Unless prescribed for medical reasons.
All preparations designed specifically to treat or stop the smoking habit (unless approved by the Lifestyle Management Department).
Household type bandages and dressings, cotton wool, syringes, needles and diagnostic agents unless used as part of chronic disease management, surgical devices and appliances and diagnostic appliances and similar requisites unless supplied to or used in a clinic or doctor’s room or during the patient’s stay in a hospital or a nursing home.
Compounded medicine that are generally promoted for commercial use will be excluded by the Fund.
Specifically used for the care and cleaning process of contact lenses, including wetting agents.
Foam preparations, jellies and condoms.
Medicated or otherwise.
Medicines used specifically to treat Acquired Immune Deficiency Syndrome (AIDS), unless the patient is registered for Case Management.
Immunosuppressives, allergens, growth hormones, immune sera, immunoglobulins, erythropoietin, unless prescribed by a medical specialist and with prior approval.
Preparations or device generally purported to improve or increase libido, or to induce, enhance, maintain and promote penile erection or to address erectile dysfunction, such as erectile appliances, auto injectors, and including, but not limited to, drugs such as Sildenafil Citrate (Viagra).
Including patent foodstuffs, baby food and special formulas.
Applicable if the recipient is not a member of the Fund.
Patent and secret medicines and preparations, household remedies, and preventative preparations generally promoted to the public to increase consumption including essential and non-essential fatty acids.
Oral preparations intended as dietary supplements when intake is considered inadequate unless:
- Prescribed together with diuretics e.g. Slow K.
- Prescribed for electrolyte replacement therapy with diarrhoea.
- Prescribed together with hormonal replacement therapy in the case of calcium supplements; provided that the elemental calcium dose is greater than 300mg per tablet.
- Prescribed for osteoporosis in the case of calcium supplements; provided that the elemental calcium supplements or prescribed for patients older than 50 years of age (full motivation required).
Preparations used specifically to treat and/or prevent obesity or overweight or any slimming preparations.
Soaps, shampoos, and other topical applications (of a cosmetic nature) medicated or otherwise. Items other than those intended to treat lice, scabies and other parasitic infestations/fungal infections, as indicated by the doctor's diagnosis.
New indication for existing medicines, new medicines and specialised drugs defined as exclusions by the relevant Managed Healthcare Programme unless reviewed and pre-authorised.
Medicines used specifically for the treatment of sterility, impotence and infertility.
Stimulants for the non-medicinal purposes such as increasing alertness and wakefulness during studying or examination period.
Unless the patient is registered for Case Management.
Sun screening agents unless prescribed by a dermatologist for medical reasons and tanning agents.
Medicines and products not registered with the Namibian Medicine Control Council including complimentary medicine.
Vitamins, multivitamins, vitamin combinations and tonics, unless:
- prescribed for members older than 50 years of age and children aged 5 years and younger,
- prescribed as supplements during pregnancy and lactation,
- injections (unless prescribed for the treatment of obesity),
- claimed as self-medication.
Appointments with a supplier of services not kept by the patient and charged for by such supplier of services.
Direct or indirect costs are excluded from benefits unless approved by the Board of Trustees.
- Gold in dentures and fillings.
- Dental devices and materials such as dental floss, tooth brushes and tooth paste.
- Bleaching of teeth or any dental procedures that are recommended for cosmetic purposes.
- Oral hygiene instructions.
- Nutritional or tobacco counselling.
- Laboratory costs where associated dental procedure is not covered.
The purchases or hire of external appliances other than those specified on the list of External Medical Appliances covered by NMC.
Group Counselling/Therapy/Rehabilitation/Assessment/Screening/Immunisation including services provided to individual members in a group setting such as in schools and companies.
Not applicable even if it is deemed medically necessary.
- Accommodation in old age homes and similar institutions.
- Hospitalisation or accommodation in an institution similar to a hospital for breastfeeding mothers for the sole benefit of their newborn babies.
Examinations, investigations, treatment or surgery for infertility, sterility, impotence and artificial insemination or hormone treatment for infertility, including all costs relating to surrogacy.
All costs pertaining to pregnancies for the first 9 months of membership in the case of members who are registered as individuals.
Examinations, investigations, treatment or surgery for obesity and overweight including gastric bypass, reversal of gastric bypass and any other procedures performed in combination with gastric bypass.
*Gastric bypass is only covered as part of gastric protocol of the Fund.
- Ophthalmic examinations by anyone other than an eye specialist or registered optician.
- Sunglasses and spectacle cases.
- Tinting of prescription lenses by 35% or more.
Plastic surgery and cosmetic treatments (excluding dental implants and refractive surgeries) of a member’s own choice or which are recommended for psychological reasons only or surgery directly or indirectly caused by or related to or in consequence of cosmetic surgery.
Any procedure of a purely diagnostic nature, any other examination where there is no objective indication of impairment in normal health or no actual presumed illness exists, and laboratory diagnostics or x-ray examinations, except in the course of a disability establishment by prior call or attendance of a medical practitioner.
Suicide, attempted suicide or intentional self-inflicted injury, whether the patient concerned is of sound mind or not. Except if the patient qualifies in terms of the self-inflicted injury protocol of the Fund.
Telephonic and virtual consultations and prescriptions unless approved by the Board of Trustees during state of emergency pandemic and where members require isolation as a result of contracting infectious disease.
All costs incurred for treatment of injuries that are paid by another party (subject to the Fund Rules).
Upon joining the fund
- Accommodation and treatment in stress-relief clinics, spas and resorts whether deemed medically necessary or not.
- Accommodation other than a recognised hospital/medical institution for treatment, investigation, operation and procedure outside the boarders of Namibia unless such treatment, investigation, operation and procedure cannot be done in Namibia, as part of Case Management and with prior approval.
Preparation and storage.
Dreaded diseases or critical illnesses which are not listed on the NMC Chronic Disease Management Programme.
Any procedure intended to induce, enhance, maintain and promote penile erection or to address erectile dysfunction.
- Cost incurred in respect of any medical condition (whether chronic or otherwise) or a combination thereof, which in the exclusive opinion of the BOARD, warrants to be excluded from the BENEFITS including medical expenses by members who were subjected to risk rating and incurred within three months upon joining the Fund due to non-disclosure of pre-existing condition.
- Cost incurred in respect of medical services provided by disciplines other than those covered by the Fund.
- Medical, travel and accommodation expenses for any planned or non-emergency consultations, examinations, procedures and treatment incurred in foreign countries other than in the Republic of South Africa as per the Fund Accommodation and Travelling Expenses Reimbursement Policies.
- Subsistence, travel and accommodation expenses incurred during unexpected medical treatment while in foreign countries resulting in prolonged stay.
- Travelling and accommodation expenses incurred by the organ donor.