Kemi: "My HMO said I have to go through a waiting period to access a particular benefit."

Toni: "Me too. My HMO said I can't get treated for something yet because it's a pre-existing condition."

What do these things mean? We'll explain in this thread.

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There are so many misconceptions about HMO terminologies such as pre-existing conditions, exclusions, waiting periods, etc. This thread is an attempt to educate & empower people to make informed decisions on choosing the right health plan.

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1. WaitingPeriods.

Certain health plans have waiting periods for some medical conditions. These protect the system from 'adverse selection'. Remember that all premiums are significantly lower than even just one of the benefits that are covered.
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Adverse selection is when people who know they are already faced with a medical expense rush to buy the Health plan. This can bankrupt any HMO within months so waiting periods are used to mitigate this risk.
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For instance, an annual premium of about N50k would cover childbirth and intermediate surgeries. Labour costs are at least N100k, same for Hernia surgeries. If there are no waiting periods, virtually everyone with a medical condition would buy the plan.

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2. Pre-Existing Conditions

These are medical conditions that already exist before buying a health plan. Some people think that if they don’t put it on their application, the insurer will not find out.
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You owe your insurer a duty to list any pre-existing health conditions; to do otherwise would be fraudulent.

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Some HMOs may decide to waive the pre-existing condition, charge an additional premium or deny the application altogether. They are within their rights to do this.
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#HealthInsurance plans are meant to protect you and cater for unplanned, unforeseen and unexpected medical expenses. We all pray to be healthy all year, every year... but hey, we all fall ill and sometimes very seriously too, without any warning.

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Trying to buy a health plan because you want to offload an onerous financial burden as a result of an existing medical condition is actually an attempt to scam the system. It puts the entire system in jeopardy and can lead to collapse.
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3. Exclusions

Globally, health insurance policies contain exclusions which clarify the causes & types of medical conditions that aren’t covered. HMOs across the world have a core set of exclusions that are universal in nature.
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These universal exclusions include war injuries, self-inflicted injuries, injuries sustained as a result of riots, a felony crime, illegal drug use, terrorist attacks, cosmetic treatments, etc.
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4. Restrictions/Limits

Some medical conditions are not necessarily excluded but they contain limits/restrictions on their benefits. This might relate to maternity benefits and pre-existing conditions.
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There are certain treatments where the HMO will only pay up to a specific amount or cover a particular number of treatments while the person pays the rest.
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5. Hospital network

HMOs have a list of health care providers in its network who cover a wide range of services including GPs, specialists, pharmacies, labs, optical and dental facilities, etc.
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Often, you are asked to pick a primary provider within your network, preferably one closed to your home or workplace. If you get care out-of-network, the HMO may not pay for it.
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There are a few exceptions to the requirement to stay in-network, such as medical emergencies, if you travel out of town or if the HMO doesn’t have an in-network provider for the speciality service you need (this is rare). Still, keep your HMO in the loop.
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Also, access to certain hospitals is based on your premium. While quality is maintained across the board, hospitals charge differently so someone on a N20,000 plan may not be able to access the same hospital or benefits as someone with a N70,000 plan.
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This is is why there are different HMOs, each one offering different plans. The final choice is yours to choose the one that's right for you.
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Once you choose, the HMO is legally (and morally) obligated to provide you with all it states as covered benefits under the plan. With @AVONHMO what you see is what you get. If we don't have the capacity to provide it, we would not communicate it.
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So find an HMO you can trust, choose a plan that works for you and then face your work hustle with all your might .... confident that your health is covered!
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We hope this thread has educated and empowered you. Visit http://avonhealthcare.com  for more empowering health information or check out our Health plans. We have a variety and you can conclude your purchase online in minutes.
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