OVERALL ANNUAL BENEFIT
(OVERALL ANNUAL LIMIT)
|
|
N$520 000 PER BENEFICIARY
N$780 000 PER FAMILY |
|
CATEGORY A: HOSPITALISATION BENEFIT
|
% NAMAF TARIFF
|
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.
|
|
Additional Hospital Benefit Cover: GP’s and
Specialists In-hospital services
are paid up to a MAXIMUM of 215% of
NAMAF Tariff
|
| 1. |
Hospitalisation (Subject to Pre-authorisation) |
|
OVERALL ANNUAL LIMIT |
|
1.1 Accommodation & Theatre |
100% |
Overall Annual Limit |
|
1.2 Accommodation other than a recognised
hospital/medical institution
(Subject to
prior approval & Accommodation
Expenses Re-imbursement Policy)
|
|
Limited to N$600 per day per Family (Maximum of 2 days)
Overall Annual Limit
|
|
1.3 Blood Transfusions |
100% |
Overall Annual Limit |
|
1.4 Intensive and High Care
- Maximum of 3 days then motivation
|
100% |
Overall Annual Limit |
|
1.5 Medicine, fixed tariff procedures, hospital
apparatus and To Take Out Medicine (7 days supply only)
|
100% |
Overall Annual Limit |
|
1.6 Radiology & Pathology (in hospital)
- Additional Hospital benefit Cover excluded
|
100% |
Overall Annual Limit |
|
1.7 Physiotherapy
- Additional Hospital Benefit Cover excluded
|
|
|
|
1.7.1 Physiotherapy ( in hospital) |
100% |
Overall Annual Limit Sub-limit 1.7
|
|
1.7.2 Physiotherapy (post rehabilitation)
- Additional benefit once the patient is out of hospital
(Subject to prior approval)
|
|
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)
| |
Overall Annual Limit
|
|
2.1 MRI & CT Scans |
100% |
Limited to N$11 950 per Family
Sub-limit 2
|
|
2.2 Nuclear Medicine |
100% |
Sub-limit 2 |
| 3. |
General Practitioners and Specialists
(in hospital services, procedures & operations)
- Additional Hospital Benefit Cover included
|
100% |
Overall Annual Limit |
| 4. |
Internal Appliances & Materials
(Subject to pre-authorisation)
|
|
Subject to Bankmed Namibia Protocol
Overall Annual Limit
|
|
4.1 Artificial Eyes |
100% of cost |
No Benefit
|
|
4.2 Artificial Limb |
100% of cost |
No Benefit |
|
4.3 Other Internal Appliances & Materials |
100% of cost |
Sub-limit 4 |
| 5. |
Dialysis
(Subject to Case Management and MHC Guidelines)
|
100% |
Overall Annual Limit |
| 6. |
Oncology
(Subject to Case Management and MHC Guidelines )
|
100% |
Limited to N$ 400 00 per Beneficiary
Overall Annual Limit |
| 6.1 Consultations and Procedures Out-of-Hospital
| 100%
| Sub-limit 6
|
| 6.2 MRI/CT Scans & Other Specialized Radiology in & Out of Hospital - Additional Hospital Benefit Cover Excluded - Referral from medical specialist only | 100% | Sub-limit 6 |
| 6.3 Radiation Oncology (referral from medical specialist only)
| 100%
| Sub-limit 6
|
| 6.4 Oncology Medication (chemotherapy, radiotherapy and hormone therapy)
| 100%
| Sub-limit 6
|
| 6.5 Hospitalisation
and Related Procedures In-Hospital
| 100%
| Overall Annual Limit
|
| 7. |
Organ Transplant
-Including immunosuppresant drugs
(Subject to Case Management and MHC Guidelines)
|
100% |
Overall Annual Limit |
| 8. |
Private Nursing / Frail Care / Hospice
(Subject to pre-authorisation)
|
100% |
Limited to N$12 350 per Family
Overall Annual Limit
|
| 9. |
Frail Care / Hospice
(Subject to pre-authorisation)
|
100% |
Sub-limit 8 |
| 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$8 500 per Family
Overall Annual Limit
|
11.
| Drug & Alcohol Addiction
| 100%
| Sub-limit 10
|
| 12. |
Refractive Surgery (all-inclusive)
(Subject to pre-authorisation)
|
|
No Benefit |
| 13. |
Phakic Implants (lens Implant)
(all-inclusive)
(Subject to pre-authorisation)
|
|
No Benefit |
| 14. |
Reconstructive Surgery (Medical necessity only) (all-inclusive)
(Subject to pre-authorisation and strict MHC Guidelines)
|
|
No Benefit |
| 15. |
Dental Surgery
- Additional Hospital Benefit Cover Excluded
(Subject to pre-authorisation)
|
|
Overall Annual Limit
|
|
15.1 Dental Implants - Hospitalisation
|
|
No benefit |
|
15.2 Maxillo Facial & Oral Surgery (Non-Elective Only)
- All-inclusive (including dental extractions for children less than 10 years old and wisdom teeth extractions) |
100% |
Limited to N$63 000 per Family
(Benefit for Trauma only)
Sub-limit 15
|
| 16. |
Maternity |
|
|
|
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
|
|
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
|
| 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
|
|
16.4 Sonar Scans - Additional Hospital Benefit Cover excluded
|
100% |
Limited to 3 scans per Beneficiary per pregnancy Sub-limit 16
|
|
16.5 Tests for Chromosomal and Foetal abnormalities
- Additional Hospital Benefit Cover excluded
|
100% |
Sub-limit 16 |
|
16.6 Midwifery Service
- Additional Hospital Benefit Cover excluded
|
100% |
Sub-limit 16 |
| 17. |
Insertion Intrauterine Device w/ hormone (Mirena) (All-inclusive)
(Subject to Prior approval)
|
100% |
Limited to N$6 250 per beneficiary (pro-rated from date of joining)
Overall Annual Limit
|
18.
| Stomatherapy
| 100%
| No benefit
|
| 19. |
Ambulance & Evacuation Services (subject to prior approval)
|
|
Overall Annual Limit |
|
19.1 Emergency Ambulance & Flights
(Subject to prior approval)
|
100% |
Unlimited Benefit |
|
19.2 Ambulance/Inter-hospital transfer
(Subject to prior approval)
|
100% |
Sub-limit 19
|
|
19.3 Other Transport
Transport benefit for medical services available only in RSA (Subject to prior approval and MHC Guidelines) |
80% of cost
|
Limited to N$ 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)
|
100% of cost |
N$10 000 000 per incident
|
| 21. |
Specified Illness Conditions
(Subject to pre-authorisation)
|
|
Limited to N$34 550 per Beneficiary
Overall Annual Limit
|
|
21.1 HIV/AIDS
(As per National Guidelines for Antiretroviral Therapy)
|
|
|
|
21.1.1 Medicine
- Paid at Maximum Namibia Medicine Price List on generics
|
100% |
Sub-limit 21 |
|
21.1.2 First Full HIV Consultation / Assessment
|
N$480
|
Once off benefit
Sub-limit 21
|
|
21.1.3 Consultation (after the first full HIV consultation
/ assessment)
|
N$425
|
Limited to 6 consultations per Beneficiary
Sub-limit 21
|
|
21.1.4 HIV Counselling
|
100% |
Limited to N$1 150 per Beneficiary
Sub-limit 21
|
|
21.1.5 Pathology Tests
|
100% |
Sub-limit 21 |
|
21.1.6 HIV Resistance Test
(Subject to pre-authorisation)
|
100% |
Sub-limit 21 |
|
21.2 Prevention of Mother-to-Child Transmission (PMTCT)
|
100% |
Sub-limit 21
As per National Guidelines
|
|
21.3 Post-Exposure Prophylaxis (PEP)
|
100% |
Sub-limit 21
As per National Guidelines
|
|
21.4 Pre-Exposure Prophylaxis (PrEP)
|
100% |
Sub-limit 21
As per National Guidelines
|
