Our Benefits - Options & Benefits

Key Benefits

Hospital: Major Medical Expenses

AHB Cover: GP & Specialist in-hospital services payable to a maximum of 200% of the NAMAF Tariff

Benefit	Cover
Accommodation and Theatre	100%
Physiotherapy & Biokinetics (post-rehabilitation)	100%
MRI & CT Scans	100%
Internal Appliances & Materials	100% of the Cost
Oncology – (All-inclusive In and Out of Hospital) Consultations and Procedures Hospitalisation Radiation Oncology (A referral is only acceptable from a medical specialist) Oncology Medication (Chemotherapy, Radiotherapy and Hormone Therapy)	100%
Organ Transplant	100%
Maternity Confinement – Full Procedure 12 Ante-natal Consultations per Beneficiary 6 Sessions, Ante / Post-natal Classes & Education 3 Sonar Scans per Beneficiary per Pregnancy	100%

Ambulance and Evacuation Services

Benefit	Cover
Emergency Ambulance & Flights	100%
Ambulance/Inter-hospital Transfer	100%

International Medical Travel Insurance

Benefit	Cover
Medical cover when travelling to foreign countries. For emergency cases only	100% of the Cost

Contributions

Individuals
Age Band		Main	Adult	Child
0	25	1,881	1,171	521
26	30	2,081	1,316	521
31	35	2,266	1,479	521
36	40	2,540	1,672	532
41	45	2,781	1,833	532
46	50	2,980	2,004	532
51	55	3,243	2,210	532
56	60	3,458	2,372	532
60	65	3,681	2,535	532
66+		3,906	2,719	532

Groups
Income Band		Main	Adult	Child
0	4,150	1,693	1,096	313
4,151	5,490	1,950	1,244	359
5,491	8,390	2,088	1,291	386
8,391	12,330	2,146	1,384	395
12,331	13,860	2,401	1,538	443
13,861	15,710	2,659	1,692	491

OVERALL ANNUAL BENEFIT (OVERALL ANNUAL LIMIT)			N$474 750 Per Beneficiary N$712 400 Per Family
Category A: Hospital Benefit		% the NAMAF Tariff	Pre-authorisation: 100% of the tariff will be paid out. Without Pre-authorisation: No benefit will be paid except in the case of emergency hospital admissions and after-hours emergencies, weekends and public holidays.
Additional Hospital Benefit Cover: GPs and Specialists In-Hospital services are paid up to a maximum of 200% of the NAMAF Tariff
		COVER
1.	Hospitalisation	100%	Overall Annual Limit
	1.1. Accommodation and Theatre
	1.2. Intensive and High Care (Maximum 3 days, then motivation)
	1.3. Blood Transfusions
	1.4. Radiology & Pathology (in-hospital) Additional Hospital Benefit Cover is excluded
	1.5 Physiotherapy & Biokinetics Additional Hospital Benefit Cover is excluded
	1.5.1 Physiotherapy & Biokinetics (in-hospital)
	1.5.2 Physiotherapy & Biokinetics (post-rehabilitation) Additional benefit. once the patient is out of the hospital 9 sessions/visits per Beneficiary (Benefit available within 3 months from hospital discharge (Subject to prior approval)
	1.6. Medicine, Fixed Tariff Procedures, Hospital Apparatus and To-Take-Out medicine (7 days' supply only)
	1.7. Dialysis (Subject to Case Management and MHC guidelines)
	1.8. Organ Transplant (Subject to Case Management and MHC guidelines) Including medical expenses incurred by the donor if the recipient is a Fund member
	1.9. Internal Appliances & Material (As per NMC protocol)	100% of the Cost
2.	General Practitioners and Specialists (In-Hospital Services) Additional Hospital Benefit Cover is included	200%	N$ 36 100 per Family Overall Annual Limit
3.	Specialised Radiology Procedures (In & Out of Hospital) Additional Hospital Benefit Cover is xcluded 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$16 600 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		Overall Annual Limit
	4.2. Ante-natal Consultation 12 consultations per Beneficiary (Pro-rated from the date of joining) Additional Hospital Benefit Cover is excluded		Payable from the Maternity Benefit
	4.3. Ante-natal Consultation / 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 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 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$350 000 per Beneficiary Overall Annual Limit
	6.1. Consultation and Procedures Out-of-Hospital
	6.2. MRI/CT Scans & 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 (Referral from a medical specialist only)
	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	100%	No Benefit
8.	Reconstructive Surgery (medical necessity only)	100%	No Benefit
9.	Private Nursing/Frail Care/Hospice (Subject to Case Management)	100%	N$8 300 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)	100%	N$32 750 per Family Overall Annual Limit
12.	Specialised Dental Surgery Additional Hospital Benefit cover is excluded (Subject to Pre-Authorisation)	100%	No Benefit
	12.1. Maxillo-Facial and Oral Surgery All-inclusive (trauma/non-elective)
	12.2. Maxillo-Facial and Oral Surgery Hospitalisation Only (Other/Elective)
	12.3. Dental Implant - Hospitalisation
	12.4. Maxillo-Facial & Oral Surgery - internal prosthesis (Excluding dental implant component)
13.	Stomal Therapy (All-inclusive) (Subject to prior approval)	100%	N$17 000 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$2 480 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$10 500 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 national guidelines	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
	17.1.1. 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)	100%	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)

Category B: DAY-TO-DAY BENEFIT		COVER	Overall Sub-benefit limit N$18 550 Per Beneficiary N$25 100 Per Family Sub-limits are pro-rated from the date of joining except for the optical benefit. OVERALL ANNUAL LIMIT
18.	General Practitioners & Specialists (out-of-hospital including casualties)		N$6 200 per Family
	18.1. Consultations/Visits	100%	Payable from General Practitioners and Specialists Benefit
	18.2 Procedures/Services (out-of-hospital, including casualties)
	18.3. Materials and Disposable Items (Out-of-Hospital)
	18.4. Radiology & Pathology (Out-of-hospital, including radiography, sonography, medical laboratory technology and chemical biochemistry) (A referral from a Medical Practitioner is required)
	18.5 MRI and CT Scan		Payable from the MRI & CT Scan Benefit
	Benefit Booster is Applicable (Additional Benefit once limit is exceeded)
19.	Medicine & Injections	100%	N$13 000 per Family
	19.1. Medicine & Injections (Acute & Chronic) Paid at the maximum Namibia medicine Price List on generics		N$6 500 per Beneficiary
	19.2. Essential Vaccination/Immunisation Paid at the maximum Namibia Medicine Price List on generics		Payable from the Medicine and Injections
	19.3. Self Medication Paid at the maximum Namibia Medicine Price List on generics		N$860 per Family N$125 per claim per Beneficiary
20.	Primary Health Care Services	100%	N$1 000 per Family
	20.1. Consultations & Procedures		Payable from Primary Health Care Services
	20.2. Medicine & Injections Paid at the maximum Namibia Medicine Price List on generics		Payable from Medicine (Acute & Chronic)
	Benefit Booster is Applicable (Additional Benefit once limit is exceeded)
21.	Dentistry	100%
	21.1. Conservative & Specialised Dentistry (Including Dental Therapy) Benefit Booster Applicable ( Additional benefit once limit is exceeded)		N$4 500 per Family
	21.2. Dental Implants (in-hospital & in-practice) (Pre-authorisation required)		No Benefit
	21.3. Orthodontics (Prior approval is required)
	21.4 Maxillo-Facial and Oral Surgery (In-Hospital and In-Practice) (Elective)
22.	Optical Every 2 years (including frame) (2022/2023)	100%	N$3 670 per Family
	22.1. Eye Tests, Spectacles & Contact Lenses		N$1 300 per Beneficiary every 2 years
	22.2. Frame		N$520 per Beneficiary
23.	Auxiliary Services (Supplementary Services)	100%	N$2 370 per Family
	23.1. Consultation & Procedure		Payable from Auxiliary Services
	23.2. Medicine		Payable from Medicine (Acute & Chronic)
	Benefit Booster is Applicable (Additional Benefit once limit is exceeded)
24.	External Appliances (Subject to MHC Guidelines)	80% of the Cost	N$ 2 600 per Family
25.	Wheelchair, Artificial Limbs, Artificial Eyes, Hearing Aid Apparatus, Devices for Diabetes Management		No Benefit
26.	Benefit Booster Applicable if medicine & injections, dentistry, GPs’ & Specialists, primary health care & auxiliary services benefits are depleted		N$1 200 per Family
	26.1. Medicine & Injections (Acute & Chronic) Excluding self-medication	70%	Payable from Benefit Booster
	26.2. Dentistry	70%
	26.3. General Practitioners & Specialists (Consultations/visits & procedures/services out-of-hospital, including casualties)	80%
	26.4. Primary Health Care	80%
	26.5. Auxiliary Services	70%

Download Opal 2023 Detailed Benefits

Our Benefits - Options & Benefits | NMC

Opal

Key Benefits

Ambulance and Evacuation Services

International Medical Travel Insurance

Contributions

Announcements

Our Benefits - Options & Benefits | NMC

Key Benefits

Ambulance and Evacuation Services

International Medical Travel Insurance

Contributions

Announcements ×

Log in

Announcements