AHB Cover pays (from the first dollar) the excess of NAMAF tariff for General Practitioners and/or Specialists should a member/dependant be hospitalised. Hospitalisation can be traumatic, unexpected and expensive, and NMC believes that AHB will be of immeasurable financial value when our members need it most. NMC pays 100% of the NAMAF tariff PLUS a maximum of 100% additional cover for any excess of the NAMAF tariff that General Practitioners and Medical Specialists may charge.
The Back-up Benefit aims to reward members and their dependents with low claims on the following specified day-to-day benefits:
- Medicine and Injections per family limit
- Optical per family limit
- Auxiliary Services per family limit
- Suppose the actual total amount paid by NMC per family on the day-to-day benefits above for the current benefit year is less than the threshold limit. In that case, the member qualifies for the Back-Up Benefit the following year, such as on the 2023 benefit year.
- The Back-up Benefit is calculated as 15% of the difference between the Threshold Limit and the actual total amount paid by NMC on the day-to-day benefits above.
- The Back-up Benefit will only be calculated at the end of April 2023 to ensure that all day-to-day claims of the current benefit year are included.
- Claims against the Back-up Benefit for the current benefit year will only be processed after the end of April 2023.
- The unused Back-Up Benefit can be accumulated and carried over to the following benefit year.
- If the member resigns from NMC, any Back-Up benefit balance will go to the Fund reserves.
- If the member passes away and their dependants remain with NMC, the Back-Up Benefit will be transferred to the remaining dependants.
- The Back-up Benefit can be used to pay the excess on the NAMAF Tariffs, member co-payments and rejected claims in terms of NMC rules.
- The Back-Up Benefit cannot be used to pay for claims rejected due to non-compliance to the NAMAF billing rules and guidelines.
*Disclaimer: The Back-up Benefit is only available on the Opal, Jade and Ruby options.
The Benefit Booster is a supplementary benefit on certain day-to-day medical services where the overall annual limits have been exceeded. Should a member or a dependant’s day-to-day benefit limit on General Practitioner, Specialist, Medicine (self-medication excluded), Primary Healthcare, Dentistry, Auxiliary and Out-of-Hospital casualties be depleted, the Benefit Booster will automatically take effect.
The Benefit Booster is only applicable to the Diamond, Sapphire, Ruby, Jade and Opal options.
*The Benefit Booster is not applicable to Topaz and Topaz Plus members.
Ex gratia is an additional grant from the Board of Trustees, approved on certain criteria for unexpected major medical expenses and costs outside the scope of benefits of NMC.