Benefit Packages and Coverage

BENEFITU-HEALTH CLASSICU-HEALTH GOLDU-HEALTH DIAMONDU-HEALTH DIAMOND PLUS
OUTPATIENT SERVICES
General Consultation
Specialist Consultation: a) Paediatrician, b) Gynaecologist & Obstetrician
Rare Specialist Consultation:
a) Orthopaedic Surgeon, b) General surgeon, c) ENT surgeon,
d) Psychiatrist etc,

Covered

Covered



3times/year


Covered

Covered



5times /year

Covered

Covered



8times/ year

Covered

Covered



12times/ year
INPATIENT SERVICES
General Consultation
Specialist Consultation: a) Paediatrician, b) Gynaecologist & Obstetrician
Rare Specialist Consultation:
a)Orthopaedic surgeon,b)General surgeon,c)ENTsurgeon,d)Psychiatrist

Admission

Feeding
Nursing Care
Oxygen Administration
Blood Transfusion
Prescribed Medications And Consumables


Covered
Covered



3times/year


General Ward 15days
Covered
Covered
24hours
2pints /year
Covered

Covered
Covered



5times/year


GeneralWard 15 days
Covered
Covered
72hours
3pints /year
Covered

Covered
Covered



8times/year


Private Ward 30 days
Covered
Covered
7days
4pints/year
Covered

Covered
Covered



12times/year


Private Ward
30 days
Covered
Covered
7days
6pints/year
Covered
EMERGENCY AND EVACUATION SERVICES
Ambulance Services: a) Hospital to Hospital, b) Roadside to Hospital
• Emergency Room Stabilization
• Intensive Care Unit (ICU) Services



No
Covered
No



Covered
Covered
No



Covered
Covered
2 day



Covered
Covered
3 days
INVESTIGATIONS:
•HAEMATOLOGY:
a) Haemoglobin, b) RBC, c)PCV, d)WBC, e)Platelets, f)Malaria, g) FBC,
h) ESR, i) Reticulocyte, j) Bleeding time, k) Clotting time, l) Prothrombin time,
m) Blood grouping(ABO, RH), n) HB Genotype, o) Cross match

Covered

Covered

Covered

Covered
MICROBIOLOGY/PARASITOLOGY
• URINE:a) Microscopy, b) Urinalysis, c) Culture & Sensitivity
• STOOL: a) Microscopy R/E, b) Culture & Sensitivity, c) Occult Blood-Fecal
• BLOOD:a) Culture & Sensitivity, b) Trypanosomes
• SEMINAL FLUID: a) Analysis, b) Culture & Sensitivity
• SPUTUM:a) Z.N stain for AFB,b) Culture & Sensitivity
• C.S.F a) Microscopy & Count, b) Gram Stain, c) Culture & Sensitivity,
• SWABS- Pus, Wound, Throat, Eye, Ear, Urethral, Aspirates, HVS,
Endo-cervical e.t.c. a) Microscopy, b) Culture & Sensitivity
• SKIN:
a) Snip (microfilaria),b) Heaf’s/ Mantoux test)
c) Microscopy (KOH mount)
d) Scraping For Fungal Element (culture


Covered

Covered


No

Once a year

Covered

Covered

Covered




Covered

No
No

Covered

Covered


No

Once a year

Covered

Covered

Covered




Covered

Covered
No

Covered

Covered


No

Once a year

Covered

Covered

Covered




Covered

Covered
No

Covered

Covered


Covered

Once a year

Covered

Covered

Covered




Covered

Covered
Covered
• BLOOD CHEMISTRY
Full Electrolytes-(a-d)
a) Sodium
b) Potassium
c) Chloride
d) Bicarbonate
Calcium
Phosphate
Urea
Creatinine
Random Blood Sugar
Fasting blood Sugar
Liver Function Tests-(a-e)
a) Total Bilirubin
b) Direct Bilirubin
c) Alkaline Phosphatase
d) Alanine Aminotransferase (SGPT)
e) Aspartate Aminotransferase (SGOT)
Total Protein
Albumin
Globulin
Cholesterol
Triglyceride
Urinalysis
Lipid profile
Hr Post Prandial Blood Sugar
Oral Glucose Tolerence Test ( GTT)
Uric Acid
Glycocylated Heamoglobin
Pregnancy Test (a-b)
a) Urine
b) Blood
calcium
Hormonal Profiles (A –F )
a) Follicle Stimulating Hormone ( FSH)
b) Luteinizing Hormone (LH)
c) Prolactin
d) Progesterone
e) Testosterone
Creatinine_clearance
Molar Pregnancy (HCG-B )
Thyroid Screening (a-c)
a) Triiodothyronine (T3)
b) Thyroxine (T4)
c) Thyroid Stimulating Hormones(TSH)

Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
No
No
No

Covered
Covered
Covered
Covered
Covered
Covered
No
Covered
Covered
Covered
No
Covered
Covered
Covered
Covered
No
No

No
No
No
No
Covered
Covered
No
No
No
No

Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
No
No
No

Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
No
Covered
Covered
Covered
Covered
Covered
Covered

Covered
Covered
Covered
Covered
Covered
Covered
No
No
No
No

Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered

Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered

Covered
Covered
Covered
Covered
Covered
Covered
No
No
No
No

Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered

Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered

Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
• OTHER SEROLOGICAL TESTS:
a) Widal Test
b) VDRL
c) Rheumatiod Factor
d) Anti-Streptolysin O Titre
e) Hepatitis B Surface Antigen
f) Hepatitis Confirmatory Test
g) HIV Screening
h) HIV Confirmatory Test
i) AIDS Screening:
j) a) CD4 Count
k) b) Viral load
l) Hepatitis C Antigen (HbcAg)
m) Serum Tuberculosis Antigen
n) Chlamydia Antigen
o) Herpes Simplex 1 & 11 Antigen
p) Toxoplasma Gondii
q) Rubella
r) Helicobacter Pylori
s) HISTOLOGY/CYTOLOGY
t) Tissue Biopsy
u) Lymph Nodes Biopsy
v) Pap Smear
w) Fine Needle Aspiration

Covered
Covered
No
No
Covered
No
Covered
No
No
No
No
Covered
No
No
No
No
No
Covered
Covered
Covered
Covered
No
No

Covered
Covered
No
No
Covered
No
Covered
No
No
No
No
Covered
No
Covered
No
No
No
Covered
Covered
Covered
Covered
No
No

Covered
Covered
No
No
Covered
No
Covered
No
No
No
No
Covered
No
Covered
No
No
No
Covered
Covered
Covered
Covered
No
No

Covered
Covered
Covered
Covered
Covered
No
Covered
No
No
No
No
Covered
No
Covered
No
No
No
Covered
Covered
Covered
Covered
No
No
• X-RAYS
a. Upper limb
b. Lower limb
c. Pelvic
d. Chest Xray
e. Cervical Spine
f. Thoracic Spine
g. Thoraco Lumber Spine
h. Lumbar Spine
i. Lumbo Sacral Spine
j. Abdomen
k. Skull

Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
No

Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
No

Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
No

Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered


ULTRASOUND SCANS
a. Obstetric Scan
b. Abdominal Scan
c. Pelvic Scan
d. Breast Scan
e. Bladder Scan
f. AbdominoPelvic Scan
g. Prostate Scan
h. Neck/Thyroid Scan
i. Testes/Scrotal Scan
j. Ovulometry/TV Scan
i. ECG
ii. EEG
iii. CT Scan
iv. MRI Scan

Covered
Covered
Covered
No
Covered
Covered
No
No
No
No
No
No
No
No

Covered
Covered
Covered
Not-Covered
Covered
Covered
Covered
Not-Covered
Not-Covered
Not-Covered
Not-Covered
Not-Covered
Not-Covered
Not-Covered

Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Once/year
Once/year

Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Once/year
Once/year
MATERNITY SERVICES
a. Antenatal Care (ANC)
b. Normal Delivery
c. Assisted (Forceps) Delivery
d. Caesarean Section
e. Anti – D Rogan injection
f. Post Natal Care for New Born Babies
g. Gynaecology Care Investigations: Hormonal assay
Prolactin, FSH, LH, T3, T4, Oestrogen, Progesterone
Investigation of infertility HSG & SFA


Covered
Covered
Covered
No
No
6 weeks

Once a year


Once a year

Covered
Covered
Covered
Covered
Covered
6 weeks

Once a year


Once a year

Covered
Covered
Covered
Covered
Covered
6 weeks

Once a year


Once a year

Covered
Covered
Covered
Covered
Covered
6 weeks

Once a year


Once a year
PAEDIATRICS
a. Incubator Care
b. Child Welfare
c. Exchange Blood Transfusion
• Immunization (National Programme On Immunization):BCG,Measles,
Yellow Fever,Oral Polio,Hepatitis,Penta
•Secondary immunization Pneumovax, Rotavirus, MMR
Meningococcal,meningitis

24hrs
Covered
No



Covered
No
No

48hrs
Covered
No



Covered
Covered
No

72hrs
Covered
No



Covered
Covered
Covered

72hrs
Covered
Covered



Covered
Covered
Covered
DENTAL CARE: (Financial LIMIT)
a) Consultation, b) Primary Dental Care, c) Simple Extractions,
d) Surgical Extractions, e) Scaling & Polishing,
f) Amalgam Filling, g) Composite Filling, h)Root Canal Treatment (RCT),
i)Dental X-ray
N10,000


Covered
N20,000


Covered
N30,000


Covered
N35,000


Covered
OPTICAL CARE: (Financial Limit)
a)Consultation, b) Examination, c) Refraction, d) Tonometry,
e)Provision of Eye Glasses
OPHTHALMOLOGY CARE: a) Consultation,b) Conservative Eye Treatment


N10,000

Covered
Covered
N20,000

Covered
Covered
N30,000

Covered
Covered
N35,000

Covered
Covered
EYE SURGERIES & PROCEDURES (Financial Limit):
a) Pterigium excision,b) Corneal laceration repair,
c) Squint surgery, d) Glaucoma surgery, e) Cataract surgery,
f) Trabeculectomy

No

No
N60,000

Covered
N100,000

Covered
N150,000

Covered
GENERAL SURGERIES:
a) Minor Surgeries
b) Intermediate Surgeries
c) Major Surgeries
Covered
N100,000
No
Covered
N150,000
No
Covered
N250,000
N350,000
Covered
N250,000
N400,000
PHYSIOTHERAPY SERVICES6 sessions/yr10sessions/yr10sessions/yr15 sessions/yr
HEALTH EDUCATION COUNSELING INCLUDING ANNUAL
MEDICAL CHECK UPS:

Health Talks and Preventive Health Tips on Preferred Topics
Family Planning
Covered
Orals only
Covered
Orals & injects
Covered
Covered
Covered
Covered
HIV/AID Voluntary CounsellingCoveredCoveredCoveredCovered
Annual Comprehensive Medical Check up:
Female
a)Full physical examination, b) Full blood count,
c) Blood sugar, analysis, d) Urinalysis, e) Urea,
f) Electrolytes, g) Creatinine, h) Chest x – ray,
i) Lipid profile, j) Breast examination, k) (mammogram if indicated),
l) ECG check for individuals above 35 years, o) Pap Smear for individuals 35 years

Male
a) Full physical examination, b) prostate examination, c) Full blood count,
d)Blood sugar analysis, e) Urinalysis, f) Urea, g) Electrolytes
h) Creatinine, i) Chest x – ray, j) Prostate screening for males above 50 years,
k) ECG check for individuals above 35 years,l) Lipid profile




No












No


No












No


Covered












Covered


Covered












Covered

EXCLUSIONS:

The policy excludes the treatment of chronic ailments which are of a long term nature for which cure is not easily obtainable e.g. Cerebrovascular accident (CVA, Stroke), Degenerative Nerve Diseases, hepatitis/HIV Aids not covered including viral load

The treatment of cancer and leukaemia;The cover granted excludes provision of prosthesis, corrective devices, hearing aids and medical appliances;

Adult immunization is not covered;

Artificial heart implantation and all organ transplants;

The cover excludes all forms of high-tech surgeries e.g. elective cosmetic surgeries, laser surgeries etc.

Self-inflicted injuries, drug addiction or alcoholism or treatment occasioned by the abuse and/or influence of alcohol or hard drugs;

The policy excludes provision of contact lenses and other illness that is not in the benefit package.

The policy excludes treatment of congenital anomaly/birth defects.

The cost of dentures (false teeth), braces, bleaching, implant capping, cosmetic dental procedures and other advanced restorative dental procedures;

The policy shall not cover cost of treatment by alternative medicine and other unorthodox medical practice;

The treatment resulting from participating in war and/or on the outbreak of war, participating in riots, strike, civil commotion or any illegal act.

The treatment resulting from participating in motor racing, motorcycle racing and/or other high-risk sports;

The treatment of Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex Syndrome (ARCS) and all diseases caused by and/or related to Human Immunodeficiency Virus (HIV).

The policy shall exclude treatment arising from occupational accidents. However, the HMO shall treat all occupational accidents for expediency and seek reimbursement for medical bills settled from the client, the clients Employers’ Liability Insurance or other insurance which covers occupational accidents.

The policy shall exclude treatment in the event of epidemics such as tuberculosis, cholera, etc and other medical examination for a group of staff at the request of an employer.

Investigations and treatment for problems relating to infertility e.g. laparoscopy, hydrotubation, I.V.F, G.I.F.T and artificial insemination.

Virility enhancing drugs.

Other advanced immunizations not specified in the plan benefits.

Treatment of obesity.

Speech disorders.

All children (0-20years) on the scheme are not covered for maternity care, cannot undergo evacuation of retained product of conception.

Consultations with unrecognized consultants, hospitals, family doctors, therapists, dental practitioners or complementary medicine practitioners.

Any other treatment, service procedure or investigation not listed in the schedule of covered medical services.

 

 

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