1.
|
Hospitalisation
|
100%
|
Overall Annual Limit
|
|
1.1 Accommodation & Theatre
|
|
1.2 Accommodation in private wards
(Difference between the general ward and private ward tariffs)
|
N$7 500 per Beneficiary
N$16 500 per Family
|
|
1.3. Intensive and high care
(Maximum 3 days, then motivation)
|
Overall Annual Limit
|
|
1.4. Blood transfusions
|
|
1.5. Radiology & Pathology (in-hospital)
Additional Hospital Benefit Cover is excluded
|
|
1.6. Physiotherapy & Biokinetics
- Additional Hospital Benefit Cover is excluded
|
|
1.6.1. Physiotherapy & Biokinetics (in-hospital)
|
|
1.6.2. Physiotherapy & Biokinetics (post-rehabilitation)
- Additional benefit once the patient is out of the hospital
- 12 sessions/visits per Beneficiary (Benefit available within 3 months from hospital discharge)
(Subject to prior approval)
|
|
1.7. Medicine, fixed tariff procedures, hospital apparatus, and to take out medicine (7 days' supply only)
|
|
1.8. Dialysis
(Subject to Case Management and MHC Guidelines)
|
|
1.9. Organ Transplant
(Subject to Case Management and MHC Guidelines)
Including medical expenses incurred by the donor if the recipient is a Fund member
|
|
1.10. Internal Appliances & Materials
(As per NMC protocol)
|
100% of the Cost
|
|
1.11. Medical & Surgical Appliances (External)
|
|
Payable from the Day-to-day Back-Up Benefit
|
2.
|
General Practitioners and Specialists (in-hospital services)
-
Additional Hospital Benefit Cover is included
|
200%
|
Overall Annual Limit
|
3.
|
Specialised Radiology Procedures (in & out of hospital)
Additional Hospital Benefit Cover is excluded
- A referral is only acceptable from a medical specialist (a referral from GP acceptable in places where there is no medical specialist)
(Subject to prior approval)
|
100%
|
Overall Annual Limit
|
|
3.1 MRI & CT Scans
|
N$30 000 per Family
|
|
3.2 Nuclear Medicine
|
Overall Annual Limit
|
4.
|
Maternity
(Groups have cover from the date of joining. Individuals have a 9-month waiting period)
|
100%
|
Overall Annual Limit
|
|
4.1 Confinement – Full Procedure
|
|
4.2 Ante-natal Consultation
12 consultations per Beneficiary (Pro-rated from the date of joining)
- Additional Hospital Benefit cover is excluded
|
Payable from Maternity Benefit
|
|
4.3 Ante-natal / Post-natal Classes & Education
6 sessions per Beneficiary (Pro-rated from the date of joining)
-
Additional Hospital Benefit Cover is excluded
|
|
4.4. Sonar Scans (excluding 3D)
3 scans per Beneficiary per Pregnancy
- Additional Hospital Benefit Cover is excluded
|
|
4.5 Amniocentesis
-
Additional Hospital Benefit Cover is excluded
|
|
4.6 Midwifery Service
-
Additional Hospital Benefit cover is excluded
|
5.
|
Insertion of Intrauterine Device w/ Hormone (all-inclusive)
(Subject to prior approval)
|
100%
the of Cost
|
N$6 500 per Beneficiary
Overall Annual Limit
|
6.
|
Oncology
(Subject to Case Management and MHC Guidelines)
|
100%
|
N$600 000 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.
|
Refractive 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%
|
N$6 200 per Beneficiary once-off
N$7 500 per Family
Overall Annual Limit
|
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$6 750 per Family
|
|
8.2 Hospitalisation
|
Overall Annual Limit
|
9.
|
Private Nursing/ Frail Care / Hospice
(Subject to Case Management)
|
100%
|
N$21 750 per Family
Overall Annual Limit
|
10.
|
Psychiatric Treatment – Hospitalisation
(Subject to prior approval)
|
100%
|
N$32 750 per Family
Overall Annual Limit
|
11.
|
Alcoholism/Drug Addiction
(Subject to prior approval and MHC Guidelines)
|
12.
|
Specialised Dental Surgery
- Additional Hospital Benefit cover is excluded
(Subject to Pre-Authorisation)
|
100%
|
Overall Annual Limit
|
|
12.1. Maxillo-Facial & Oral Surgery
- All-inclusive (trauma/non-elective) (Including dental extractions for children less than 10 years old and wisdom teeth extractions)
|
N$ 92 500 per Family
|
|
12.2. Maxillo-Facial & Oral Surgery
- Hospitalisation (other/elective)
|
N$14 000 per Family
|
|
12.3. Dental Implant – hospitalisation
|
|
12.4. Maxillo-Facial & Oral Surgery – internal prosthesis
(Excluding dental implant component)
|
Payable from Internal appliances under Hospital Benefit
|
13.
|
Stomal Therapy (all-inclusive)
(Subject to prior approval)
|
100%
|
N$28 750 per Family
Overall Annual Limit
|
14.
|
Ambulance & 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)
|
Overall Annual Limit
|
15.
|
Medical Referral
Subject to accommodation and travelling reimbursement protocols
(Subject to prior approval)
|
|
Overall Annual Limit
|
|
15.1. Transport
|
80% of the Cost
|
N$10 150 per Family
|
|
15.2. Accommodation Other than a Recognised Hospital/Medical
Institution
(Maximum of 2 days)
|
100%
|
N$620 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 the Cost
|
N$10 000 000 per Incident
|