leave?

Your employer will only cover your health plan while you are employed with the company. Once you leave employment, you will be responsible for buying an individual health plan to suit your needs.

What is a moratorium?

A moratorium refers to a delay in medical coverage if you have had a pre-existing condition. It excludes all pre-existing conditions for a certain period, usually one to two years, but may then include them after that.

Purchasing A Plan Online


How do I make payment online?

  • Click on “BUY A HEALTH PLAN NOW”
  • Fill in Details and click “Next”
  • Enter the quantity in the box beside the chosen/desired plan and click “Next”
  • Read the Exclusions and the tick the box “I have read and understand the terms and conditions*
  • Choose your payment method and click on “Buy Your Plan”
  •  If you have chosen “Pay Online via U-Bills (Mastercard/Visa/Interswitch/Verve)” you will be redirected to the UBills payment portal where, after confirmation of payment amount, you will be transferred to a secure payment merchant.
  • Select your payment option and click on “Make Payment”

Are my transactions secure?

Your data will be handled confidentially and encrypted with SSL (Secure-Socket-Layer) secure server software. The encrypted information of your order, your name, address, credit card or bank details cannot be read by any third party.

Which payment methods area available on avonhealthcare.com?

We accept payment by debit cards (Verve cards, Naira MasterCard and VISA cards) and by direct bank transfer services.

Are there any fees added to the total when you pay online?

A N100 convenience fee is charged for each successful transaction

I made a payment that was not successful, but I have been debited. What do I do?

Your bank should reverse the transaction within 24 hours. If the funds are yet to be reversed into your account or card you may email info@avonhealthcare.com or call 0700-277-9800.

Membership FAQs


What ages are eligible to apply?

Adults over the age of 18 are eligible to apply for coverage under Avon HMO health plans.

What are the main differences between the health plans?

The main differences between our health plans are the benefits available within each. Pricing for each health plan will also vary by levels of care available with the purchase.

Can I get cover if I am pregnant?

Yes, but only if your plan includes maternity cover.

Can I pay my premium on a monthly basis?

No, the premium is payable annually for the number of members enrolled at the beginning of the policy year.

How many people will the family plan cover?

The family plan will provide coverage for you, your spouse and up to four children.

Do you cover children?

Yes, up to four children are covered within our family health plans.

Can I register with more than one hospital?

No. Kindly select one hospital from our national network of hospitals. This hospital serves as your primary care provider for proper coordination and management of your care. You can change your hospital on request.

How can I change my hospital?

Kindly send an email to callcentre@avonhealthcare.com, stating the name of the new hospital you want to use. You would receive a response confirming the effective date. The operational cut-of date is the 20th day of every month and the effective date is the 1st day of the following month.

Can I choose other hospitals apart from those on your network?

No. We kindly ask that you select a primary care provider on our network. New hospitals may however be included on our network from time to time.

How do you ensure that only hospitals of high standards are on your network?

Avon HMO adopts a rigorous selection process in on-boarding hospitals to our network. This includes a review of the credentials/certifications of the hospital/ staff, and further inspection of the facilities on an ongoing basis. We also welcome feedback from our members.

Is there a guide for the treatment provided by the hospitals?

Yes. Avon HMO has entered into formal agreements with every hospital on our network. The Agreements include guidelines for treatment in line with best practices. This is also monitored by our medical team to ensure that standards are maintained and shortfalls corrected immediately.

What happens if I go to the hospital and I am told that the service I require is not covered?

Kindly verify from your plan handbook. You may also contact the Avon HMO 24-hour Call Centre for verification/ clarification.

How do you monitor the activities of the hospitals on the scheme?

Our medical team monitors the hospitals in various ways, including routine and spot checks. In addition, we have case managers who review admissions and other cases.

What happens if I am dissatisfied with the quality of care from a particular hospital?

You should please formally inform us using any of the above-mentioned channels. This would enable us investigate the case and adequately address the issue. You would also be allowed to change hospital, should you prefer.

In a medical emergency, am I allowed to obtain treatment from healthcare providers within the Avon HMO Provider Network that I am not registered with?

Yes. The provider would only need to contact us to confirm that you are an active member (since you are not registered with them).

What happens in a life-threatening emergency situation or I get involved in an accident and none of your provider hospitals is nearby?

In the event of a life-threatening emergency, you may access care from the closest hospital to you, but kindly contact Avon HMO within 24/ 48 hours max.

If I travel out of station, what happens?

If you are out-of-station (out of your state of registration) and need medical attention, you can access care at any of the Avon HMO Provider Hospitals nationwide. Please contact the Avon HMO 24-hour Call Centre for further assistance.

If I want to get an international health plan, how do I arrange treatment?

Before you seek medical advice and/or treatment overseas, please contact us first. This will allow us to verify the benefits covered by your plan, confirm that your proposed treatment is eligible for payment, and in many cases, contact your provider hospital to arrange direct settlement.

What is your complaints process?

We welcome your feedback on all aspects of your experience with Avon HMO and our network of providers. If you have a complaint, kindly inform us via our 24-hour Call Centre by dialling 0700 277 9800 or contact your Avon HMO client manager to enable us resolve your complaint as efficiently as possible.

How are claims processed?

Your claims can be processed in two ways:

Direct Settlement

  • You contact us to advise what treatment you intend to receive.
  • We confirm that treatment is eligible and that we can pre-authorise (guarantee) payment for it.
  • We send pre-authorisation to you and your chosen medical provider.
  • You complete and sign the pre-authorisation form.
  • Your medical provider attaches the invoice(s) for your treatment and returns the pre-authorisation documents to us.
  • We process the claim and pay your medical provider directly.
  • We send you a ‘payment statement’ advising when and how it was paid, and who received the payment.
  • You settle any shortfall with your medical provider.

Pay and Claim

  • You contact us to advise what treatment you intend to receive.
  • We confirm your cover and benefit limits.
  • You receive treatment and pay your medical provider (usually at time of treatment).
  • You and your medical provider fully complete a claim form and return the claim form to us.
  • We process the claim and pay you. We send you a ‘payment statement’ advising when and how it was paid, and who received the payment.

Can I call the Call Centre anytime?

Yes, the Call Centre is accessible 24 hours a day, 7 days a week.

After payment for the health plan, what next?

You will receive an introductory welcome pack, which will include your Avon ID card and a member handbook that contains all the information about your health plan that you will require for the year.

Provider FAQs


Who can become a contracted healthcare provider with Avon HMO?

Healthcare providers, i.e. hospitals, clinics, etc., that pass our rigorous selection process may become eligible to join the Avon HMO provider network. This involves submission of an application by the prospective provider, followed by a review of your credentials and/or certifications and regular inspection of your facilities.

How soon before we start seeing members at our hospital?

Once you join our Provider Network, your facility will immediately be made available to our members.

How do you develop your tariffs?

Tariffs are a set of prices and rules that help our providers give our members the best value for their plans. Our tariffs were developed in agreement with our providers to ensure they are adequately reimbursed for the delivery of high quality and cost-effective care.

What are the eligibility criteria for capitation?

Any Provider Hospital with a registered member base of 51 and above is eligible for capitation.

What is your fee schedule?

Avon HMO ensures payments are paid to relevant provider hospitals before the first day of the month and that claims are processed and paid within 30-45 days of receipt.

Who do I contact for more information?

For more information, kindly contact our 24-hour Call Centre at 0700 277 9800 to speak with an Avon HMO representative.

General


What is an exclusion?

An exclusion is a condition/ procedure or service that is not covered by your health plan. Any benefit that is not listed on your health plan is an exclusion. Please always seek necessary clarification where required.

What is a pre-existing condition?

A Pre-existing condition is any condition that already existed at the time of purchasing the health plan. All new members are required to disclose this at the time of enrollment and remain liable for non-disclosure or the lack of knowledge should the condition be discovered afterwards.

What is the ‘waiting period’

Some benefits on your health plan are subject to a waiting period of up to 12-18 months. After the waiting period has been completed, these benefits would become automatically active and available permanently.

Can I upgrade my plan whenever I wish?

No. Your health plan is fixed for a period of 12 months and can only be upgraded at renewal, subject to review by the HMO.

How many people does the family plan cover?

Up to six (6) people. The principal, spouse and four legal children under 18 years of age.

What is the maximum age that can be enrolled?

The maximum age is 60 years old.

Can I select a different health plan for each member of my family?

Yes, you can buy different individual plans for each member of your family. Please note that this is different from the option to buy a ‘family plan’ in which case, all family members must be on the same plan.

Can I use my card to get treatment or drugs for my dependants or relative?

No, this is illegal. The ID card is to be used by the owner only.

What happens if I misplace my ID card especially when I need to visit the doctor?

Please notify us promptly and apply for a replacement (charges apply).

Can I call the Call Centre anytime?

Yes, the Call Centre is accessible 24 hours, 7 days a week we are happy to respond to any queries you may have. You can also email us at callcentre@avonhealthcare.com.