|
1.
|
Hospitalisation
|
100%
|
Overall Annual Limit Accomodation & Theatre: Sub-limit 1
|
|
|
1.1. Accommodation and Theatre
|
|
|
1.2. Accommodation in private wards
(Difference between the general ward and private ward tariffs)
|
N$11 285 per Beneficiary
N$24 750 per Family
|
|
|
1.3. Intensive and high care
(Maximum three days, then motivation)
|
Overall Annual Limit
|
|
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1.4. Blood transfusions
|
|
|
1.5. Radiology and Pathology (in-hospital)
Additional Hospital Benefit Cover excluded
|
|
1.6. Physiotherapy and Biokinetics
- Additional Hospital Benefit Cover excluded (Subject to prior approval)
|
|
|
1.7. Post Rehabilitation
Physiotherapy, Biokinetics and Occupational Therapy- Additional Hospital Benefit Cover excluded
- Additional benefit once the patient is out of hospital or transferred to rehabilitation facility
Benefit available within three months from hospital discharge (Subject to prior approval)
|
N$5 435 per Beneficiary Overall Annual Limit
|
|
|
1.8. Medicine, fixed tariff procedures, hospital apparatus, and to take out medicine (Seven days' supply only)
|
Overall Annual Limit
|
|
|
1.9. Dialysis
(Subject to Case Management and MHC Guidelines)
|
|
|
1.10. Organ Transplant
(Subject to Case Management and MHC Guidelines)
Including medical expenses incurred by the donor if the recipient is a Fund member
|
|
|
1.11. Internal Appliances and Materials
(As per NMC protocol)
|
100% of Cost
|
|
|
1.12. Medical and Surgical Appliances (External)
|
|
No Benefit
|
|
2.
|
General Practitioners and Specialists (In-hospital services)
-
Additional Hospital Benefit Cover is included except the use of
equipment and equipment hire fees
|
100%
|
Overall Annual Limit
|
|
3.
|
Specialised Radiology Procedures (in and out of hospital)
Additional Hospital Benefit Cover is excluded
- A referral is only acceptable from a medical specialist (a referral from a GP acceptable in places where there is no medical specialist)
(Subject to prior approval)
|
100%
|
Overall Annual Limit
|
|
|
3.1 MRI and CT Scans
|
N$42 960 per Family
|
|
|
3.2 Nuclear Medicine
|
Overall Annual Limit
|
|
4.
|
Maternity
(Groups have cover from the date of joining. Individuals have a nine-month waiting period)
|
100%
|
Overall Annual Limit
|
|
|
4.1 Confinement – Full Procedure
|
|
|
4.2 Antenatal Consultation
12 consultations per Beneficiary (Prorated from the date of joining)
- Additional Hospital Benefit cover is excluded
|
Payable from Maternity Benefit
|
|
|
4.3 Antenatal/Post-natal Classes and Education
Six sessions per Beneficiary (Prorated from the date of joining)
-
Additional Hospital Benefit cover excluded
|
|
|
4.4. Sonar Scans (excluding 3D)
Three scans per Beneficiary per Pregnancy
- Additional Hospital Benefit cover excluded
|
|
|
4.5. Amniocentesis
-
Additional Hospital Benefit cover excluded
|
|
|
4.6. Midwifery Service
-
Additional Hospital Benefit cover excluded
|
|
5.
|
Insertion of Intrauterine Device w/ Hormone (all-inclusive)
(Subject to prior approval)
(Benefit is prorated from the date of joining)
|
100% of Cost
|
N$7 040 per Beneficiary
Overall Annual Limit
|
|
6.
|
Oncology
(Subject to Case Management and MHC Guidelines)
|
100%
|
N$815 100 per Beneficiary
Overall Annual Limit
|
|
|
6.1. Consultations and procedures
|
|
|
6.2. Hospitalisation
|
|
|
6.3. Radiation oncology (A referral is only acceptable from a medical specialist)
|
|
|
6.4. Oncology medication (Chemotherapy, radiotherapy and hormone therapy)
|
|
|
6.5. Hospitalisation and related procedures in-hospital
|
Overall Annual Limit
|
| 7.
|
Corrective Eye Surgery – All-inclusive (Subject to prior approval and MHC guidelines) Groups have cover from the date of joining. Individuals have a one-year waiting period | 100%
|
Overall Annual Limit
|
|
|
7.1. Refractive Surgery |
N$25 100 per Beneficiary once-off N$32 200 per Family |
|
|
7.2. Cataract Surgery and Lens Implants |
N$27 200 per eye per Beneficiary once-off |
|
8.
|
Reconstructive Surgery (medical necessity only)
(Subject to prior approval and subject to strict MHC guidelines)
|
100%
|
Overall Annual Limit
|
|
|
8.1. Consultations and Procedures
|
N$15 800 per Family
|
|
|
8.2. Hospitalisation
|
Overall Annual Limit
|
|
9.
|
Private Nursing/Frail Care/Hospice
(Subject to Case Management)
|
100%
|
N$42 050 per Family
Overall Annual Limit
|
| 10. | Psychiatric Treatment (Subject to prior approval) | 100% | Overall Annual Limit |
| 10.1 Consultations and Procedures |
| Sub-Limit 10 |
| 10.2 Hospitalisation |
| N$34 500 per Family |
| 11. | Alcoholism/Drug Addiction
(Subject to prior approval and MHC Guidelines) |
| Sub-Limit 10.2 |
|
12.
|
Specialised Dental Surgery
- Additional Hospital Benefit cover excluded
(Subject to pre-authorisation)
|
100%
|
Overall Annual Limit
|
|
|
12.1. Maxillo-Facial and Oral Surgery (trauma/non-elective) | N$143 450 per Family
|
|
|
12.2. Maxillo-Facial and Oral Surgery - (Including Dental Implants) (other/elective)
- All-inclusive
| N$42 450 per Beneficiary
N$52 800 per Family N$5 175 per dental implant component |
| 12.3. Maxillo-Facial and Oral Surgery - (Including Dental Implants)
- In-practice (performed in a doctor’s room)
- Procedures only
| 150% | Payable from maxillo-facial, oral surgery and dental implants (other/elective) |
| 12.4. Maxillo-Facial and Oral Surgery - Internal Prosthesis (excluding dental implant component) | 100% | Payable from Internal appliances under Hospital Benefit |
|
13.
|
Stomal Therapy (all-inclusive)
(Subject to prior approval)
|
100%
|
N$29 800 per Family
Overall Annual Limit
|
|
14.
|
Ambulance and Evacuation Services
(Subject to prior approval)
|
100%
|
Overall Annual Limit
|
|
|
14.1. Emergency Ambulance & Flights
(Territory: SADC countries)
(Subject to prior approval)
|
Unlimited Benefit
|
|
|
14.2. Ambulance/Inter-Hospital Transfer
(Subject to prior approval)
|
N$5 985 per Beneficiary |
|
15.
|
Medical Referral
Subject to accommodation and travelling reimbursement protocols
(Subject to prior approval)
|
|
Overall Annual Limit
|
|
|
15.1. Transport
|
70% of Cost
|
N$10 510 per Family
|
|
|
15.2. Accommodation Other than a Recognised Hospital/Medical
Institution
(Maximum of two days)
|
100%
|
N$642 per day per Family
|
|
16.
|
International Medical Travel Insurance
- Medical cover when travelling to foreign countries
- For emergency cases only (not for elective surgery or procedure)
|
100% of Cost
|
N$10 000 000 per Incident
|
|
17.
|
Lifestyle Management Screening Tests
(Subject to Clinical Guidelines and Protocols)
|
100%
|
N$15 000 per Family
|
| 17.1 Screening Tests |
| Sub-limit 17 |
| 17.2 Rapid Tests |
| N$ 1 500 per Family Sub-limit 17 |
