OVERALL ANNUAL BENEFIT
(OVERALL ANNUAL LIMIT)
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N$500 000 PER BENEFICIARY
N$750 000 PER FAMILY |
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CATEGORY A: HOSPITALISATION BENEFIT
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% NAMAF TARIFF
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Pre-notification: 100% of tariff will be paid out.
Without Pre-notification: No benefit will be paid out except in the case of emergency hospital admissions and emergencies after hours, weekends and public holidays.
Sub-limits are not Pro-rated. OVERALL ANNUAL LIMIT.
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Additional Hospital Benefit Cover: GP’s and
Specialists In-hospital services
are paid up to a MAXIMUM of 215% of
NAMAF Tariff
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| 1. |
Hospitalisation (Subject to Pre-authorisation) |
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OVERALL ANNUAL LIMIT |
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1.1 Accommodation & Theatre |
100% |
Overall Annual Limit |
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1.2 Accommodation other than a recognised
hospital/medical institution
(Subject to
prior approval & Accommodation
Expenses Re-imbursement Policy)
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Limited to N$600 per day per Family (Maximum of 2 days)
Overall Annual Limit
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1.3 Blood Transfusions |
100% |
Overall Annual Limit |
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1.4 Intensive and High Care
- Maximum of 3 days then motivation
|
100% |
Overall Annual Limit |
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1.5 Medicine, fixed tariff procedures, hospital
apparatus and To Take Out Medicine (7 days supply only)
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100% |
Overall Annual Limit |
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1.6 Radiology & Pathology (in hospital)
- Additional Hospital benefit Cover excluded
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100% |
Overall Annual Limit |
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1.7 Physiotherapy
- Additional Hospital Benefit Cover excluded
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1.7.1 Physiotherapy ( in hospital) |
100% |
Overall Annual Limit Sub-limit 1.7
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1.7.2 Physiotherapy (post rehabilitation)
- Additional benefit once the patient is out of hospital
(Subject to prior approval)
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No benefit |
| 2. |
Specialised Radiology Procedures (in & out of hospital)
- Additional Hospital Benefit Cover excluded
- Referral from a medical specialist
only (referral from GP acceptable in places where there is no medical
specialist)
(Subject to prior approval)
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Overall Annual Limit
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2.1 MRI & CT Scans |
100% |
Limited to N$11 500 per Family
Sub-limit 2
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2.2 Nuclear Medicine |
100% |
Sub-limit 2 |
| 3. |
General Practitioners and Specialists
(in hospital services, procedures & operations)
- Additional Hospital Benefit Cover included
|
100% |
Overall Annual Limit |
| 4. |
Internal Appliances & Materials
(Subject to pre-authorisation)
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Subject to Bankmed Namibia Protocol
Overall Annual Limit
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4.1 Artificial Eyes |
100% of cost |
No Benefit
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4.2 Artificial Limb |
100% of cost |
No Benefit |
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4.3 Other Internal Appliances & Materials |
100% of cost |
Sub-limit 4 |
| 5. |
Dialysis
(Subject to Case Management and MHC Guidelines)
|
100% |
Overall Annual Limit |
| 6. |
Oncology (all-inclusive in and out of hospital)
Active therapy (surgery, chemotherapy and radiotherapy)
(Subject to Case Management and MHC Guidelines )
|
100% |
Limited to N$ 400 00 per Beneficiary
Overall Annual Limit |
| 6.1 Consultations and Procedures
| 100%
| Sub-limit 6
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| 6.2 Hospitalization
| 100%
| Sub-limit 6
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| 6.3 Radiation Oncology (referral from medical specialist only)
| 100%
| Sub-limit 6
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| 6.4 Oncology Medication (chemotherapy, radiotherapy and hormone therapy)
| 100%
| Sub-limit 6
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| 7. |
Organ Transplant
-Including immunosuppresant drugs
(Subject to Case Management and MHC Guidelines)
|
100% |
Overall Annual Limit |
| 8. |
Private Nursing
(Subject to pre-authorisation)
|
100% |
Limited to N$11 000 per Family
Overall Annual Limit
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| 9. |
Frail Care / Hospice
(Subject to pre-authorisation)
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100% |
Limited to N$11 000 per Family
Overall Annual Limit
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| 10. |
Psychiatric Treatment – hospitalisation
(Subject to pre-authorisation)
- Referral from Psychiatrist only (Referral by GP acceptable in places where there is no Psychiatrist)
|
100% |
Limited to N$8 250 per Family
Overall Annual Limit
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11.
| Drug & Alcohol Addiction
| 100%
| Sub-limit 10
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| 12. |
Refractive Surgery (all-inclusive)
(Subject to pre-authorisation)
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No Benefit |
| 13. |
Phakic Implants (lens Implant)
(all-inclusive)
(Subject to pre-authorisation)
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No Benefit |
| 14. |
Reconstructive Surgery (Medical necessity only) (all-inclusive)
(Subject to pre-authorisation and strict MHC Guidelines)
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No Benefit |
| 15. |
Dental Surgery
- Additional Hospital Benefit Cover Excluded
(Subject to pre-authorisation)
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Overall Annual Limit
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15.1 Dental Implants - Hospitalisation
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No benefit |
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15.2 Maxillo Facial & Oral Surgery (Non-Elective Only)
-Full Procedure
|
100% |
Limited to N$63 000 per Family
(Benefit for Trauma only)
Sub-limit 15
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| 16. |
Maternity |
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16.1 Confinement (all-inclusive)
(Limited to 1 confinement per year for dep. Other than the spouse)
(Subject to pre-authorisation)
|
100% |
Sub-limit 16
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16.2 Ante-natal Consultation
- Additional Hospital Benefit Cover excluded
|
100% |
Limited to 12 consultations per Beneficiary
(Pro-rated from date of joining)
Sub-limit 16
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| 16.3 Ante-natal / Post-natal C;asses & Education - Additional hospital benefit cover excluded
| 100%
| Limited to 6 sessions per Beneficiary per pregnancy (pro-rated from date of joining) Sub-limit 16
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16.4 Sonar Scans - Additional Hospital Benefit Cover excluded
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100% |
Limited to 3 scans per Beneficiary per pregnancy Sub-limit 16
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16.5 Tests for Chromosomal and Foetal abnormalities
- Additional Hospital Benefit Cover excluded
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100% |
Sub-limit 16 |
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16.6 Midwifery Service
- Additional Hospital Benefit Cover excluded
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100% |
Sub-limit 16 |
| 17. |
Insertion Intrauterine Device w/ hormone (Mirena) (All-inclusive)
(Subject to Prior approval)
|
100% |
Limited to N$6 000 per beneficiary
Overall Annual Limit
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18.
| Stomatherapy
| 100%
| No benefit
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| 19. |
Ambulance & Evacuation Services (subject to prior approval)
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Overall Annual Limit |
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19.1 Emergency Ambulance & Flights
(Subject to prior approval)
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100% |
Unlimited Benefit |
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19.2 Ambulance/Inter-hospital transfer
(Subject to prior approval)
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100% |
Sub-limit 19
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19.3 Other Transport
Transport benefit for medical services available only in RSA (Subject to prior approval and MHC Guidelines) |
80% of cost
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Limited to N$ 9 800 per Family
Sub-limit 19 |
| 20. |
International Medical Travel Insurance
- Medical cover when travelling to foreign countries
- For emergency cases only (not for elective surgery or procedure)
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100% of cost |
N$10 000 000 per incident
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| 21. |
Specified Illness Conditions
(Subject to pre-authorisation)
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Limited to N$33 250 per Beneficiary
Overall Annual Limit
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21.1 HIV/AIDS
(As per National Guidelines for Antiretroviral Therapy)
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21.1.1 Medicine
- Paid at Maximum Namibia Medicine Price List on generics
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100% |
Sub-limit 21 |
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21.1.2 First Full HIV Consultation / Assessment
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N$440
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Once off benefit
Sub-limit 21
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21.1.3 Consultation (after the first full HIV consultation
/ assessment)
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N$405
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Limited to 6 consultations per Beneficiary
Sub-limit 21
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21.1.4 HIV Counselling
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100% |
Limited to N$1 100 per Beneficiary
Sub-limit 21
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21.1.5 Pathology Tests
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100% |
Sub-limit 21 |
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21.1.6 HIV Resistance Test
(Subject to pre-authorisation)
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100% |
Sub-limit 21 |
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21.2 Prevention of Mother-to-Child Transmission (PMTCT)
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100% |
Sub-limit 21
As per National Guidelines
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21.3 Post-Exposure Prophylaxis (PEP)
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100% |
Sub-limit 21
As per National Guidelines
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21.4 Pre-Exposure Prophylaxis (PrEP)
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100% |
Sub-limit 21
As per National Guidelines
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