Terms and Conditions

Last updated: 18th March, 2021

Lafya HealthShare Sharing Guidelines / Terms and Conditions.

This document and its contents contain the official Lafya HealthShare sharing guidelines/ terms and conditions of service.


The following Terms and Conditions (the “Terms”) is a contract between you and Lafya Technologies Limited (“Lafya HealthShare”), a private limited liability company incorporated under the laws of the Federal Republic of Nigeria.

These Terms govern your use of the Lafya HealthShare App, which is a health savings wallet that facilitates the sharing of healthcare costs/medical bills between its customers. By using Lafya HealthShare and all its services, you agree to be bound by the Terms and Sharing Guidelines of Lafya HealthShare. "You" and "your" mean the person who uses or accesses the Lafya HealthShare App. "We," "us," and "our" mean Lafya HealthShare and its successors, affiliates, and assignees.

By registering and signing up to use the Lafya HealthShare App, you agree that you have read, understood, and accepted all of the Terms contained in this Agreement. You also accept and agree that you are solely responsible for understanding and complying with all laws, rules and regulations that may be applicable to your use of the application.

This Agreement is legally binding and serves to govern your use of the Lafya HealthShare App. PLEASE READ AND UNDERSTAND THE TERMS CAREFULLY BEFORE AGREEING TO BE BOUND BY THEM.

Your use of and access to the Lafya HealthShare App are subject at all times to our Terms and Privacy Policy. Please read these Terms and our Privacy Policy carefully. By using or accessing the Services, you represent that you have read and understood these Terms and our Privacy Policy and you agree to be bound by these Terms and our Privacy Policy. If you do not agree to all the terms and conditions of these Terms and our Privacy Policy, do not use or access the Services.

  • By using and accessing the Lafya HealthShare App, you agree that:
  • Lafya HealthShare is not health insurance and is not subject to insurance regulations.
  • Lafya HealthShare is not an insurance company nor any of its services offered through an insurance company.
  • Lafya HealthShare should never be considered as a substitute for a health insurance policy.

    Lafya HealthShare is the product name of Lafya Technologies Ltd, which is a health savings wallet that facilitates the sharing of healthcare costs/medical bills between its customers.

    Customers share one another’s medical expenses, and Lafya HealthShare serves only to facilitate this mutual sharing by deducting part of a customer's savings to cover the bills of those who have incurred eligible medical expenses.

    Subscription to the Lafya HealthShare service and accepting its terms and conditions automatically authorizes Lafya to deduct from your monthly savings the cost of verified medical bills incurred by other customers.

    The sum to be deducted from customers’ accounts is the total medical bill incurred by one customer divided by the total number of participating customers.
    Total sum will include a 9% admin fee.

    It is the obligation of each adult customer to read and understand our Sharing Guidelines.

    • Purpose of Guidelines

      These Guidelines are for use by Lafya HealthShare in directing monthly contributions and deductions in accordance with the service Guidelines. The Guidelines describe the types of medical expenses the members will be covered for.

    • Participation is by Monthly Savings.

      Customers must save monthly to become eligible for Lafya HealthShare. Each member is a self-pay patient who saves monthly contributions, part of which is used to assist another member who has incurred medical expenses. Once on the Lafya HealthShare service, sharing of medical expenses by customers’ is compulsory. Saving on the Lafya HealthShare app creates a legally enforceable right and/or authorization for Lafya to deduct funds from customers’ accounts for the purpose of settling healthcare expenses incurred by fellow customers.


    • Lafya Plus

      Covers the medical bills of an individual by sharing expenses for the treatment of all the approved illnesses under this plan.

      Customers on this plan can get medical cover for up to N2.5 million within one financial year.

      As long as all other guidelines are met, the total bill incurred per medical incident must exceed N1000 to be eligible for sharing.

    • Lafya Ultimate

      Covers the medical bills of a couple (Husband and Wife, or any two persons within one family e.g Brother and Sister or Father and Son etc) by sharing expenses for all the approved illnesses under this plan.

      Customers on this plan can get medical cover for up to N2.5 million within one financial year.

      As long as all other guidelines are met, the total bill incurred per medical incident must exceed N1000 to be eligible for sharing.

    • Lafya Complete

      Covers a Family of five (5) (Husband, wife and a maximum of three children) by sharing expenses for all the approved illnesses under this plan.

      Customers on this plan can get medical cover for up to N2.5 million within one financial year.

      As long as all other guidelines are met, the total bill incurred per medical incident must exceed N1000 to be eligible for sharing.

    • Lafya Rx

      This savings plan covers the drug prescription cost for people with pre-existing conditions and who will be on long term maintenance medication. Lafya Rx plan does not have an age limit and is open to anyone with a pre-existing condition.


    In order to become and remain a Lafya healthShare Member, a person must meet and satisfy the following criteria and requirements:

    • Apply to be a Member.

      Each person(s) applying for Lafya HealthShare membership must signup via the mobile wallet, create a profile, select a plan, submit the medical history form, pay monthly contributions, and be accepted into the program by Lafya HealthShare. Membership begins on the Enrollment Date specified by Lafya HealthShare via email and/or text message to the Sharing Member. If a person(s) does not qualify for membership, the monthly contributions/savings submitted at the time of application will remain in the customers’ wallet but will not be deducted to pay the medical bills of other customers.

    • Submit Medical History.

      To qualify as a Sharing Member, customers must submit a detailed account of their medical history by completing a medical history form on the Lafya HealthShare mobile app. If, at any time, it is discovered that a Sharing Member did not submit a complete and accurate medical history on the Medical History form, either a sharing benefit limitation or membership declination may be issued retroactively to his/her Enrollment Date. In such an event, monthly contributions/savings paid at the time of application will not be refunded.

    • Select at least one Lafya HealthShare Plan

      During sign-up/enrollment, customers must select either the Lafya Plus, Lafya Ultimate or Lafya Complete plan. The Lafya Rx plan can be selected as a single plan or in addition to the other plans.

      The different Lafya HealthShare Plans classifies customers to a selected household size either as single, couple or family. Depending upon household composition, couples and families may be subject to the provisions in Paragraph E below defining dependent children.

      • A single is one Sharing Member on the Lafya Plus or Lafya Rx Plan.
      • A couple is two Sharing Members of the same household related by birth, marriage or adoption.
        This would include:
        • A married couple
        • A parent/guardian and the second Sharing Member as a dependent child.
        • Two dependent children, participating without either parent; (see guidelines regarding dependents below, Paragraph E).
      • A family consists of a minimum of three (3) and a maximum of five (5) Sharing Members of the same household related by birth, marriage or adoption.
        This would include:
        • A married couple and a maximum of three (3) dependent children.
        • One parent/guardian and a maximum of four (4) dependent children.
        • Five (5) dependent children, participating without either parent.
    • Contribute/Save for at least three (3) months.

      To qualify as a sharing member, customers must contribute/save the amount required for the selected plan for three months from the date of enrollment/signing up.

    • List Dependents Accurately

      • An unmarried dependent child may participate with his or her parent(s) or legal guardian(s) under a Sharing Membership up to and including age 21 years.
      • Newborns. A newborn may be added as a dependent to membership.
      • Newly Adopted. A newly adopted child may be added as a dependent to a membership provided all medical criteria is met within the program for acceptance. Parents must however provide adoption papers for verification.
      • Medical Expenses Eligible for Sharing.

        Lafya HealthShare distributes medical expenses on a per person per incident basis for illnesses or injuries provided by clinics, hospitals (inpatient and outpatient), or other Lafya approved providers. Medical expenses eligible for sharing include, but are not limited to, hospital services, emergency medical care, medical testing, x-rays, emergency ambulance transportation and prescriptions, unless otherwise limited or excluded by these Guidelines. Total bills incurred must not exceed the total coverage amount the customer is eligible for in one financial year.
        A Medical Expense Incident is any medically diagnosed condition receiving medical treatment and incurring medical expenses for the same diagnosis.

        Members share these kinds of costs, which may be limited in extent by other paragraphs in these Sharing Guidelines:

        • Acute/Emergency Room Services:Emergency room services for stabilization or initiation of treatment of medical emergencies as well as hospital admissions.
        • Outpatient services:Outpatient consultations, treatment and elective procedures including day case surgeries.
        • Subacute Healthcare services: Facility for Inpatient rehabilitation up to 45 days.
        • Ancillary Therapies (Physiotherapy, dietetics, Speech Therapy, Occupational Therapy, Respiratory Therapy): Up to 12 visits of each therapy type per financial year and must be provided by a Lafya approved therapist/therapy facility, with an additional 8 visits potentially available after reassessment, for a total of 20 visits. All visits after the initial assessment visit require prenotification to be considered for sharing. Up to 36 visits for cardiac rehabilitation.
        • Limb Prosthetics: and their replacement, if medically indicated.
        • Vaccinations: Vaccinations for infectious diseases.
      • Medical Expenses NOT eligible for sharing.

        Medical expenses arising from any one of the following are not eligible for sharing among members.

        • Abortion, Contraceptives, Gender reassignement: Treatment in connection with abortion unless the mother’s health is endangered by the continuation of the Pregnancy and that treatment via a cesarean section has been determined by a neonatologist to be inadvisable. Oral, injectable, implantable and patch contraceptive,IUCDs, condoms, diaphragms, cervical caps, contraceptive sponges, spermicides, vasectomies, tubal ligation and other therapies provided for purposes of contraception. Provision of services/care or treatment for non-congenital transsexualism, gender dysphoria or sexual reassignment or change. This includes medications, implants, hormone therapy, surgery, medical or psychiatric treatment.
        • Alcohol/Drugs: Treatment provided to a Sharing Member for Injury and/or disease and/or organ dysfunction which occurred as a result of that Sharing Member’s abuse and/or use of alcohol or drugs/pharmaceuticals, including, but not limited to, Drug and/or Alcohol Rehabilitation Treatment.
        • Breast Implants: The placement, replacement or removal of breast enhancement devices and complications related to breast implants unless related to reconstructive mammaplasty.
        • Charges before or after Membership: Medical care or treatment for which a charge was incurred before a person was a Sharing Member or after membership ceased or became inactive.
        • Complications of non-eligible treatments: Care, services or treatment required as a result of complications from a treatment not eligible for sharing, or that result from a therapy determined by Lafya HealthShare not to be medically necessary.
        • Custodial care: Services or supplies provided mainly as a rest cure, maintenance, custodial care or other care that does not treat an illness or injury.
        • Dental prostheses: and care or treatment of the person’s teeth above or below the gums, except: the repair of sound natural teeth due to injuries that occur while the person is a Sharing Member.
        • Durable Medical Equipment: The purchase, rental or replacement of durable or reusable equipment or devices. The term "durable medical equipment" - DME - includes, but is not limited to, internal or external hearing aids, orthotics (foot, back, hand, and others), wheelchairs (manual and electric), hospital beds, traction equipment, canes, crutches, walkers, ventilators, oxygen, tubing, masks, monitors, pressure mattresses, lifts, bili blankets and bili lights, external or implanted neurostimulators.
        • Exercise programs: Exercise programs for treatment of any condition, except for Physician supervised cardiac rehabilitation and or physiotherapy.
        • Excessively billed services (See IV.C.5 Excess Charges, below)
        • Expenses where conflicts-of-interest exist: Expenses that result in unnecessary or inappropriate diagnostic or wellness testing being ordered, or which lead to excessive charges, may not be shared. Examples include orders by HCPs that generate revenues for the hospitals or clinics from laboratories or radiology procedures or other tests that they order. Conflicts of interest do not necessarily preclude sharing. But the prices charged, and the appropriateness of the services provided, will be subject to scrutiny by Lafya HealthShare, and may or may not be shared in, partially or completely, based on the results of such scrutiny.
        • Experimental, Investigational, Unproven or Unapproved Services: Care and treatment that is either Experimental, Investigational or Unproven, or that has not been approved by industry recognized authoritative bodies, or that is illegal by Nigerian law.
        • Eye care: Eye exercise therapy, radial keratotomy or other eye surgery to correct short- sightedness or long-sightedness or any other visual problems that could be corrected with corrective eyewear; also, routine eye examinations, including refractions, lenses for the eyes and exams for their fitting. This exclusion does not apply to the initial permanent lenses following cataract removal.
          Ineligible: Optometry. Routine vision exams or any treatment related to vision correction.
          Eligible: Ophthalmology. Treatment of disorders and diseases of the eye not routinely vision correction related.
        • Food or Nutritional formula: Food, including adult or child or baby formulas of any kind. This applies whether or not a prescription is written for the over-the-counter food or formula, and regardless of whether there is a specific medical disease the therapy for which is dietary restriction (such as gluten sensitivity). Individual determinations will be made for cases in which an infant or child requires formula specifically formulated for the individual child in question because of an underlying metabolic disorder.
        • Gastric Bypass: Gastric Bypass/Sleeve or other types of bariatric/weight loss surgery are not eligible for sharing.
        • Genetic Testing Not eligible, with the exception to aid in the treatment of a previously diagnosed condition which was eligible for sharing.
        • Gross Negligent Acts, Hazardous Hobbies, Illegal acts, Professional Racing or Competitive Events, Self-Inflicted Injury: Expenses resulting from an illness or injury as to which the Sharing Member has acted with gross negligence or with reckless disregard to safety, as evidenced by medical records and as determined by Lafya HealthShare. Care and treatment of an injury or illness that results from engaging in a hazardous activity is not eligible for sharing.
          • An activity is hazardous if it is an activity which is characterized by a constant or recurring threat of danger or risk of bodily harm. Examples of hazardous hobbies include, but are not limited to, rock/cliff climbing, spelunking, skydiving, or bungee jumping.
          • Charges for services received as a result of injury or illness caused by engaging in an illegal act or occupation; by committing or attempting to commit any crime, criminal act, assault or other illegal behavior; including but not limited to illegal drug activity, crimes against persons, crimes against property and gun offenses are not eligible for sharing.
          • Charges for treatment of injuries or illness while racing or competing as a professional are not eligible for sharing. Professional racing means that such activity is one’s primary vocation and means of financial support. Professional racing and competitive events include, but are not limited to, automobile, motorcycle, watercraft, or other types of competitions.
          • Any medical expense due to an intentionally self-inflicted Injury while sane is not eligible for sharing.
        • Hair loss: Care and treatment for hair loss, hair transplants or any drug that promises hair growth, whether or not prescribed by a Physician.
        • Hormone Replacement Therapy: Except in children, where prescribed by a physician for short term (not maintenance) use.
        • Mental Health Services: Charges for psychiatric or psychological counseling, mental disability, learning disability, bereavement counseling, biofeedback therapy, psychological testing, treatment, medication and hospitalization.
        • Miscarriage: Expenses related to miscarriage when conception was prior to Enrollment Date are not eligible for sharing.
        • Non-Emergency Transportation; Emergency or Non-Emergency Travel or accommodations: Expenses resulting from transportation by ambulance for conditions that will not seriously jeopardize the Sharing Member's health or life are not eligible for sharing. Also, the additional expense for transportation to a facility that is not the nearest facility capable of providing medically necessary care is not eligible for sharing. Charges for travel or accommodations, whether or not recommended by a Physician are not eligible for sharing.
        • Non-Compliance with Medical Advice: Failure or refusal to comply with physician treatment plan shall be subject to clinical review and may result in a determination of ineligibility for sharing.
        • No obligation to pay: Charges incurred for which the Sharing Member has no legal obligation to pay.
        • Not a Medically Indicated Service: Care and treatment that does not meet the criteria for a Medically Indicated Service or is not specified as a Medically Necessary Service, or care, treatment/ services or supplies not recommended and approved by a Physician; or treatment/services or supplies when the Sharing Member is not under the regular care of a Healthcare Provider. Lafya HealthShare reserves the right to, and will frequently undertake a process to review bills submitted by providers for payment, and upon review by a qualified medical professional, decline to share expenses deemed not to be a Medically Necessary Service.
        • Nutritional supplements: Prescribed and/or over the counter supplements.
        • Outpatient prescribed or non-prescribed medical supplies: Outpatient prescribed or non prescribed medical supplies including, but not limited to, over-the-counter drugs and treatments, nutritional formulas (regardless of age), elastic stockings, tubing, masks, ostomy supplies, insulin infusion pumps, ace bandages, gauze, syringes, glucometers and test strips, BP machines and similar supplies. Some supplies may be allowed if a member is on the Lafya Rx Plan.
        • Personal comfort items: Personal comfort items or other equipment, such as, but not limited to, air conditioners, air-purification units, humidifiers, electric heating units, orthopedic mattresses, scales, elastic bandages or stockings, non-prescription drugs and medicines, and first-aid supplies and hospital/non-hospital adjustable beds.
        • Replacement of braces: Replacement of braces of the leg, arm, back, neck, unless there is sufficient change in the Sharing Member’s physical condition to make the original device no longer functional.
        • Sports-related safety/performance devices and programs: Devices used specifically as safety items or to affect performance primarily in sports-related activities.
      • Sharing Limits: The members of Lafya HealthShare do not have unlimited resources. In order to both settle the medical bills of Sharing Members and avoid burdensome share amounts beyond the ability of the members savings, total eligible medical bills for sharing among the members are limited as defined in this section and as indicated in writing to the individual Sharing Member.
        • Maximum Shareable amount per financial year: The amount of medical expense eligible for sharing must not exceed N2.5 million which is the annual cumulative amount for each single, couple or family membership in a financial year. A financial year shall be calculated upon each member’s Enrollment Date. All eligible medical expenses that exceed the annual cumulative amount shall be subject to the program limits.
        • First Three (3) Months of Participation: For three (3) months after Enrollment Date as a Sharing Member, medical expenses for any reason, other than accidents, or injury, are not eligible for sharing among members.
        • Case Management: In cases where the Sharing Member’s condition is expected to be, or is, of a serious nature, Lafya HealthShare may arrange for case management/alternative care services to be performed. Lafya HealthShare may alter or waive the normal provisions of the Guidelines when it is reasonable to expect a cost-effective result without a sacrifice to the quality of care. The use of case management or alternate treatment is always voluntary to the Sharing Member; however, failure to participate may affect eligibility for sharing.
        • Cosmetic procedures: Cosmetic care and treatment provided for disfigurement caused by amputation, disease (including acne), accident or initial breast reconstruction following a mastectomy, is eligible for sharing. All other elective cosmetic treatment, including but not limited to, pharmacological regimens; nutritional procedures or treatments; plastic surgery; salabrasion, chemosurgery and other such skin abrasion procedures associated with the removal or revision of scars, tattoos or actinic changes, is not eligible for sharing.
        • Excess Charges: It is the duty of each member to protect all members from unreasonable charges submitted by providers. All charges submitted by providers will undergo an assessment to determine if charges are reasonable. If an expense is determined to be unreasonable, then negotiations will be required between Lafya HealthShare and the provider before the expense is eligible for sharing. This negotiation will include verification of the standard billing rates for care and services given by the provider. Lafya HealthShare reserves the right, on behalf of its members, to determine what part of an expense is unreasonable and may choose to advocate on behalf of members against any provider demanding payment of an unreasonable expense.
        • Hysterectomy: Expenses related to a Hysterectomy are eligible for sharing only when medically necessary. Hysterectomies intended for the purpose of preventing normal or perimenopausal variations in menstruation are not eligible for sharing.
        • Organ Transplant: Expenses incurred in connection with any organ or tissue transplant may be shared among the members up to a maximum of the member’s shareable limits per organ transplant. This includes, but is not limited to, expenses incurred in evaluation, screening, candidacy determination process, organ transplantation, organ procurement, transportation of organ, donor expenses, follow-up care, immuno-suppressant therapy, and re-transplantation. This organ transplant includes, but is not limited to, transplantation of the heart, lungs, kidneys, liver, pancreas and bone marrow. Expenses incurred in connection with any organ or tissue transplant that exceed the maximum shareable limit per organ are not eligible for sharing.
        • Pre-Existing Conditions: Lafya healthShare members with pre-existing conditions must in addition to other plans subscribe to the Lafya Rx Plan. A condition for which signs, symptoms or treatment were present prior to application, or can be reasonably expected to require medical intervention in the future, need to be declared upon application for Lafya HealthShare membership, and updated with any new symptoms/signs or diagnoses that become apparent after the application submission. Failure to declare a medical condition upon application, or failure to update Lafya HealthShare after application, may preclude sharing in that condition any time in the future. Failure to fully disclose known or suspected pre-existing condition information at the time of application and before the Enrollment Date is a violation of our shared trust between members and may subject the member to termination of membership.
        • Prescription Drugs: Medications available over-the-counter are not eligible for sharing, regardless of whether a prescription is written. Inpatient medications are eligible for sharing.
        • Pre-Notification of Medical Expense: Pre-Notification is a process by which Lafya HealthShare can assist members to avoid unnecessary services, hospitalizations, and shorten inpatient medical stays. Our goal is to improve the quality of care and reduce expenses deemed necessary by providers and shared by the members. Providing sufficient advance notice, whenever possible and as required, is a responsibility of a sharing member in order to allow Lafya HealthShare the opportunity to provide a variety of suggestions designed to avoid unreasonable billing practices by some Healthcare providers. Our processes do not dictate what medical treatment a member chooses, but rather are designed to help members assess impending interactions with a complex and confusing medical system. Because Lafya HealthShare membership does not share in medically unnecessary interventions, we provide a process to help guide the member to assess medical necessity in a setting that is separate from their physician office. To be considered for cost sharing, a member MUST notify Lafya HealthShare IN ADVANCE (Pre-notification) by calling our Pre-Notification hotline or sending an in app message for any services and procedures, and diagnostics listed below, except in the case of true emergencies. The Sharing Member, their healthcare provider, should call the Pre-Notification hotline or send an in app message as soon as the need for admission or services is recognized. To contact PreNotification, the hotline number can be found in the Lafya HeathShare mobile app or the Lafya HealthShare website. It is the responsibility of the Sharing Member to make sure that Lafya HealthShare is contacted and to not count on the Healthcare provider to do so.

          The following require Pre-Notification to be eligible for consideration for cost sharing:

          • Inpatient Hospital Confinements (including Hospital, Inpatient Rehabilitation Facility and Hospice) The term "Inpatient" includes any facility admission, observation or other confinement that lasts more than 23 hours.
          • Emergency Admissions as soon as it becomes evidently needed.
          • Extended emergency department observation periods and observation care.
          • All Surgeries (including surgical centers, clinics, hospitals).
          • Organ/Tissue Transplant Services.
          • Obstetric and prenatal needs—members must notify Lafya HealthShare directly upon learning of pregnancy—as early as possible.
          • Maternity. Upon admission or anticipated admission for Labor and Delivery, C Section or other issues during pregnancy.
          • Non-emergent Magnetic Resonance Imaging (MRI) scans
          • Positron Emission Tomography Scanning (PET).
          • Cardiac catheterization.
          • Cardiac rehabilitation.
          • Endoscopy: OGD(oesophago-gastro duodenoscopy), colonoscopy, and sigmoidoscopy
          • Before initiation of chemotherapy or radiotherapy.
          • Upon diagnosis of cancer while therapeutic decisions are being considered.
          • Any expected regular or repeated utilization of the following services.
            • Acupuncture
            • Physiotherapy
            • Speech Therapy
            • Respiratory therapy
            • Occupational therapy
          • Diagnostic Mammogram

          The following specifically do not require pre-notification: CT scans, outpatient visits, ECG, emergency unit visits, routine laboratory testing, wellness mammograms, ultrasound, wellness and flu vaccinations, plain x-rays, initial evaluations by therapists, and skin biopsies. Tests where pre-notification is not required are not necessarily eligible for sharing, based on the Sharing Guidelines.

          When admitted in a Hospital, a Lafya HealthShare Pre-Notification Staff will continue to evaluate the Sharing Member’s progress to monitor the length of hospital stay and make a recommendation as to the maximum days of stay. The Sharing Member and his/her healthcare provider will be advised. If the PreNotification Staff determines that continued hospital confinement is no longer necessary, additional days will not be eligible for cost sharing among the members. Additional days not recommended by the Pre-Notification staff will not be eligible for sharing.

          All Hospital admissions AND Maternity admissions MUST be reported to the Pre- Notification Staff within forty-eight (48) hours following admission, or on the next business day after admission.

          If the Sharing Member is unable to Pre-Notify due to the severity of the Illness or Injury, then a Physician, or a responsible party representing the member should Pre- Notify at the earliest time reasonably possible.

          To determine eligibility for sharing, all Hospital Admissions may be reviewed retrospectively to determine if the treatment received was Medically indicated and appropriate.

        • Payments of Members’ Medicals Bills:Payment of medical bills by Lafya HealthShare is highly dependent on the number of members subscribed to the Lafya HealthShare plan at a time. The higher the number of subscribed members the greater the chance of covering the complete medical bills of a member up to the maximum amount (N2.5 million) per financial year..
          Where the cost of healthcare for a member is too high, even if it is less than the maximum amount (N2.5 million.) such that sharing (distributing it across members) will cause considerable decline(more than 40%) in existing members savings, or such that Lafya HealthShare is unable to pay because of low signups, Lafya HealthShare will process and pay between 20% - 60% of the bill depending on the number of subscribers.
      • Maternity: For a mother who has been a Sharing Member prior to conception, medical expenses for Maternity are eligible for sharing up to the maximum sharing limit (whether for a single or multiple birth pregnancy), including but not limited to, charges and expenses arising from physician care and hospital or birthing center admissions. Medical expenses for Maternity ending in a delivery by cesarean section that is medically necessary because of complications that arise at the time of delivery are eligible for sharing up to the maximum sharing limit (whether for a single or multiple birth pregnancy). Needs for Maternity ending in a natural delivery but with complications that threaten the life of the mother or infant and requiring care or services not normally rendered at the time of delivery are eligible for sharing up to the maximum amount (whether for a single or multiple birth pregnancy).
        Medical expenses for a newborn, including congenital birth defects, and/or complications at the time of delivery, including, but not limited to, premature birth, are eligible for sharing up to the maximum sharing amount.
      • Provision for Eligible Medical Expenses after Death: If a Sharing Member, at the time of his or her death, has outstanding Eligible Medical Expenses that have not been shared at the time of death, the following provision applies:
        • Eligible Medical Expenses submitted by the provider in the normal course of business, shall be shared in the same manner, as if the member had not died.

    Lafya HealthShare is a healthcare cost sharing platform which helps its members distribute and share medical expenses between themselves with less financial risk. We understand that in the course of members interacting with Lafya HealthShare and Healthcare providers, it is possible that differences of opinion will occur and that a methodology for resolving disputes must be available. Therefore, by becoming a Sharing Member of Lafya HealthShare, you agree that any dispute you have with or against Lafya HealthShare, will be settled using the following steps of action, and only as a course of last resort.

    If a determination is made with which the Sharing Member disagrees and believes there is a logically defensible reason why the initial determination is wrong, then the Sharing Member may file a complaint. The appeal letter must be sent via email to complaints@lafya.co

    The letter must contain the case or bill number along with the reason for the complaint. Complaints will be accepted from Sharing Members only; complaints will not be accepted from providers. Sharing Members cannot complain based on Lafya HealthShare guidelines nor matters relating to Lafya healthShare enrollment.

    • First Level Appeal: Most differences of opinion can be resolved simply by calling Lafya HealthShare. If this option of an informal call does not resolve the dispute, an Appeals Review personnel will review the appeal letter and all supporting documentation, and contact the member within 5 working days via phone or email with the determination. The appeal letter must contain the case or bill number along with the reason for the appeal (what and why the Sharing Member is appealing).
    • Second Level Appeal: If the Sharing Member is dissatisfied with the determination of the Appeals Review personnel, then the Sharing Member may request a second level appeal. The appeal must be in writing, must contain the case or bill number, and state the elements of the dispute and the relevant facts. Importantly, the appeal should address all of the following:
      • What information does Lafya HealthShare have that is either incomplete or incorrect?
      • How do you believe Lafya HealthShare has misinterpreted the information it already has?
      • What provision in the Lafya HealthShare Guidelines do you believe Lafya HealthShare applied incorrectly?
      Within ten (10) days, the Appeals review Manager and the Vice President of Medical Services will review the appeal, and the aggrieved party will be contacted via phone or email with the determination.
    • Third Level & Final Appeal: Should the matter still remain unresolved, then the aggrieved party may request a third and final appeal. This will be submitted to three or more randomly chosen Sharing Members, in good standing and chosen by Lafya HealthShare, who shall agree to review the matter and shall constitute an External Resolution Committee. Within thirty (30) days the External Resolution Committee shall render their determination and the appealing member will be notified. The determination of the external resolution committee shall be final and is the last dispute resolution option available for sharing members.

    • Lafya HealthShare Members have a right to:

      • Receive considerate, courteous service from all employees and representatives of Lafya HealthShare;
      • Receive accurate information regarding Lafya HealthShare Guidelines and eligibility;
      • Have medical expense needs processed accurately once all necessary documentation has been received;
      • Have all medical records and personal information handled in a confidential manner by Lafya and in compliance with privacy standards;
      • Be informed about health care providers approved by Lafya HealthShare;
      • File a dispute when you have one without fear of prejudice or reprisal.
    • Lafya HealthShare Members have responsibility to:

      • Ensure Health care providers to submit medical bills within 24 hours of the date of service in order to be shared.
      • Be consistent with saving the required amount for any of the Lafya HealthShare plans monthly.
      • Treat Lafya HealthShare employees and representatives in a considerate and courteous manner.
      • Read all Lafya HealthShare materials carefully as soon as you receive them and ask questions when necessary;
      • Take personal charge of your medical care, and make informed and knowledgeable health care choices;
      • Seek medical advice when appropriate, take the necessary steps to understand the medical advice you receive and any diagnosis you are given, and obtain needed care in a timely manner.
      • Be informed about the policies and practices of Lafya HealthShare and follow them for the benefit of all Sharing Members.
      • Allow Lafya HealthShare access to your medical records via your Healthcare provider.
      • Be honest about your health conditions, and provide all pertinent information to your doctor, family members, and Lafya HealthShare when needed

    • Enacting Changes: These Guidelines may be amended from time to time as circumstances require and as determined to be appropriate by Lafya HealthShare.
    • Notification of Changes: Sharing Members will be notified of changes to the Guidelines in the normal course of communication with members. Notice of material changes to the Guidelines will be given within sixty (60) days.
    • Effective Date: Amendments to the Guidelines will take effect as soon as is administratively practical or as otherwise designated by Lafya HealthShare. Medical expenses submitted for sharing will be subject to the edition of the Guidelines in effect on the relevant Dates of Service.