OVERALL ANNUAL BENEFIT
(OVERALL ANNUAL LIMIT)
|
|
UNLIMITED BENEFIT
|
|
|
|
|
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)
|
|
|
|
1.1 Accommodation & Theatre
|
100%
|
Sub-limit 1
|
|
1.2 Accommodation other than a recognised hospital/medical institution
|
100% of cost
|
Limited to N$600 per day per Family
(Maximum of 2 days)
Sub-limit 1
|
|
1.3 Blood Transfusions
|
100%
|
Sub-limit 1
|
|
1.4 Intensive and High Care
- Maximum of 3 days then motivation
|
100%
|
Sub-limit 1
|
|
1.5 Medicine, fixed tariff procedures, hospital apparatus and To Take Out Medicine (7 days supply only)
|
100%
|
Sub-limit 1
|
|
1.6 Radiology & Pathology (in hospital)
- Additional Hospital benefit Cover excluded
|
100%
|
Sub-limit 1
|
|
1.7 Physiotherapy
- Additional Hospital Benefit Cover excluded
|
100%
|
Sub-limit 1
|
|
1.7.1 Physiotherapy (in hospital)
|
100%
|
Sub-limit 1.7
|
|
1.7.2 Physiotherapy (post rehabilitation)
- Additional benefit once the patient is out of hospital
(Subject to prior approval)
|
100%
|
Limited to N$5 800 per family
(Benefit available within 3 months from hospital discharge)
Sub-limit 1.7
|
2.
|
Specialised Radiology Procedures (in & out of hospital)
- Additional Hospital Benefit Cover excluded
- Referral from a medical specialist only (referral from GP acceptable in places where there is no medical specialist)
(Subject to prior approval)
|
|
Overall Annual Limit
|
|
2.1 MRI & CT Scans
|
100%
|
Sub-limit 2
|
|
2.2 Nuclear Medicine
|
100%
|
Sub-limit 2
|
3.
|
General Practitioners and Specialists
(in- hospital services, procedures & operations)
|
100%
|
Overall Annual Limit
|
4.
|
Internal Appliances & Materials
(Subject to pre-authorisation)
|
|
Subject to Bankmed Namibia Internal Prosthesis Protocol
Overall Annual Limit
|
|
4.1 Artificial Eyes
|
100% of cost
|
Limited to N$ 16 430 per Beneficiary every 4 years (2020/2023)
Sub-limit 4
|
|
4.2 Artificial Limb
|
100% of cost
|
Limited to N$ 32 860 per Beneficiary every 4 years (2020/2023) Sub-limit 4
|
|
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) (Subject to Case Management and MHC guidelines)
|
100%
|
Limited to N$ 750 000 per Beneficiary Overall Annual Limit
|
|
6.1 Consultations and Procedures
|
100% |
Sub-limit 6
|
| 6.2 Hospitalization
| 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
|
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$33 250 per Family
|
9.
|
Frail Care / Hospice
(Subject to pre-authorisation)
|
100%
|
Limited to N$33 250 per Family
|
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$30 500 per Family
|
11.
|
Alcoholism / Drug Addiction
(Subject to prior approval and MHC Guidelines)
|
100%
|
Sub-limit 10
|
12.
|
Refractive Surgery (all-inclusive) (Subject to pre-authorisation & MHC Guidelines)
|
100%
|
Limited to N$30 000 per Beneficiary (once off benefit)
|
13.
|
Phakic Implants (lens Implant)
(all-inclusive)
(Subject to pre-authorisation)
|
100%
|
Limited to N$34 750 per Beneficiary (once-off benefit)
|
14.
|
Reconstructive Surgery (Medical necessity only)
(Subject to pre-authorisation and strict MHC Guidelines)
|
100%
|
Overall Annual Limit
|
|
14.1 Consultation and Procedure
|
100%
|
Limited to N$13 750 per Family Sub-limit 14
|
|
14.2 Hospitalisation
|
100%
|
Sub-limit 14
|
15.
|
Dental Surgery
- Additional Hospital Benefit Cover Excluded
(Subject to pre-authorisation)
|
|
Overall Annual Limit
|
|
15.1 Dental Implants – Hospitalisation
|
100%
|
Limited to N$9 500 per Beneficiary
Limited to N$16 750 per Family
Overall Annual Limit
Sub-limit 15
|
|
15.2 Maxillo-acial & Oral Surgey (Elective & Non-elective) Full procedure
|
100%
|
Limited to N$133 250 per Family
Sub-limit 15
|
16.
|
Maternity
|
|
Overall Annual Limit
|
|
16.1 Confinement (all-inclusive)
(Limited to 1 confinement per year for dep. other than the spouse)
(Subject to pre-authorisation)
|
|
|
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 Classes & 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%
|
Overall Annual Limit
Sub-limit 16
|
|
16.6 Midwifery Service
- Additional Hospital Benefit Cover excluded
|
100%
|
Overall Annual Limit
Sub-limit 16
|
17.
|
Insertion of Intrauterine Device w/ hormone (Mirena) (All-inclusive)
(Subject to Prior approval)
|
100%
|
Limited to N$6 000 per Beneficiary
Overall Annual Limit
|
18.
| Stomatherapy (all-inclusive) (Subject to prior approval)
| 100%
| Limited to N$ 28 750 per Family Overall Annual Limit
|
19.
|
Ambulance & Evacuation Services (subject to prior approval)
|
|
Overall Annual Limit
|
|
19.1 Emergency Ambulance & Flights
|
100%
|
Unlimited |
|
19.2 Ambulance/Inter-hospital transfer
|
100%
|
Sub-limit 19
|
|
19.3 Other Conveyances
Transport benefit for medical
services available only in RSA (Subject to prior approval)
|
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$33 250 per Beneficiary
Overall Annual Limit
|
|
21.1 HIV/AIDS
(As per National Guidelines for Antiretroviral Therapy)
|
|
Sub-limit 21
|
|
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$440
|
Once off benefit
Sub-limit 21
|
|
21.1.3 Consultation (after the first full HIV consultation / assessment)
|
N$405
|
Limited to 6 consultations per Beneficiary
Sub-limit 21
|
|
21.1.4 HIV Counselling
|
100%
|
Limited to N$1300 per Beneficiary
|
|
21.1.5 Pathology Tests
|
100%
|
Sub-limit 21
|
|
21.1.6 HIV Resistance Test
(Subject 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%
|
|
22.
|
Wheelchair
(Subject to prior approval)
- Inclusive of repair & maintenance
|
100% of cost
|
Limited to N$13 250 per Beneficiary every 4 years (2019/2022)
Overall Annual Limit
|
23.
|
Appliances (External)
(Subject to MHC guidelines)
|
80%
|
Limited to N$4 500 per family
Overall Annual Limit
|
24.
|
Hearing Aids Apparatus
(Subject to prior approval)
- Inclusive of repair & maintenance
|
100% of cost
|
Limited to N$30 000 per Family every 2 years (2020/2021)
Overall Annual Limit
|
25.
|
Medical Devices for Diabetes Management (Subject to prior approval and MHC guidelines)
|
|
No benefit
|