Essence Hospital - Benefits | Bankmed

Key Benefits

  • Adequate range of benefits
  • 100% of NAMAF Tariffs
  • Limited private hospitalisation
  • Limited individual benefit amounts
  • Premiums range between N$1,192 and N$5,784

Contribution Table

Income Band  Family Member
Option  Member  Adult  Child
N$0 - N$2 860 1,170 940 219
N$2 861 - N$3 690 1,243 1,000 229
N$3 691 - N$4 770 1,324 1,058 242
N$4 771 - N$5 610 1,612 1,286 294
N$5 611 - N$7 530 1,741 1,399 319
N$7 531 - N$9 450 1,853 1,488 341
N$9 451 - N$14 060 1,950 1,563 364
N$14 061 - N$18 780 2,040 1,637 387
N$18 781 - N$23 540 2,133 1,712 403
N$23 541 - N$28 290 2,219 1,778 421
N$28 291 - N$37 540 2,239 1,798 423
N$37 541 - N$46 700 2,260 1,813 430
N$46 701 + 2,285 1,824 441

Detailed Benefits

 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 225% of NAMAF Tariff 
1.  Hospitalisation (Subject to Pre-authorisation) 
1.1 Accommodation & Theatre  100%  Overall Annual Limit 
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) 
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 

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 
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) 

2.1 MRI & CT Scans  100%  Overall Annual Limit 
2.2 Nuclear Medicine  100%  Overall Annual Limit 
2.3 Radiation Oncology  100%  Overall Annual Limit 
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 
4.1 Artificial Eyes  100% of cost  Sub-limit 4 
4.2 Artificial Limb  100% of cost  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 -Active therapy

(surgery, chemotherapy, radiotherapy and hormone therapy) 

100%  Overall Annual Limit 
(Subject to Case Management and MHC Guidelines) 
7. 

Organ Transplant 

- Including immunosuppresant drugs

(Subject to Case Management and MHC Guidelines) 

100%  Overall Annual Limit 
8. 

Hospice Facilities 

(Subject to pre-authorisation) 

100%  Overall Annual l Limit 
9. 

Private Nursing 

(Subject to pre-authorisation) 

100%  Limited to N$33 250 per Family 
10. 

Frail Care

(Subject to pre-authorisation) 

100%  Limited to N$33 250 per Family 
11. 

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 
12. 

Alcoholism / Drug Addiction 

(Subject to prior approval and MHC Guidelines) 

100%  Sub-limit 11 
13. 

Refractive Surgery (all-inclusive)

(Subject to pre-authorisation & MHC Guidelines) 

100%  Limited to N$30 000 per Beneficiary (once off benefit) 
14. 

Phakic Implants (lens Implant)  (all-inclusive) 

(Subject to pre-authorisation) 

100%  Limited to N$34 750 per Beneficiary (once-off benefit) 
15. 

Reconstructive Surgery (Medical necessity only) 

(Subject to pre-authorisation and strict MHC Guidelines) 

100% 
14.1 Consultation and Procedure  100%  Limited to N$13 750 per Family 
14.2 Hospitalisation  100%  Overall Annual Limit 
16. 

Dental Surgery 

- Additional Hospital Benefit Cover Excluded 

(Subject to pre-authorisation) 

16.1 Dental Implants – Hospitalisation  100% 

Limited to N$9 500 per Beneficiary 

Limited to N$16 750 per Family 

16.2 Maxillo Facial & Oral Surgery  (Elective & Non-Elective) 

- All-inclusive   

100%  Limited to N$133 250 per Family 
17.  Maternity 

17.1 Confinement (all-inclusive) 

(Limited to 1 confinement per year for dep. other than the spouse) 

(Subject to pre-authorisation) 

Overall Annual Limit 

17.2 Ante-natal Consultation 

- Additional Hospital Benefit Cover excluded 

100%  Limited to 12 consultations per Beneficiary  (Pro-rated from date of joining) 

17.3 Sonar Scans (excluding 3D) 

- Additional Hospital Benefit Cover excluded 

100%  Limited to 3 scans per Beneficiary per pregnancy 

17.4 Amniocentesis 

- Additional Hospital Benefit Cover excluded 

100%  Overall Annual Limit 

17.5 Midwifery Service 

- Additional Hospital Benefit Cover excluded 

100%  Overall Annual Limit 
18. 

Insertion of Intrauterine Device w/ hormone (Mirena) (All-inclusive) 

(Subject to Prior approval) 

100%  Limited to N$6 000 per Beneficiary 
19.  Ambulance & Evacuation Services 
19.1 Emergency Ambulance & Flights  100%  Overall Annual Limit 
19.2 Ambulance/Inter-hospital transfer  100%  Overall Annual Limit 

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 

Overall Annual Limit 

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 

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$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) 
23.  Appliances (External)  (Subject to MHC guidelines)  80%  Limited to N$4 500 per family 
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 
25.  Essential Vaccination/ Immunization  (As per WHO Guidelines)  Paid at Maximum Namibia Medicine Price List on generics  100%  Overall Annual Limit 
CATEGORY B:  DAY TO DAY POOLED BENEFIT  100% Tariff 

N$5 000 per Beneficiary per Annum 

N$10 000 per Family per Annum 

OVERALL ANNUAL LIMIT 

Benefits are prorated from Date of Joining  Ex Gratia not Applicable 

26. 

General Practitioners & Specialists 

100%  Paid from Day to Day Pooled Benefit 
 

26.1 Consultations/Visits

 

26.2 Procedures/Services

 

26.3 Materials and Disposable Items 

 

26.4 Radiology & Pathology 

27. 

Dentistry 

100%  Paid from Day to Day Pooled Benefit 
 

27.1 Basic /Conservative Dentistry

 

27.2 Specialised / Advanced Dentistry 

 

27.3 Dental Implants 

  No benefit 
 

27.3.1 Consultation & Procedure 

 

27.3.2 Implant Component

  27.4 Orthodontics    No benefit 
28. 

Medicine & Injections 

80% 

Paid from Day to Day Pooled Benefit 

Paid at Maximum Namibia Medicine Price List on generics 

 

28.1 Acute Medicine

 

28.2 Chronic Medicine 

  28.3 Chronic Medicine (Pensioners)  100% 

Paid from Day to Day Pooled Benefit 

Paid at Maximum Namibia Medicine Price List on generics 

  28.4 Self Medication  100% 

Paid from Day to Day Pooled Benefit 

Paid at Maximum Namibia Medicine Price List on generics 

29.  Primary Health Care Services       
  29.1 Consultations 100% Paid from Day to Day Pooled Benefit 
  29.2 Medicine & Injections  80% 

Paid from Day to Day Pooled Benefit 

Medicines paid at Maximum Namibia Medicine Price List on generics 

30. 

Auxiliary Services (Supplementary Services) 

100%  Paid from Day to Day Pooled Benefit 
 

30.1 Art Therapy 

 

30.2 Audiology/Speech Therapy 

 

30.3 Biokineticist  30.4 Chiropractor 

 

30.4.1 Consultation & Procedure 

 

30.4.2 Medicine 

 

30.5 Clinical Psychology / Psychological Counsellor

 

30.6 Clinical Technology

 

30.7 Dietician 

 

30.8 Hearing Aid Acoustician 

 

30.9 Homeopathy/Naturopathy/ Phytotherapy 

 

30.9.1 Consultation & Procedure 

 

30.9.2 Medicine 

 

30.10 Occupational Therapy 

 

30.11 Orthotist/Prosthetist

 

30.12 Physiotherapy 

 

30.13 Podiatry/Chiropody

 

30.14 Social Worker

31. 

Optical 

100% 

Limited to N$4 750 per Family 

Limited to N$2 400 per Beneficiary every 2 years (including frames) (2019/2020) 

Paid from Day to Day Pooled Benefit 

 

30.1 Eye Test 

 

30.2 Contact lenses/Spectacle lenses

 

30.3 Frame 

32.  Health SmartCard  No Additional Costs. Each Dependant will receive his/her own smartcard. Benefits can be verified at Service Providers 24/7. In case of Emergency, Member and Dependants can be identified without Health Smartcard. Next of Kin can be contacted immediately. 
CATEGORY C:  ADDITIONAL FUND BENEFITS  (DAY TO DAY EXPENSES)  %  NAMAF TARIFF 

BENEFIT BOOSTER  

Benefit available only once day-to-day benefit claims paid from Day to Day Pooled Benefit (Category B) plus rejected day to day claims exceed 35% of the annual premium  

Calculated according to NAMAF Tariff Amount and not Claimed Amount   

33.  Benefit Booster  Applicable if Medicine & Injections, Dentistry, GP’s & Specialists, Primary Health Care and Auxiliary Services benefits are depleted 

Limited to N$3 250 per Beneficiary 

Limited to N$6 000 per Family 

33.1 Medicine & Injections (Acute & Chronic) 

- Excluding Self-Medication 

70%  Sub-limit 33 

33.2 Medicine & Injections

(Chronic Pensioner) 

90%  Sub-limit 33 

33.3 Dentistry 

(Excluding Dental Implants & Orthodontic) 

70%  Sub-limit 33 

33.4 General Practitioners & Specialists

(Consultations/Visits & Procedures/Services out-of-hospital, including casualties) 

80%  Sub-limit 33 
33.5 Primary Health Care  80%  Sub-limit 33 
33.6 Auxiliary Services  70%  Sub-limit 33 

Download the Essence HOSPITAL Benefit PDF

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Managed Healthcare

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HIV/AIDS Programme

Hospital Bedside Support Services

Chronic Medication Programme

Emergency Evacuation Services

Pregnant Members

Self Medication

Self-medication is medicine that can be obtained from the pharmacy for minor ailments.

Covered Medical Appliances

The following external medical appliances are covered by the Fund.

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