1.
|
Hospitalisation
|
100%
|
Overall Annual Limit
|
|
1.1. Accommodation and Theatre
|
|
|
1.2 Accommodation in private wards
(Difference between the general and private ward tariffs)
|
N$5 200 per Beneficiary
N$10 400 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 (post-rehabilitation)
-
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
-
9 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 & Material
(As per NMC protocol)
|
100% of the Cost
|
|
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 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$20 750 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/Postnatal Classes & Education
6 sessions per Beneficiary (Pro-rated from 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. Tests for Chromosomal and Foetal Abnormalities
-
Additional Hospital Benefit Cover is excluded
|
|
4.6. Midwifery Service
-
Additional Hospital Benefit Cover is excluded
|
|
5.
|
Insertion of Intrauterine Device with Hormone (All-inclusive)
(Subject to prior approval)
(Pro-rated from the date of joining)
|
100%
|
N$6 500 per Beneficiary
Overall Annual Limit
|
|
6.
|
Oncology
(Subject to Case Management and MHC Guidelines)
|
100%
|
N$450 000 per Beneficiary
Overall Annual Limit
|
|
6.1. Consultation and Procedures
|
|
6.2. MRI/CT Scans and Other Specialised Radiology Procedures In & Out-of-Hospital
- Additional Hospital Benefit Cover is excluded
- A referral is only acceptable from a medical specialist
|
|
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$6 150 per Beneficiary once-off
N$7 300 per Family
Overall Annual Limit
|
|
8.
|
Reconstructive Surgery (medical necessity only)
Subject to prior approval and subject to strict MHC guidelines
|
100%
|
No Benefit
|
|
9.
|
Private Nursing
/ Frail Care / Hospice
(Subject to Case Management)
|
100%
|
N$10 900 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 and Oral Surgery
- All-inclusive (trauma/non-elective)
(Including dental extractions for children less than 10 years old and wisdom extractions)
|
N$57 000 per Family
|
|
12.2 Maxillo-Facial and Oral Surgery
- Hospitalisation Only (other/elective)
|
N$10 900 per Family
|
|
12.3 Dental Implant - Hospitalisation
|
No Benefit
|
|
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$22 100 per Family
Overall Annual Limit
|
|
14.
|
Ambulance & Evacuation Services
|
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$4 400 per Family
|
|
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
|
|
17.
|
Specified Illness Conditions
As per the national guidelines
(Sub-limits are pro-rated from the date of joining)
|
100%
|
N$42 600 per Family
Overall Annual Limit
|
|
17.1 HIV/AIDS
(As per national guidelines for antiretroviral therapy)
|
N$25 100 per Beneficiary
|
|
17.1.2. Medicine (Paid at the maximum Namibia Medicine Price List on generics)
|
Payable from Specified Illness Conditions
|
|
17.1.2. First Full HIV Consultation/Assessment
Once-off Benefit
|
N$480
|
|
17.1.3. Consultation (after the first full HIV Consultation/Assessment)
6 consultations per Beneficiary
|
N$440
|
|
17.1.4. HIV Counselling
- Payable from Specified Illness Conditions
|
100%
|
N$1 300 per Beneficiary
|
|
17.1.5. Pathology Tests
- Payable from Specified Illness Conditions
|
N$5 650 per Beneficiary
|
|
17.1.6. HIV Resistance Test
(Subject to prior approval)
|
100%
|
Payable from Specified Illness Conditions
|
|
17.2. Prevention of Mother-to-Child Transmission (PMTCT)
|
|
17.3. Post-Exposure Prophylaxis (PEP)
|
|
17.4. Pre-Exposure Prophylaxis (PrEP)
|
