Were about you

2013
User Guide
Table of contents

1. Introduction
2. How do I become a member of NHP?
3. Important to know once membership is approved
4. Understanding your Medical Aid Fund
5. How do I claim?
6. What medical benets are excluded?
7. The NHP Wellness Programme
8. NHP Lifestyle Management Programme
Contact us
tel +264 61 285 5400
fax +264 61 223 904
email info@nhp.com.na or newbusiness@nhp.com.na
website www.medscheme.com.na
1st Floor, Hidas Centre, 21 Nelson Mandela Avenue
PO Box 23064, Windhoek
Disclaimer
The NHP benets, contributions and Rules for 2013 are subject to
approval by the Registrar of Medical Aid Funds/NAMFISA.
2
Introduction
About NHP
Thank you for choosing the Namibia Health Plan (NHP).
NHP was established in 1995 to provide a world class, uniquely
Namibian medical aid plan to help cover medical costs.
Since then, NHP has grown rapidly to become one of the largest
medical aid funds in our country, providing for the healthcare
needs of almost 45 000 people. We are also the rst choice
of Namibians as shown by the results of the 2010 and 2011
PMR.africa surveys where NHP was presented with the
Diamond Arrow Award for excellence in the medical aid
industry in Namibia.
While we are proud of these awards (which shows that were on
the right track), ultimately NHP exists to provide you and your
family with meaningful medical aid benets that help you cover
your medical costs.
That is why we believe that our very reason for existence is all
about you our members. Were about you.
How NHP is managed
NHP is registered in terms of the Act on Medical Aid Funds (Act
23 of 1995). The Fund is supervised by the Namibia Financial
Institutions Supervisory Authority (NAMFISA) and the Namibian
Association of Medical Aid Funds (NAMAF), the controlling body
for medical aid funds in Namibia. The Fund is managed by a
Board of Trustees elected by the members.
The Board of Trustees manages the Fund on your behalf and
according to the Rules of the Fund which changes from time
to time to take changing circumstances into account. When the
Rules are changed you will be informed.
Introducing your Principal Ofcer
Mr. Joern Wiedow
Introducing your NHP Board of Trustees
Dr. Gert Lbbert - Chairperson
Mr. Etienne Steenkamp - Vice Chairperson
Mr. Bennie Venter
Mr. Bertus Mattee
Mr. Brian Schickerling
Mr. Colin Katjitae
Ms. Ellen Maasdorp
Ms. Glynis Labuschagne
Dr. Martin Diekmann
Mr. Peter von Khne
Ms. Rika Beuke
Ms. Suzie Chamberlain
Your Guides as a tool to understanding the Rules
of the Fund
The User Guide explains in brief the salient points contained in
the Rules at present. You are provided with the User Guide only
when joining the Fund. Any subsequent changes to the Fund
Rules as well as changes to the benets and contributions will
be announced in the summary of changes document annually.
You will also receive a new copy of the Benet Guide annually.
Therefore it is important for you to retain the summary of
changes form for future reference.
Please note The Rules may change and if there is any
discrepancy between the Guide and the Rules,
the Rules will apply. If you have any questions
after reading through this User Guide, please
do not hesitate to contact NHP or your Client
Liaison Ofcer.
3
NHP produces an annual Benet Guide. This Guide is written in
a simple, easy-to-read language to help you understand your
medical aid fund and how the Fund works. When we use the
word your we are referring to the principal member.
The words your family mean any dependant of the principal
member who has been admitted to the Fund. The Benet Guide
contains the benets and contributions as approved by the
Board of Trustees and will apply for 2013. The changes for 2013
are subject to approval by NAMFISA.
The Fund will not be held liable if your rights are prejudiced
or forfeited as a result of failure or neglect to comply with the
Rules of the Fund which may arise from failure or neglect to
read the communications issued by the Fund in order to inform
you, educate and create an awareness of the Rules of the Fund
as well as the benet and contributions offered there under.
What role does NAMFISA and NAMAF play in the medical
aid industry?
Private medical aid funds must be registered with the Registrar
of Medical Aid Funds in Namibia. NAMFISA is the registrar of
non-banking nancial institutions and is responsible for the
supervision of these institutions in terms of the NAMFISA Act
(Act 3 of 2001).
The function of NAMAF is to protect members of medical aid
funds against abuse from both medical aid funds and providers
of healthcare services, and to serve as an advocate between
medical aid funds and their members. Medical aid fund members
may therefore approach NAMAF should they feel that their
claims or membership status is being unfairly treated by a
medical aid fund. Members are encouraged to exercise the
above option only after they have exhausted all possible
avenues with their medical aid fund, without success. If the
complaint is found to be valid, NAMAF will take the matter up
with the relevant medical aid fund on behalf of the member
with the aim of rectifying the situation.
What is meant by medical aid tariff?
NAMAF is the legislated entity authorised to negotiate and
set tariff structures on behalf of all medical aid funds. These
tariffs are commonly referred to as the NAMAF benchmark
tariffs, scale of benets or medical aid tariffs. The NAMAF
benchmark tariffs are endorsed by medical aid funds and
therefore also represent the 100% benchmark to which
reference is typically made in the Benet Guide and User Guide.
As such the Fund pays out according to the set NAMAF
benchmark tariffs and if a healthcare provider charges above
this tariff, the member will be held liable for the difference.
Healthcare providers are not limited to charge according to the
NAMAF benchmark tariff structure.
The fee that is charged largely depends on the scarcity of skills,
demand for such skills, and a number of other factors. Members
will remain responsible for settling the full account to the
healthcare providers and as such may be required to settle
any outstanding amounts.
4
In the case of hospitalisation and treatment while in hospital,
it is often the case that members may run up a signicant bill
for expenses that is in excess of the NAMAF benchmark tariff.
It is for this reason that the additional in-hospital cover (GAP
cover) is there to assist members with defraying the cost of
huge co-payments. The Fund offers the GAP cover which will
automatically be processed and paid to the healthcare provider
as per the benet allowed per benet option. Members with
accumulated Roll-Over Benets may also request that such co-
payments in respect of out-of-hospital treatment be refunded
from their Roll-Over Benet account or alternatively contacts
NHP for further advice.
About Medscheme Namibia
Medscheme Namibia has been the administrator for NHP for the
past 18-years, during which time the Fund has grown to become
one of the largest open medical aid funds in Namibia.
Medscheme Namibia regards itself as Namibias leading
integrated healthcare fund manager and administrator.
Medscheme Namibia is supported by the Nexus Administration
System. Besides the fact that the Nexus Administration
System supports all the traditional administrative functions,
it is furthermore based on an integrated modular healthcare
system providing communication modules, which facilitates
better electronic communication with healthcare providers
and members alike.
The Nexus Administration System provides an event based
communication module, making use of SMS and emails to
communicate with members more frequently, providing the
members with the ability to manage their utilisation much
more closely. It also has the benet of a comprehensive data
warehousing facility which provides for customised reporting
formats, one of which includes the GPS contact centre
dashboard to improve efciency and service levels throughout
NHPs contact centres.
The Nexus Administration System enables for the smooth
processing of claims and administrative functions to be
performed in a totally paperless and workow based operating
environment, thus ensuring optimum efciency and lower
costs. Medscheme Namibia is capable of offering its clients
benchmark response times with a proven track record of 24/7
system capability and uptime. Medscheme Namibia is proud of
the fact that on average in excess of 80% of all claims received
and processed are in electronic format, which is regarded as
exceptional in the industry. Through its Voice of the Customer
(VOC) surveys and functionality the administrator is able
to measure service levels and customer satisfaction on a
continuous basis.
What is the relationship between Medscheme Namibia
and NHP?
Medscheme Namibia is responsible for the administration of
NHP. An independently elected Board of Trustees is responsible
for the management and decision making of the Fund. Any
member of the Fund can make them self available for election
to the Board of Trustees. The Fund has established itself as one
of the leading medical aid funds in the country and has proven
itself in terms of stability, good nancial management, sound
corporate governance principles and excellent service levels.
How do I become a member of NHP?
Application requirements for NHP membership
You can obtain an application form from any of the NHP call
centres throughout Namibia. Members can also download this
form directly from the website www.nhp.com.na
The completed application form should be accompanied by
the following documentation:
A medical certicate - As per the requirement
A copy of ID/Passport document from the principal member
and for each member of the family for whom cover is sought
A copy of birth certicate(s), except in the case of children
with different surnames, in which case a full birth certicate
will be required
A copy of the marriage certicate - If applicable
In the case of a common-law spouse - A certied declaration
under oath
Proof of previous medical aid fund membership - If applicable
Proof of legal adoption of adopted children - If applicable
Proof of legal guardianship - If applicable
Monthly contributions
Monthly contributions for employer groups, pensioners and
private individuals are set out in the contribution tables of the
Fund. All monthly contributions are determined following a
comprehensive actuarial risk assessment of the inherent risks
associated and arising from the demographic and claims prole
of the Fund or an employer group.
Monthly membership contributions to the Fund are based on the
age of the principal member. The age of the principal member in
January of each nancial year will determine the age category
and therefore the monthly contributions for the remainder of
that nancial year. Monthly contributions are not increased in
accordance with the principal members birthday during the
course of the year.
Monthly contributions are payable in advance before or on the
7th day of each calendar month. The rst payment needs to be
made in cash; cheque or alternatively electronic funds transfer.
Debit orders will only be processed as from the 2nd calendar
month of membership.
New employer groups will only be provided with a system
generated tax invoice once payment in respect of new members
has been received and all members having been loaded onto
the system. Proof of membership will only be provided once the
1st monthly contributions have been paid over. In cases where
the administrator has not received payment by the 7th day of
the calendar month, the Board of Trustees will have the right to
suspend benets or withdraw or refuse payment of benets.
Where accounts have been paid to either the healthcare
provider or the principal member during any period for which
monthly contributions have not been received, the principal
member will be held liable for the full amount. Alternatively,
should the principal member concerned settle his/her debt
to the Fund, he/she will be entitled to benets for services
rendered during the period of suspension.
Dual membership
No person may be a member of any other medical aid fund
registered, in terms of the Medical Aid Funds Act (Act 23
of 1995) or any medical aid arrangement offered by the
Government of Namibia (PSEMAS) whilst a member of
NHP. Should a member of NHP be found to be a member of
another medical aid fund or PSEMAS, they and their dependants
will immediately cease to be members of the Fund, and
all claims paid during this dual membership period will be
immediately reimbursable to the Fund.
5
Individual members
Members of the public who wish to join in their own capacity,
or employer groups with fewer than 10 employees applying
and qualifying for medical aid fund membership at the time
of commencement, are regarded as individual members. Such
persons may, subject to approval by the Board of Trustees,
register their spouse and children as dependants, provided
that they are not entitled to benets from any other medical
aid fund.
In the case of an individual member, the monthly contribution is
calculated according to his/her age and number of dependants,
as well as the benet option chosen, provided that if one of the
individual members dependants is older than such individual,
the monthly contribution will be calculated according to the
age of such dependant.
The monthly contribution is recalculated with every change in
any of the aforementioned factors. The monthly contribution
so recalculated is payable with effect from the 1st day of the
calendar month in which the event giving rise to the change
in any of the aforementioned factors shall have occurred. No
person older than 60-years of age will be allowed to join the
Fund as an individual member.
Student members
Students who are not regarded as dependants on their parents
medical aid fund, but apply for membership with the Fund,
should pay monthly contributions in advance for the whole
year once accepted.
Please note The South African Immigration Amendment Act
(Act 19 of 2004) has certain implications for
Namibian students applying for a study permit
in the Republic of South Africa. The current
arrangement between the Republic of South
African and Namibian authorities, are that all
Namibians applying for a study permit need to
show proof of membership with a medical aid fund,
registered in the Republic of South Africa. You are
advised to rst conrm with the university if this
prerequisite is enforced before applying for medical
aid within the Republic of South Africa.
Employer groups
An employer group wishing to obtain membership with the Fund
should apply in writing to the Board of Trustees, provided that
at least 10 of its employees, who qualify for membership, join
the Fund.
Employers, even if they are less than 10 employees but
registered with the Namibia Chamber of Commerce and Industry,
may join the Fund as an employer group. The employer group
will qualify for the reduced monthly contributions under the
NHP employer group structure. Employer groups with fewer
than 10 employees, and not forming part of the NCCI or any
other umbrella body, may also join the Fund, but will not be
eligible for the reduced monthly contributions.
Please note That the condition for continued employer group
status is that companies or members should renew
their membership with these umbrella bodies on
an annual basis and provide proof of such updated
subscriber status to NHP.
Membership status will become effective on the 1st day of
the calendar month, following the date on which approval
was obtained from the Board of Trustees. Employees obtain
membership with NHP by virtue of their employment with a
particular employer group.
Employees of a new employer group joining NHP from another
fund with 10 or more members are entitled to join the Fund with
the same conditions (state of health) and exclusions as were
applied by the fund they have just left. Such members have
a period of 3-months to join the Fund. Thereafter, the normal
Rules of the Fund as dened shall apply.
The provision of a medical history applies to any person who
wishes to become a member of the Fund, even if he/she does
join the Fund within the dened 3-month period. A special
application to waiver this condition may, however, be made
to the Board of Trustees in writing.
Members and their dependants transferring from another
medical aid fund will enjoy benets from day one, with the
same terms and conditions (state of health) as accepted by
the previous medical aid fund, provided such members and
dependants were members of the previous medical aid fund for
a minimum period of at least 2-years and were not without any
form of medical aid fund cover for a period exceeding 3-months.
The Fund reserves the right to place exclusions on pre-existing
conditions should a person not apply for membership within
3-months of becoming eligible for membership with the Fund.
The Board of Trustees reserves the right to impose exclusions,
in respect of pre-existing conditions, for a 12-month period after
the initial date of joining.
6
Distinguishing between the principal member and an
aged dependant
The Rules of the Fund allows a principal member to apply for
the registration of an aged parent(s), provided that they are
totally and nancially dependent on the principal member.
Acceptance of such dependants is subject to the approval of
the Board of Trustees, in terms of the Rules of the Fund, and on
such conditions as may be prescribed from time to time.
Principal members
In the case of employer groups, the person who gains access
to the medical aid fund by virtue of his/her employment with
a participating employer group, will be regarded as the principal
member. As the participating employer group is regarded as the
main contracting party to the Fund, employees may gain access
to membership of the Fund subject to the conditions
of employment prescribed by a particular employer group.
A married principal member may register as dependants, his/her
spouse and his/her children, provided that they are not entitled
to benets from any other medical aid fund.
A surviving dependant must have been registered as a
dependant of a principal member at the time of death of this
member in order to enjoy continued membership with the Fund.
For the continuation as a principal member, a death certicate
needs to be submitted together with a new application form
completed by the surviving spouse. A new membership number
will be issued in the event of the membership being continued.
Should there only be surviving child dependants then the oldest
surviving dependant, who is still regarded as a child in terms
of the Rules of the Fund, shall assume the role of principal
member. If a surviving spouse or dependant chooses to be a
member of another medical aid fund by virtue of employment,
remarriage or otherwise, membership with the Fund will cease
upon written conrmation of the intent to resign from the Fund
within 1-month of such notice being served.
If a surviving dependant is no longer regarded as a child in terms
of the Rules of the Fund, then that dependant shall cease to be
a member or dependant of the Fund. Any remaining dependants
who are still regarded as children in terms of the Rules of the
Fund may assume the role of principal member. Any person, who
no longer qualies for membership as a dependant, is eligible for
individual membership.
Registering an adult as a dependant
The spouse of the principal member provided that he/she are
not a member or entitled to membership of another medical
aid fund
A common-law spouse or same sex partner who has been
living with the principal member as a couple continuously for
12-months subject to the approval of the Board of Trustees
and an annual review. A declaration under oath is applicable
Registering a special/adult as a dependant
Children over the age of 21 suffering from mental and/or
physical defects, which have no income and are totally and
nancially dependent on the principal member
An aged parent of a principal member, who is totally and
nancially dependent on the principal member. Proof of
income will be required
Acceptance of a child born to a child dependant as a
registered dependant is subject to the approval by the
Board of Trustees
Registering a child as a dependant
Children under the age of 21, who are totally dependent on
the principal member, unemployed and are unmarried
Children over the age of 21 and under the age 25 enrolled
as a full-time student or apprentice at a registered and
accredited academic institution and who are totally and
nancially dependent on the principal member and are
unmarried
Legally adopted children
Children under the age of 21, both of whose parents have
passed away, and who are nancially dependent on the
appointed guardian. A copy of the death certicate of such
parents must be handed in as proof
Members must notify the administrator within 30-days of the
birth of an infant, in order to allow the child to be registered as a
dependant. Monthly contributions for this dependant will be due
as from the 1st day of the calendar month following the birth.
No benets will be granted unless the infant is registered as a
dependant. No restriction for congenital ailments and conditions
will be imposed by the Fund on a newly born child.
7
Acceptance of membership
A membership application form must be completed and
submitted to the administrator ofces by the applicant.
This membership application form, once accepted by the
Fund, shall be a contract of agreement. Any false declaration
by the applicant may render the agreement null and void and
may result in immediate cancellation of membership. Where
membership is cancelled, such members will be required to
reimburse the Fund of all claims paid during the period of
membership. Monthly contributions paid during this period
will be forfeited.
The declaration of health contained in the membership
application form must be lled out and signed by all members
applying for membership with the Fund. In the case of individual
members, such declaration of health must be completed and
signed by a medical practitioner. Employees and/or their
dependants, who have not applied for membership with the
Fund within the stipulated 3-month period after accepting
full-time employment with an employer group, must also have
the declaration of health completed and signed by a medical
practitioner.
As part of the underwriting process, the Fund reserves the
right to request additional information regarding the medical
history and a doctors certicate, relating to the members health
and family medical history, from either the member or medical
practitioner. Pro-rated day-to-day benets will apply as from the
date of joining, unless the joining date is 1 January.
Pre-existing conditions
The Board of Trustees reserves the right to impose exclusions
or restrictive conditions on pre-existing medical conditions as
from the date of joining the Fund and for a period not exceeding
12-months as part of its underwriting criteria. The Fund will not
impose exclusions on pre-existing conditions in the event of
employees joining the Medical Aid Fund within 3-months after
having resigned from a previous medical aid fund. New members
wishing to join as private members may be accepted onto the
Fund or declined from becoming a member of the Fund based
on the results of the underwriting criteria.
In the event of a member with a pre-existing medical
condition applying for membership with the Fund, the Rules
of the Fund provide that exclusions may be imposed subject
to the following conditions:
In the event of a private member applying for membership,
such pre-existing conditions and subsequent treatment
thereof may be excluded from cover irrespective of a
member previously having been a member of another
medical aid fund. Alternatively the application may need
to be declined
In the event of a new employee with an existing employer
group opting not to take up membership with the Fund
within 3-months after being employed, such pre-existing
conditions may be excluded since it is regarded as anti-
selective behaviour
In respect of a new employer group that has never
subscribed to the Fund, the Board of Trustees reserves
the right to impose exclusions in respect of pre-existing
conditions as part of the underwriting criteria, for a period
of 12-months after the initial date of joining. If the new
employer group does not agree to this condition then the
application for group membership may be declined if the risk
to the Fund is deemed to be too high
Medical certicate requirements for employer groups
Upon joining the Medical Aid Fund, it will not be necessary for
a new employer group to submit medical certicates for any of
its employees, provided that all employees join the Fund within
3-months after becoming eligible for such membership.
In respect of existing employer groups it is not required to
submit a medical certicate when joining a new employee,
provided that such employee joins the Fund within 3-months
after becoming eligible for such membership
All of the members details and the declaration of health,
contained in the membership application form must be
completed in full by each employee and all material or
relevant information should be disclosed upfront
The Fund reserves the right to return any incomplete
membership application forms and request that it be
completed correctly before the employee is accepted
onto the Fund
In order to manage the Funds risk and to enforce the request
for full disclosure, the administrator will continue to monitor
new members after they have joined and manage potential
cases of non-disclosure for possible exclusions
The submission of a medical certicate will be made
compulsory in the event of an employee not having
exercised his right to become a member of the Fund within
3-months after becoming eligible for membership. In the
event of an employee deciding to join at a later stage, a clear
case for potential anti-selection can be made and as such the
Fund reserves the right to impose exclusions in respect of
any pre-existing conditions identied at that stage
The submission of a medical certicate will be made
compulsory in the event of a member not having registered
all his/her dependants within 3-months after becoming
eligible for membership of the Fund. The Fund reserves the
right to impose exclusions in respect of any pre-existing
conditions identied at that stage
A medical certicate will be compulsory for any member
wishing to enrol their aged parents as special dependants
onto the Fund either immediately upon joining the Fund or
at a later stage
Medical declaration/certicate requirements for
individual members
As previously noted, a medical declaration/certicate will be
compulsory for all individual members, irrespective of whether
or not they have previously belonged to another medical aid
fund or not. Proof of previous medical aid fund membership
(membership declaration/certicate) alone will not be sufcient.
Important to know once
membership is approved
Proof of membership - Membership number and card
After receipt and processing of the membership application
form, a membership card will be issued to the principal
member, and the rst dependant. Members must ensure that
they provide all healthcare providers with their correct new
membership number after joining. The membership card must
be presented to a healthcare provider upon request. This card
remains the property of the Fund and must be destroyed upon
termination of membership.
1Number4Life
Members are able to retain their original membership number
from the date of joining to the date of termination of
membership, irrespective of whether the member has changed
benet options during his/her period of membership with
the Fund.
8
Can my exclusions be waived?
Exclusions on pre-existing conditions expire after a 12-month
period. It is the members responsibility to inform the Fund if the
exclusion did not lift automatically.
What is meant by a nancial year/benet year?
The nancial year of the Fund runs concurrently with the
benet year from 1 January until 31 December of each
consecutive calendar year. The Fund announces its new
monthly contributions and benets structure that will apply for
the following nancial period from 1 January until 31 December
on an annual basis. However, the Board of Trustees reserves
the right to adjust monthly contributions with a 1-month notice
period in the event of unforeseen market changes.
The Roll-Over Benet is a low claims incentive through which
unused day-to-day benets below the threshold value will be
transferred from one nancial year to another. At the start of
each new nancial year, new benets are thus allocated to
members in accordance with the benet structure that will
apply for the particular year.
What about benet option changes?
At the beginning of every nancial year and in conjunction with
the annual monthly contribution increases, existing members
are afforded the opportunity to change from one benet option
to another, based on their need. Benet option changes are
normally accommodated up to the end of January.
Under normal circumstances members will not be allowed to
buy-up or buy-down from one benet option to another during
the course of a benet year. In the case of a member requiring
a mid-year upgrade, a request should be addressed in writing
to the Board of Trustees for consideration. In the event of the
Board of Trustees approving such a request, the change will be
made, backdated to 1 January with additional payments being
requested to cover the difference in monthly contributions.
Therefore, members need to ensure that they are adequately
insured for any potential major medical expenses.
The following procedure will apply when changing from one
benet option to another:
An application for change of benet option form must be
lled out and sent via fax +264 230 465 or emailed
to members@nhp.com.na, please contact NHP,
tel +264 61 285 5400 or download the form from
www.nhp.com.na
A new membership card will be issued with the membership
number remaining the same
The new benet option will be indicated as selected
The personal details and beneciary details will remain the
same unless instructed to effect changes
Pro-rated annual benets
Pro-rated annual benets will apply to membership that is
shorter than one calendar year. Pro-rated annual benets will
also apply to beneciaries that may be enrolled during the
course of a benet year. On joining the Fund a member will have
the option of paying back-dated monthly contributions to the
start of the nancial year in order to increase his/her benets
to the full annual limit.
If a member joins the Fund after the 1st day of the nancial
year, he/she shall be deemed to have joined the Fund on the
1st day of the calendar month in which he/she was admitted
to membership. In such event, the maximum benets for all
services under the day-today benets are decreased for such
nancial year in the same ratio as the number of calendar
months already expired up to 12. Pro-rated annual benets
apply for all day-to-day benets, chronic medication, and
oral surgery.
Similarly if a member terminates his/her membership from the
Fund before the last day of the nancial year, he/she shall be
deemed to have terminated membership of the Fund on the
last day of the calendar month in which his/her membership
actually terminates. In such event, the provisions of the previous
paragraph shall apply mutatis mutandis.
The Fund may recoup from the member or from his/her
deceased estate, as the case may be, any sum disbursed by the
Fund, on behalf of such member or his/her dependants, that
exceeds the pro-rated portion of the annual benets applicable
to such members membership at the date of termination of
membership.
Pro-rated annual benets are not only applicable when joining
the Fund in the course of the year, but also on termination of
membership during the course of the nancial year.
Waiting periods
With the exception of refractive surgery on all benet options
and optical benets on the Blue Diamond and Litunga benet
options, there is no dened waiting period in respect of benets
from the date of submission of application for membership to
admission as a member.
The Fund reserves the right, however, to defer admission
until the Board of Trustees are satised that all conditions for
membership have been met. The effective date of membership
may be postponed until all supporting documentation in
respect of marriage certicates, birth certicate(s) or medical
declaration/certicate(s) have been submitted.
Termination of membership
An application form for termination of membership must
be lled out and sent via fax +264 230 465 or emailed
to members@nhp.com.na, please contact NHP, tel
+264 61 285 5400 or download the form from
www.nhp.com.na
An employer wishing to terminate its contract with the Fund
must provide the Board of Trustees with one calendar months
written notice of such intention. Failing to do this, the employer
will be held liable for one calendar months contributions, based
on the average, calculated over the last 6 calendar months
contributions.
A member of the Fund who is also an employee and who wishes
to terminate his/her membership must provide the Board of
Trustees with one calendar months written notice of such
intention, while the rest of the group maintains group status
with the Fund. Employees resigning voluntarily from the Fund
may only rejoin subject to the discretion and approval of the
Board of Trustees at the beginning of a new nancial year.
Members resigning from an employer group may apply for
individual membership with the Fund. Members, who are
required to terminate their membership as a consequence of
having changed from one employer to another, must note that
they will have to complete and submit a new membership
application form together with a copy of their ID/Passport
document. Normal underwriting requirements will apply.
A 30-day notice period, commencing on the 1st day of the
following calendar month, will apply to all members and
employer groups wanting to terminate their membership.
Individual members, who have joined the Fund and leave the
Fund within 3-months of having joined, will be held liable to
repay all benets utilised within such period.
9
The Board of Trustees may exclude from benets and
terminate the membership, with immediate effect, of a member
or dependant whom the Board of Trustees nds guilty of
defrauding, abusing the privileges of or otherwise acting in a
manner prejudicial to the interests of the Fund.
In accordance with the Rules of the Fund, the Board of
Trustees reserves the right to suspend or cancel membership
under the following conditions:
In the case of monthly contributions being 1-month in
arrears, unless specic arrangements have been made by
either the employer group or individual member for payment
at a later stage
If, on the date of application, the principal member submits a
false declaration or neglects to declare information regarding
his/her health or that of his/her dependant(s)
If any surcharges are outstanding
In the case of fraud or abuse against the Fund
Please note Suspension of membership in the case of monthly
contributions being in arrears does not imply
that membership will be cancelled. Payment of
outstanding claims will be temporarily withheld
until payment of any outstanding contributions
has been effected.
Fraud and abuse against the Fund
Fraudulent and abusive behaviour against the Fund will not be
tolerated. The Board of Trustees may exclude from benets or
terminate the membership of a member or dependant whom
the Board of Trustees nds guilty of defrauding, abusing the
privileges of or otherwise acting in a manner prejudicial to the
interests of the Fund. In such an event the member may be
required by the Board of Trustees to refund the Fund any sum
which, but for the abuse of privileges of the Fund, would not
have been disbursed on his/her behalf.
Members should note that the Fund reserves the right to
implement the following procedures against members
and/or healthcare providers guilty of fraudulent or
abusive practices:
Criminal proceedings shall be instituted against the
member(s) and/or healthcare provider(s), in the event
of fraudulent claims
The Fund will institute civil litigation against the member(s)
and/or healthcare provider(s) in order to recoup any money
forfeited by means of such fraudulent acts
The membership of a member guilty of fraudulent practices
will be terminated with immediate effect
In the case of the member being part of an employer
group, the employer will be informed about the employees
misconduct and fraudulent conduct
The names of member(s) and/or healthcare provider(s) guilty
of such fraudulent behaviour shall be communicated to
NAMAF for potential blacklisting with other medical aid funds
What is my liability as a member?
In the case of membership being for a period of less than
12-months, pro-rated annual benets will apply and will be
adjusted accordingly. Pro-rated annual benets are not only
applicable on termination, but also when joining the Fund during
the course of any nancial year.
In the event of a member resigning from the Fund, the liability
of the member will be limited to the amount of unpaid monthly
contributions, together with any benets incorrectly disbursed
by the Fund. Any amount owed by the member will be recouped
from that member. In the event of a member terminating
membership, any amounts still owed will be regarded as a debt
to the Fund and must immediately be refunded.
Change of address
An application form for membership record amendment must
be lled out and sent via fax to +264 61 223 904 or emailed to
info@nhp.com.na, please contact NHP, tel +264 61 285 5400 or
download the form from www.nhp.com.na
Members must notify the Fund of any change of address or
contact details immediately and without delay. The Fund will
not be held liable if a members rights are prejudiced or
forfeited as a result of neglect to comply with the requirements
of this Rule. The Fund will not be held liable for any information
not delivered to the member due to the members failure to
furnish and update his/her latest contact details, inclusive of
banking details.
Understanding your Medical Aid Fund
How are benets allocated?
All benet options on the Fund are specically designed to cater
for the needs of its members based on their medical needs and
affordability.
The 2013 range of benets includes two traditional benet
options; namely the Gold and Platinum benet options, as well
as three new generation benet options; namely the Silver,
Bronze and Hospital benet options. Two of the benet options
offered to members, the Blue Diamond and the Litunga benet
option, are primary healthcare benet options.
The Funds product range has been developed in conjunction
with consulting actuaries who specialise in healthcare nancing.
This has been done in order to create a exible range of
legislatively compliant, sustainable, actuarially sound and cost-
effective benet options, designed to meet the needs of both
employers and individuals in all spheres of employment.
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Benet options to suit your needs
The Fund prides itself on offering a range of benet options
that meets everyones needs. The Gold, Platinum, Silver and
Bronze benet options allow members to choose a level of
comprehensive cover that best suits their needs and budget.
The Hospital benet option recognises that there are members
who prefer to self-fund their day-to-day expenses, but who
want to enjoy adequate protection against unforeseen major
medical expenses. The Blue Diamond and Litunga benet
options provide access to affordable healthcare to employees
who have not previously had access to medical treatment and
membership with a medical aid fund.
Nexus Administration System
Through the Nexus Administration System, the Fund is able
to communicate with its members via email as well as a SMS
facility on a regular basis regarding their utilisation of benets
as well as changes regarding their membership status.
Typical events include notication of the following:
Claim submission - Captured
Claims payment - Next pay run
New member - Captured
New member - Active
Card generation
Change of membership details
Change of bank account details
ACB returns
Re-directs
Outstanding monthly contributions
Voice of Customer (VOC) emails
This tool also serves as a method for creating greater
awareness of claims submitted on behalf of the member,
thereby reducing abuse and fraud against the Fund.
Roll-Over Benet
If you claim less than a certain threshold amount, you will build
up a Roll-Over Benet which you can use to pay for healthcare
treatment and medical costs. Claims paid in according to the
day-to-day benets of each benet option, taking in to account
the threshold level, will rst be debited against the Roll-Over
Benet after which the normal day-to-day risk benets will
be used.
At the end of the nancial year if your day-to-day claims
excluding costs for chronic medicine are less than the Roll-Over
Benet the remaining balance will be paid into your Roll-Over
Benet account.
4-months into the new nancial year, this amount will then be
transferred into a separate Roll-Over Benet account which
you can use to pay for additional medical expenses, which are
normally excluded in terms of the Rules of the Fund.
Please note Your Roll-Over Benet accumulates in your name
for as long as you are a member of the Fund.
While you are a member of the Fund, any positive balance in
your Roll-Over Benet account may be used to pay for:
Routine medical costs
Outstanding members portions
Treatment normally excluded from your benets
Medical expenses with a valid chargeable Nappi Code which
are usually excluded by the Fund. The medical services must
be provided by a registered healthcare provider
The difference between the actual medical costs and the
NAMAF tariff for medical services covered by the Rules
Medical aid contributions and for contribution holidays
Claims for conditions, procedures or medicines excluded by the
Rules, including exclusions from optical and dental benets may
be paid from the balance of your Roll-Over Benet. Members
are requested to complete the Roll-Over claim application form.
Attach proof of purchase and the payment will be reimbursed
from the Roll-Over Benet account. Payments made from the
Roll-Over Benet will not accumulate towards reducing the next
years Roll-Over Benet.
Any non-medical expenses without a valid chargeable Nappi
Code which are not provided by a registered healthcare provider
will not qualify for benets under the accumulated Roll-Over
Benet.
You may request that any amount be allocated towards your
monthly contributions. For employer group members this will
only apply once they have consulted with their payroll or HR
department.
If you resign from NHP and become a member of another
medical aid fund, the positive balance in the Roll-Over Benet
account will be transferred to the NHP reserves.
Upon the death of the member, any positive balance due to the
member will be transferred to his/her dependants who continue
membership of the Fund. If the dependants of such deceased
member decide to resign from the Fund, then such positive
balance will be forfeited to the Fund.
Please note An application form for Roll-Over Benet claims
must be lled out and sent via fax to
+264 61 223 904 or emailed to info@nhp.com.na.
Please contact NHP, tel +264 61 285 5400 or
download the form from www.nhp.com.na
Value for money contribution tables
The Funds age-based contribution tables offer value for money
by ensuring that the Funds risk is properly distributed and that
the monthly contributions charged are fair towards all members.
It is important that members understand the relationship which
exists between the level of cover that can be provided relative
to the monthly contributions that are charged and how these
two variables inuence each other.
Overall annual limit (OAL)
The overall annual limit is a specic amount allocated and
dened by either an individual member or per family unit. The
OAL is the maximum amount that may be claimed by either the
individual member or the family unit. Different sub-limits apply
in respect of major medical expenses and day-to-day out-of-
hospital expenses.
Family focused benets
As the health status of family members within the family differs,
so the requirements in respect of medical services of the various
family members may differ too. In order to allow for greater
exibility in the utilisation of benets, these are calculated by
family unit and can be added together and allocated to a single
family member within a family, should this be required.
In principle the Fund recognises that even within the same
family the health risks and needs vary from person to person.
The Fund enables you and your family to decide how best to
utilise the benets available.
Management of risk/Managed care
The administrator has access to a comprehensive clinical team.
This team uses the latest clinical guidelines to help ensure that
the therapy prescribed by healthcare providers is the most
appropriate for members in need of treatment.
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Risks are managed by providing good value for money regarding
the t between membership contributions and the need for
comprehensive benets. In an effort to further manage the risk
of the Fund, a Roll-Over Benet reward is available to encourage
members to take control of their own medical expenditure and
entice them to claim less, i.e. consumer driven healthcare.
All monthly contributions are determined following a
comprehensive actuarial risk assessment of the inherent risk
associated and arising from the demographic and claims prole
of the Fund or an employer group.
Preventative care benet
The preventative care benet is available on the Gold, Platinum,
Silver and the Bronze benet options.
Case management
Case management ensures that the best and most cost-
effective treatment is provided to members of the Fund.
This includes liaison with the medical personnel in respect of
the patients progress, investigating alternative care and the
validation of membership.
The Fund reserves the right to suggest an alternative treatment
facility, provided that there is such a facility available and
without compromising on the quality of care provided. In the
case of the Fund being able to source an alternative treatment
facility which is to the nancial benet of both the member and
the Fund, the Fund reserves the right to impose a co-payment
onto the member should the member decide not to make use of
such a recommended facility.
Pre-authorisation for treatment in hospital
It is a requirement set by the medical aid fund, that
authorisation should be obtained from the Fund before any
hospital procedures are performed. Pre-authorisation protocols
ensure that procedures are covered by the Fund and proof of
membership is veried.
Please note Pre-authorisation is not a guarantee of payment.
Benets excluded:
Breast reduction and enlargement
Hyperbaric oxygen treatment
Injuries arising from alcohol/drug abuse
Injuries arising from riots and civil war
Complications arising from procedures not covered by
the Fund
Pre-authorisation for treatment in hospital is only valid and
restricted to conditions for which such pre-authorisation has
been requested for and subsequently granted. Any treatment
falling outside of the scope of such pre-authorised treatment
will require an update and further authorisation from NHP and
Medscheme Namibia.
Major medical expenses (MMEs)
MMEs are normally regarded as the various types of treatments
rendered while the beneciary is hospitalised or requires a
period of hospitalisation for treatment. In the case of MMEs,
benets will be allocated on either a per principal member basis
or alternatively on a per family basis, if one or more dependants
are registered with the Fund.
Accommodation other than a recognised hospital/medical
institution in the Republic of South Africa
This benet is subject to the overall annual benet. This benet
is restricted to the Gold, Platinum, Silver and Hospital benet
options. A specic amount will be paid per day per patient
for accommodation other than a recognised hospital/medical
institution. The benet will not be paid while the member/
patient is still in hospital.
This benet is aimed solely at members who are not
hospitalised but are required to attend treatment/consultations/
examinations in hospital while referred to the Republic of South
Africa for treatment. This benet will only apply to treatment
received in the Republic of South Africa and is subject to prior
approval.
Accommodation other than a recognised hospital/medical
institution within Namibia
This benet is subject to the overall annual benet and is
restricted to the Gold and Platinum benet options.
In the event of a member staying outside of a radius of
150km from Windhoek and the member being referred
to a specialist in Windhoek for treatment, the Fund will
contribute towards the cost of accommodation at a
recognised and accredited accommodation establishment
such as a guest house or bed and breakfast at the following
rates:
Gold benet option: N$350 per night, maximum of 2 nights
per family per annum
Platinum benet option: N$350 per night, maximum of 2
nights per family per annum
All claims for reimbursement are subject to pre-authorisation.
No claim will be considered if the member did not receive
prior authorisation to claim such expenses from the Fund
Travelling costs for specic medical treatment not
available in Namibia
In the event of a member being in need of a specic treatment
or procedure not available within Namibia and on application
by the member, the Fund may assist in defraying some of the
transportation costs to and from the Republic of South Africa
only. Assistance will only be granted for cases that are not
subject to specic exclusions.
Benets include:
80% of the cost of transportation in respect of the 1st and
subsequent visits
Commercial ights or approved ights will be organised by
the Funds preferred service provider for such cases
Children under the age of 18-years of age, when travelling
to the Republic of South Africa, must be accompanied by a
guardian. The transport costs of the guardian will be paid out
at 80% by the Fund
Benets excluded:
Transportation to and from the airport
Accommodation for the accompanying guardian
Please note Failure to obtain prior approval will result in the
Fund not accepting any liability in respect of such
costs, unless in the case of a medical emergency.
Travelling costs for specialist treatment within Namibia
Members residing in remote and outlying regions of Namibia
who are in need of specialist treatment, and who have been
referred by their local healthcare practitioner, provided that the
particular treatment is not available in their hometown, and
who need to travel for treatment to Windhoek, may apply to
the Fund for assistance in defraying some of the transportation
costs to and from their hometown.
12
The following conditions will apply:
No referrals within a radius of 150km outside of Windhoek
shall qualify for consideration
Only specialist treatment in Windhoek will be considered for
such travelling costs
No travelling costs for specialist referrals to Swakopmund
or any other place in Namibia will be granted, unless
Swakopmund is the closest such town with specialist
services
80% of the travelling costs to be covered in respect of the
1st and all subsequent visits for the same medical condition
All claims for reimbursement are subject to pre-authorisation.
No claim will be considered if the member did not receive
prior authorisation to claim such expenses from the Fund
Dentistry in-hospital
The Maxillo-facial and oral surgery benet is subject to prior
approval and provides cover for the following treatment:
Oral surgery: Planned surgery benet for all services,
with regards to doctor, anaesthetist, hospitalisation and
medication, involving impacted wisdom teeth, surgical
removal of Apicectomy and other surgery
Maxillo-facial surgery: Not planned, involving the case of an
accident, surgical removal of tumours and neoplasms, trauma
and congenital birth defects and other major surgery
Jaw related surgery and facial surgery: As a direct result of
trauma, e.g. motor vehicle accident
Benets for general anaesthetics, conscious analgo-sedation
and hospitalisation for dental work will only be granted in the
event of children under the age of 8-years
Additional in-hospital cover (Also referred to as GAP
cover)
The Fund offers its members a major medical expense benet
that automatically covers a certain percentage on top of the
NAMAF benchmark tariff, depending on the benet option
chosen, for services provided in hospital by healthcare providers.
This cover is over and above the normal benets.
Benets include:
Medical or dental practitioners
Medical or dental specialists
Physiotherapy, biokinetics, dieticians, occupational therapy,
speech therapy, audiology and psychology while the patient
is in hospital
Radiology
Pathology
Please note That the Gold, Platinum, Silver, Bronze and the
Hospital benet options cover is 225% of the
NAMAF tariff allowed for services provided in-
hospital by healthcare providers. This cover
is included in the normal benets.
Benets excluded:
HIV/AIDS
National epidemics
Organ transplants
Post-hospitalisation and rehabilitation medication
Pre-existing conditions
Refractive surgery
Dental surgery, but for children under 8-years of age and
maxillo facial surgery
Dental implants
Oral surgery
Orthognathic surgery
The Board of Trustees reserves the right to review all major
claims before such claims are reimbursed to members.
Please note In order to qualify for GAP cover; please ensure
that all the relevant accounts are submitted to
the administrator within the same 4-month grace
period in which to submit normal claims. Members
who have reached their benet limit in respect
of surgical prostheses will not qualify for the
GAP cover benet in respect of the additional
in-hospital cover. No additional in-hospital cover
will be granted in respect of any set benets,
for example in the case of oral surgery where a
benet for the full procedure has been granted.
Emergency evacuation
E-Med Rescue 24 is a locally owned emergency medical
evacuation company, with the appropriate infrastructure in
place to provide adequate cover and peace of mind to all NHP
members - one telephone number might be the difference
between life and death.
NHP emergency number
tel +264 61 222 223
NHP members will enjoy cover for medical emergencies, both
road and air evacuation in the SADC Region (Namibia, South
Africa, Angola, Botswana, Lesotho, Mozambique, Swaziland,
Zambia, Kenya, Tanzania, Malawi, Zimbabwe, DR Congo,
Madagascar, Mauritius, and Seychelles) and also internationally.
In addition members will also be covered by emergency medical
evacuation in the event of a motor vehicle accident.
Should E-Med Rescue 24 not have an ambulance available
or a physical presence in your town of residence, then you
as a member will still be required to contact them at the
above mentioned number and they in return will arrange
with any other emergency medical service provider, including
International SOS, to be of assistance to you during a time
of emergency.
Members requiring emergency medical assistance should
provide the following information at the time of requesting
such assistance:
Membership number
Personal particulars
The place and telephone number where you or your
representative can be reached
A brief description of the emergency
The nature of the assistance required
For any further enquiries in this regard, please contact NHP,
tel +264 61 285 5400 or any of our branches in Namibia.
Please note E-Med Rescue 24 is appointed as the preferred
service provider to the Fund, members should
note that assistance for emergency evacuation
may only be requested from E-Med Rescue 24
and not from any other service provider, such
as Municipal Emergency Ambulances or any
other service provider. Members must correctly
identify themselves as a NHP member. Under all
circumstances NHP members must contact E-Med
Rescue 24 on the emergency number provided.
Non-emergency transfers must be authorised by the Funds
service provider call centre prior to the transfer of the patient.
An authorisation number will be allocated to the case and
issued to the healthcare provider at the time of the request for
transportation. Authorisation numbers will not be issued for
cases where the member has already been transferred.
13
Please note Transfer from the hospital to the home is classied
as a non-emergency.
International travel benet
This benet provides cover for up to N$10,000,000 per
dependant for medical emergencies whilst travelling outside the
borders of Namibia including overseas.
Cover includes costs related to medical and related expenses,
emergency medical assistance, medical evacuation and
repatriation, return of child dependants and emergency
assistance.
The cover is limited to a maximum travel period of 90 days and
30 days if there is a pre-existing condition. Cover is also only
available to people between the ages of 3-months up
to a maximum of 80-years.
Repatriation benet
Should something unexpected happen to you or a member of
your family; usually a medical emergency a long distance from
where you live, the Fund will cover the costs of transporting
you or your family member back home. The Fund will either
pay the transport costs in cash or through an agreement with a
preferred transport company.
Please note You must under all circumstances contact E-Med
Rescue 24, tel +264 61 222 223.
Premium waiver
The Fund will pay the monthly contributions to allow your
dependants to remain on the Fund for up to 3-months after
your death.
For more information, contact NHP, tel +264 61 285 5400.
Optional benets
The Fund offers you the opportunity to obtain funeral cover
at a very competitive rate. The funeral cover is optional to the
normal medical aid fund benets. The risk of this product is fully
underwritten by a registered insurer as required by the Medical
Aid and Insurance Acts.
To apply for funeral cover you should either ll out a funeral
cover application form or indicate that you want funeral cover
when you apply for membership of the Fund.
You must indicate whether funeral cover should apply to your
life only or include the rest of your family as well. The funeral
cover monthly contribution will be additional to the normal
monthly contributions.
Ex-Gratia applications for additional benets
You are advised that, should a need for an Ex-Gratia request for
nancial assistance arise, you should contact the Fund in which
case you will be assisted in completing and submitting the
relevant forms.
The Board of Trustees will not authorise payment for services
other than those prescribed in the Rules of the Fund but can at
its absolute discretion, increase the amount payable in terms
of the Rules as an Ex-Gratia award, provided that the Board of
Trustees is satised that the member would otherwise suffer
undue nancial hardship.
Please note The Board of Trustees decision in such cases shall
always be nal.
In order to realise the overall objective, the following criteria
are applicable:
Each application is evaluated objectively and consistently
Each application is evaluated and rated to determine the
level of nancial hardship of the member
The identity and nature of the request shall always be
treated with the utmost discretion and condentiality
The following relates to the application and appeal process:
Only applications that contain all the required information
will be tabled for review
All applications that are incomplete will be rejected outright
and the applicant notied as such
The nal decision, with regards to the actual amount
approved or rejected, remains entirely up to the discretion of
the Ex-Gratia Committee
Any member may appeal the decision of the Ex-Gratia
Committee
Such an appeal must be brought to the attention of the
Ex-Gratia Committee. The appeal must be directed to the
Principal Ofcer of the Fund and should be submitted within
14-days of the date of the notication by the administrator
The Ex-Gratia Committee will review the merits of the appeal
application as well as the decision and forward the appeal
to the Board of Trustees. The member concerned shall be
informed of the ruling of the Board of Trustees. The ruling
of the Board of Trustees remains nal and binding on the
member
Sports injuries
Injuries as a result of professional or amateur sports and
lifestyle activities are covered. The Fund encourages a healthy
lifestyle amongst its members.
The Fund would therefore like to conrm that if a member
sustains an injury as a result of participating in any professional
and amateur sports, these injuries will be covered in full.
Please note Injuries resulting from any form of intoxication
whilst participating in sport will not be covered.
Foreign accounts
The benets available in terms of the Fund shall be provided
only within the borders of Namibia as well as within the
Republic of South Africa, provided that the Board of Trustees
may, in its absolute discretion, also pay for benets in respect
of healthcare services obtained in Botswana, Zimbabwe,
Swaziland, Lesotho, Mozambique, Angola, Zambia and Mauritius,
and further provided that all accounts are supplied in standard
English with appropriate medical terminology and breakdown
of services.
The Fund shall not be obliged to make special arrangements to
obtain foreign services or medicines for special conditions. This
includes harvesting and transportation of organs and tissue for
transplants and any medicines or medical services of any kind
available only outside of Namibia or the Republic of
South Africa.
Injuries on duty
Members of the Fund are covered for injuries on duty. Only
people earning less than N$72 000 per annum qualify for
nancial assistance relating to medical treatment from the
Workmens Compensation Act.
The Social Security Commission is not supportive of
entertaining medical claims submitted by a medical aid fund for
reimbursement. Therefore, please note that members should
institute any claims against the SSC in their personal capacity.
14
15
In order to submit a valid claim the employee and employer are
required to ll out and submit documentation to WCA.
Upon treatment for an injury at work, the member is required
to submit a copy of the WCA form and injury report to the NHP
Clinical Management Unit. The Fund reserves the right to reclaim
any amount paid in respect of medical treatment on behalf of
the member from the SSC.
Motor vehicle accident claims
The MVA Fund assumes responsibility for the recovery and
stabilisation of injured people from the scene of an accident as
well as evacuation to the nearest appropriate hospital.
A treating specialist or healthcare provider will decide whether
the patient(s) needs to be referred to a private hospital for more
complicated treatment and procedures.
NHP members have the comfort and peace of mind that they
will be evacuated either by E-Med Rescue 24, or the service
providers contracted by the MVA Fund.
Members of the Fund will still qualify for treatment in private
hospital facilities, if their benets provide for it.
Connements
The Fund will cover the costs of connements in hospital for a
period of up to 3 days for normal vertex deliveries and ve days
for caesarean sections. The patient must provide the Fund with
a motivation letter from her doctor, should the need arise for a
longer period of admission. The Fund will cover lodger fees for
breast-feeding mothers of newborn babies if motivated by the
attending doctor.
Full cover in accordance with the benets of the Fund will
apply in the event of a member transferring from a registered
medical aid fund to NHP. An individual member joining the Fund
with either the member or a dependant being pregnant at that
time will result in an exclusion being imposed in respect of the
pregnancy as well as the childbirth. Subject to registration of the
baby, the baby will be covered by the Fund following the birth.
In the event of a new employee with an existing employer
group opting not to take up membership with the Fund for
either him/herself or any dependants within 3-months after
becoming eligible for membership and if such employee nds
herself or a dependant of the principal member to be pregnant
and would like to join the Fund after the 3-month period has
expired, should note that an exclusion will be imposed with
respect to pregnancy and childbirth.
Benets excluded:
Ante- and post-natal exercises
The treatment and diagnosis of infertility and any related
expenses
Articial insemination of a person as dened in the Human
Tissue Act of 1993
Oncology Disease Management Programme
The Fund employs an Oncology Disease Management
Programme which provides authorisation for chemotherapy,
radiotherapy and symptom control that has been prescribed
for the treatment of cancer.
How to register?
It is important that, on the diagnosis of cancer, members are
registered with the Oncology Disease Management Programme
and that their treatment plan is forwarded to the Managed Care
Department with the Fund. The Oncology treatment is subject
to pre-authorisation and case management. If pre-authorisation
is not obtained, the member might be liable for the account or
might need to pay a penalty for late authorisation as per the
Fund Rules.
Once the Managed Care Department has received the treatment
plan, the members details, the disease information and
proposed treatment plan are captured. A set of cancer guidelines
and protocols are used during the pre-authorisation process.
The treatment plan is then reviewed and, if required, a member
of the clinical team will contact the treating doctor to discuss
appropriate or cost effective treatment alternatives. After
the treatment plan has been assessed and approved, an
authorisation code will be sent to the members treating doctor.
The member will also be issued with an authorisation letter.
It is important that the Oncology Disease Management team is
informed of any changes made to the members treatment, as
their authorisation will need to be reassessed and updated.
Treatment and medication
Chemotherapy, radiotherapy, oncology related pathology;
general oncology related radiology and medication directly
associated with the treatment of cancer will be paid from the
Oncology Benet, provided a valid authorisation code has been
obtained. Specialised radiology (e.g. scans, MRIs, angiography,
radio isotopes) requires a separate pre-authorisation.
PET scans are used most often to detect cancer and to examine
the effects of cancer therapy by characterising biochemical
changes in cancer. Currently NHP members do not qualify for
any PET scans from the Oncology Benet.
Surgery and hospitalisation
A cancer patient admitted for hospitalisation needs to obtain
pre-authorisation. The case will be assigned to a case manager
who will follow up on the patients progress in hospital.
Stoma therapy
A member needs to obtain pre-authorisation from the Managed
Care Department before claiming for any stoma care.
Wigs and external breast prosthesis
Wigs and external breast prosthesis will be paid from the
members appliances benet, subject to prior approval.
Hospice care and private nursing
Accommodation in a hospice for the care of patients in a
terminal stage of cancer will be covered from the private nursing
benet, where available. Pre-authorisation must be obtained
beforehand.
Oncology claims
Claims will be paid in accordance with the NAMAF tariff
structure if there is a valid authorisation and benet available.
Oncology patients with a specic claim query need to contact
NHP for assistance.
Please note The Oncology Disease Management unit does not
deal with claim queries.
Aid for AIDS (AfA) Programme
The Aid for AIDS Programme is available to all members, at no
additional cost. All interaction between the members and the
AfA Programme is kept strictly condential in order to reassure
the member that his/her status will remain condential. The AfA
Programme provides comprehensive benets for the treatment
of HIV/AIDS.
16
The AfA Programme is in full compliance with the guidelines
provided by the Namibian HIV Clinicians Society. In addition, the
AfA Programme is also supported by its own local clinical expert
panel, with Dr. Paul Kanyama chairing the AfA panel in Namibia.
The AfA Programme is advised by a team of experts who are
acknowledged leaders in the eld of HIV medicine in Sub-
Saharan Africa. These consultants also serve on the guidelines
committee of the Southern African HIV Clinicians Society and
regularly interact with Namibian and other regional experts.
The AfA Programme ensures condentiality whilst managing
the signicant healthcare costs associated with the disease.
Benets include education, counselling, vaccinations, medication
including anti-retroviral therapy, hospitalisation and regular
consultations and tests. The AfA Programme also provides for
the monitoring of clinical outcomes and the measurement of
patient compliance to treatment.
Help is available to manage your medical condition
The Fund has a benet option amount specically for HIV/
AIDS related medicine. This benet option also protects against
illnesses, such as TB and u, and pays for vitamins to boost the
immune system.
Your condition will stay condential
HIV/AIDS is a sensitive matter and every effort is made to keep
a members condition condential. The staff members at our
AfA Programme unit have all signed condentiality
agreements and work in a separate area away from
the medical aid fund.
They use separate telephone, fax and private email facilities.
Members must make use of these facilities to maintain
condentiality.
tel +264 61 256 214
fax +264 61 271 674
PO Box 5948, Ausspannplatz, Windhoek
You must register on the AfA Programme
If a member tests HIV-positive then he/she must register with
AfA Programme as soon as possible to make use of the benets
available under this benet option. An application form can be
downloaded from the website www.nhp.com.na; the members
doctor can also contact the AfA Programme directly on
his/her behalf.
After you have registered
After the member has received the application form, he/she
and his/her doctor, must complete the form and return it to the
AfA Programme, using the condential fax line number on the
form. A highly qualied medical team will examine the members
details and, if necessary, discuss cost-effective and appropriate
treatment with the members doctor.
Once treatment has been agreed upon, the member and his/her
doctor will receive a detailed treatment plan, which explains the
approved medication as well as the regular tests that need to be
done to ensure that medication is working correctly and safely.
The AfA Programme is a complete HIV/AIDS Disease
Management Programme that offers both members and
registered dependants:
Medication to treat HIV, including drugs to prevent mother-
to-child transmission and infection after sexual assault or
needle-stick injury at the most appropriate time
Treatment to prevent opportunistic infections such as certain
serious forms of pneumonia and TB
Regular monitoring of disease progression and response to
therapy through regular tests to pick up possible side-effects
of treatment, subject to benets available
On-going patient support via a nurse-line
Clinical guidelines and telephonic support for doctors
Help in nding a registered counsellor to give emotional
support
If any member suspects that he/she has been exposed to HIV/
AIDS virus through sexual assault or needle-stick injury, he/she
should please ask his/her doctor to contact AfA to authorise
special anti-retroviral medicine to help prevent possible HIV/
AIDS infection.
It is best to take this medicine as soon as possible (ideally within
6-hours) after exposure. If the incident has occurred over the
weekend, members should ensure that they get the necessary
medication on time. A member or his/her doctor can contact the
AfA Programme on the 1st working day following the incident in
order to arrange authorisation for payment of the drugs by his/
her medical aid fund.
Day-to-day medical expenses
On joining the Fund, the principal member will be granted a set
amount of benets and, in the event of there being one or more
dependants, an additional amount per beneciary is granted.
The amount granted per beneciary will be added to the
amount initially allocated to the principal member.
The benet of the family based benet structure means that
any of the registered dependants of the family unit may use
any amount of the allocated day-to-day benet. The Fund
continues to provide generous chronic medication benets,
acute medication benets and self-medication benets.
A further advantage is that homeopathic, phytotherapy
medicines and vitamins are also covered.
Generic industry medicine reference pricelist
The Generic medicine reference pricelist is a cost management
tool to assist members in extending their annual medicine
limits. The pricelist only applies to medications for which generic
equivalents are available. All medications with the same active
ingredient, formulation and strength are categorised into groups
and a maximum price is set for each group.
The reference price reects the maximum amount that the Fund
will pay for any of the medications within that specic group.
The balance between reference price and the actual price of the
medicine will be for the account of the member.
Please note Members are reminded to ask the pharmacist
for the generic equivalent, in order to minimise
co-payments.
The Generic medicine reference pricelist strives to bring about
a decrease in the total cost of medicines to the Fund with
regards to anticipated lower annual contribution increases.
The pricelist acts as a guide for medicine prices and is updated
regularly according to various factors such as clinical data from
manufacturers, single exit prices in the Republic of South Africa
and the cost of procurement from Namibian wholesalers.
Generic medicines
A generic medicine has the same active ingredient, strength and
formulation (i.e. tablet, syrup etc.) as the original product. The
Medicines Control Council analyses each medicine for safety
and efcacy before it is registered. Generic medicines offer the
consumer a product that is as effective but generally is cheaper
than the original.
17
Why are generic medicines cheaper than ethical drugs?
Much of the cost of an ethical drug covers the money spent
on research and development. Generic manufacturers do not
duplicate the research conducted by the original manufacturer,
so the cost of the generic drug is usually less.
Are generic medicines as reliable as ethical products?
Drugs generically equivalent to an ethical drug must meet strict
manufacturing standards set by the Medicines Control Council.
Tests must ensure the product is bio-equivalent to the ethical
product, which means that it must have the same amount of
active ingredients delivered to the body at the same time, to
be used by the body in the same way as the ethical product.
Generically equivalent drugs should produce the same results
as the ethical product.
Chronic medication benet
A chronic condition can be dened as a condition for which
continuous treatment is required to prevent long-term damaging
side effects, potentially life-threatening conditions or morbidity.
This benet relates to the medication only, and does not include
the doctors consultations. It should be noted that a 20% levy
applies to all chronic medication prescribed, irrespective of
whether it is dispensed by a pharmacy or a healthcare provider.
A minimum co-payment of N$30 in respect of any prescribed
medication applies.
It should be noted that no chronic medication benets are
available on the Blue Diamond and Litunga benet options.
Chronic medication application forms can be accessed on the
website at www.nhp.com.na or collected from any of the NHP
branches countrywide.
The following vitamins may be covered by the Fund in
respect of certain protocols that apply:
Registered multi-vitamin preparations and vitamin
combinations including minerals payable by the Fund from
the chronic medications benet
Registered combined mineral preparations and trace
elements payable by the Fund from the chronic medications
benet
Registered prenatal vitamins and vitamin/mineral
supplements payable by the Fund from the chronic
medications benet
Registered geriatric vitamin/mineral supplements payable by
the Fund from the chronic medications benet
Registered single vitamin preparations payable by the Fund
from the chronic medications benet
Haematinics, calcium supplements, magnesium supplements
and potassium supplements payable by the Fund from the
chronic medications benet
Registered infant vitamins payable by the Fund from the
chronic medications benet
For more information on the above, please contact NHP.
To ensure payment, the products must be prescribed by a
healthcare provider for a period of 3-months or longer and
should be registered with the Fund as chronic medication.
For further information on the protocols regulating the
provision of vitamins please visit www.nhp.com.na
Automated chronic application process
The automatic chronic and acute script splitting processing
system is designed to allow pharmacies to submit acute and
chronic products on a single claim to Medscheme Namibia using
the Interpharm real time claiming facility. These claims are
processed separately on the system and then recombined into
a single response back to the switch. One of the distinguishing
factors of the automated programme is the Chronic Drug List,
which contains certain algorithms responsible for creating a
match between the various chronic conditions and the matching
types of medication. As a result it is no longer necessary to
indicate chronic products on the prescription before submitting
the claim.
The claims processing system will identify the chronic
products through the use of the following rules:
If the product appears on the CDL, it is a chronic product
Otherwise, the product is an acute or pharmacy advised
therapy product
18
Chronic authorisations, as per the current process, can be
obtained for any product which has been identied by the
CDL as a chronic product
Although the renewal of chronic medications will be automatic,
the healthcare provider will still be required to submit a new
prescription in respect of the chronic condition every 6-months.
Medications and chronic conditions, which could potentially be
described as grey areas, will still be subjected to the manual
registration and allocation process, but these cases should
be the exception rather than the rule. It is expected that the
automated process will be good for approximately 80% of all
cases requiring chronic medication.
The following benets that can be derived from the
automated chronic medication process have been identied:
Chronic medication will immediately be paid from the correct
benet without requiring members to request
pre-authorisation
The accompanying administrative hassle to the member,
treating specialist/pharmacy and administration is
signicantly reduced
Patients can start with therapy immediately without a delay
for registration on the Chronic Programme
Pharmacies will submit only one claim, with the system
automatically splitting the medication into chronic and acute
medication, with the respective levies, clinical and Fund Rules
being applied automatically
Acute medicines
Acute medicines are those medications prescribed by a
healthcare provider, which are generally required for the
treatment of an acute condition and are used for a limited
period. Immunisations not covered under the preventative care
benet will be payable from the acute medicine benet. For
more information on the schedule regulating immunisations
please visit www.nhp.com.na
It should be noted that a 20% levy applies to all acute
medication prescribed, irrespective of whether it is dispensed by
a pharmacy or a general practitioner. A minimum co-payment of
N$30 in respect of any prescribed medication applies.
The Fund will pay for immunisations against the HP virus
e.g. Cervarix, Gardasil on the following conditions:
On application only
Proper medical recommendation for female members older
than 25-years
Benet will be granted only to female members between the
ages of 10-years to 25-years
To be deducted from normal acute medicine benet subject
to 80% of the NMPL, up to a maximum amount of N$530 per
script
Limited to a maximum of 3 injections per female beneciary
Please note Oral and parenteral contraceptives limited to
N$160 per claim should be claimed under the acute
medication benet.
Self-medication
Self-medication is medication obtained from a pharmacy without
a doctors prescription (Pharmacy Advised Therapy/Pharmacy
Initiated Therapy or commonly referred to as over-the-counter
medicines.
Only medication that may be legally dispensed by a pharmacist
without a prescription from a healthcare provider qualies under
this benet. This includes all schedule 0, 1 and 2 medication.
Claims in respect of self-medication vary per benet option.
No levy will be applied in respect of self-medication. This benet
excludes consultations charged by a pharmacist.
Members are able to use their self-medication benet at
pharmacies without having to pay rst and claim later. Instead,
the pharmacy can claim electronically for payment from the
Fund. Also note that medications normally excluded by the Fund
are also excluded from self-medication.
Please note No medication that can be acquired off the shelf
in supermarkets will qualify for a self-medication
benet. Sun-block may be purchased at pharmacies
under the self-medication benet.
Dentistry out-of-hospital
The dentistry benet will include conservative dental treatment,
orthodontic treatment and dental implants under day-to-day
benets.
Orthodontics
For any orthodontic claims, members must submit the
following information with their rst account:
A treatment plan indicating the total cost that will be charged
by the orthodontist for the treatment, the duration of
treatment, the initial fee payable and the monthly fee,
which will be levied on the member
Applicable NAMAF guideline tariff codes
Upon submitting the orthodontic treatment plan, an
authorised orthodontic contract will be allocated on the
member records, which will specify the manner in which the
treatment will be covered
Please note To avoid future disappointment members need
to disclose fully and upfront any orthodontic
treatment plans and associated costs, which may
result in later orthognathic surgery for,
split osteotomy.
Dental implants
Are subject to prior approval, please refer to the sub-limit
applicable to the different benet options. A set benet for the
full procedure will apply, e.g. metal implant, doctor, hospital and
anaesthetist.
Benets excluded:
A Labial Frenectomy in respect of beneciaries under the age
of 8-years
Orthodontic treatment over the age of 25-years
Periodontal plastic procedures for cosmetic reasons
Dental procedures or devices which are not regarded by
the relevant Managed Healthcare Programme as clinically
essential or clinically desirable, e.g. dental oss, tooth
brushes and tooth paste
Gold in dentures and llings
Bleaching of teeth
Any dental procedures that are recommended for cosmetic
purposes
General anaesthetics, conscious analgo sedation and
hospitalisation for dental work, except in the case of patients
under the age of 8-years or bony impaction of the 3rd molars
All general anaesthetics and conscious analgo sedation in the
practitioners rooms, unless pre-authorised
19
Optical
All optical claims are limited according to the sub-limit applicable
to each benet option. It is possible for one dependant to use
the full family benet, but each claim is limited as specied.
In such circumstances, the member needs to submit a
motivation letter from his/herself as well as from the optician to
support the claim. Opticians may under no circumstances change
the date of service of a client in order to facilitate payment of
the claim. Any such behaviour is tantamount to fraud and may
result in disciplinary measures against both the member and the
optician.
Members are limited to one set of frames with a monetary limit
per registered beneciary, every 2nd year. A frame can only
be claimed when the invoice states that the old lenses are
transferred or re-edged, and must be accompanied by an eye
test consultation.
Lenses may be replaced more frequently as your prescription
changes. If the tint of the glasses exceeds 35%, this will not be
paid, as the glasses will then be regarded as sunglasses.
Please note These claims are limited to your applicable optical
sub-limit as well as the per frame limit. Refractive
surgery is covered under the refractive surgery
benet.
Benets excluded:
All types of sunglasses, whether or not prescribed by an
optometrist or ophthalmologist
Contact lenses preparation
Colour contact lenses
Auxiliary services
Members are limited to 15 visits per beneciary per annum for
each discipline contained within the sub-limit. The auxiliary
services benet may not be sufcient in the event of a patient
requiring access to external appliances such as hearing aids,
wheel chairs, prosthesis and articial limbs. Members are
advised to apply for additional benets via the Ex-Gratia process
should their normal benet not be sufcient.
Benets include:
Medical appliances and devices: Payable from the annual
appliances benet, sub-limited under the benet for
paramedical services. Pre-authorisation with the Fund
is required
Blood pressure monitors: Limited to N$390 per beneciary
Disease management disposables for diabetes, and syringes
and needles for diabetes: Payable from the chronic medicines
benet. If a member has requested to be registered under
the chronic medication benet, or the annual appliances
benet, sub-limited under the benet for paramedical
services
Oxygen: Payable from the annual appliances benet,
sub-limited under the benet for paramedical services.
Pre-authorisation with the Fund is required
Aero chambers: Payable from the annual appliances benet,
sub-limited under the benet for paramedical services.
Pre-authorisation with the Fund is required
Quit Smoking Programme
The Fund will assist members who wish to stop smoking.
The Fund will pay for Zyban, in which case the member will
be reimbursed.
The following procedure must be followed:
A valid prescription should be obtained from a healthcare
provider
Upon receiving Zyban, the Fund will reimburse the member
The Fund will pay for Zyban at 80% against the acute
medicine benet with the member responsible for a 20%
levy
Weight Management Programme
The Fund will pay for Xenical for members who need to lose
weight, in which case the member will be reimbursed.
The following conditions apply:
Xenical will only be paid for if clinically motivated by a
healthcare provider
Proof of the use and effect of Xenical will then be required
and the full clinical motivation and details should be
submitted to the Medical Advisory Committee for evaluation
Once the Medical Advisory Committee has reached a decision,
the member will be informed of the outcome and whether or not
claims may be submitted for reimbursement.
How do I claim?
Members can post or hand-deliver their original copies of
medical claims directly to the Fund.
Claims should be submitted without delay and within a 4-month
period after the 1st date of the services having been rendered
by the healthcare provider. Members should ensure that they
sign each account and that their full membership number is
correctly quoted. Members should state whether they want
payment to be made to them personally, or whether the
payment should be made directly to the service provider.
In addition, please ensure that all of the following details are
stated correctly on each account:
Name of principal member
Name of patient
Full details of treatment and/or medicines
Date(s) of treatment
The healthcare provider is obliged, in terms of the Medical Aid
Funds Act, to quote his/her practice number and the NAMAF
procedure codes for each charge on the account. Omission of
such information will cause a delay in settlement, or non-
settlement of a members account.
Members are urged to submit their claims without delay. Any
account, which is not submitted within the prescribed period
of 4-months from date of service, will not qualify for benets.
Claims are processed by the administrator on a daily basis
in either an electronic format or manual claim format. Some
healthcare providers also process and submit claims online
via the Funds Nexus Administration System, whereupon a
guarantee of payment is issued to such healthcare providers.
This system will prevent benets from being paid to a
healthcare provider if another has already claimed, or if the
member has exhausted his/her benets.
20
Claims are paid weekly by means of EFT into beneciaries
(members/healthcare providers) accounts. No cheques will
be issued to members. Members must complete and submit
their banking details for EFT transactions when lling out the
application for membership form or application for member
record amendment. These forms must be lled out and sent via
fax to +264 61 223 904 or emailed to info@nhp.com.na, please
contact NHP, tel +264 61 285 5400 or download the form from
www.nhp.com.na
How do I know that my account has been paid?
An email and/or SMS can be sent to any internal or external
party either through the Nexus Administration System in
the case of emails, or the contracted aggregator in the
case of SMSs.
The Nexus email and SMS alert module caters for the
automatic triggering of emails and SMSs to be sent if
specic criteria are met. Some examples are:
Claim submission - Captured
Claims payment - Next payrun
In the event of the administrator not having the members email
address, the member will receive a printed claims transaction
statement or remittance statement via regular mail, reecting
full details of how the account has been processed and paid.
It remains the responsibility of the member to scrutinise
the remittance statement in detail. This is to ensure that all
outstanding accounts have been paid and that members can
ascertain whether there is any member co-payment which
should be settled directly with the service provider.
Payments can also be viewed at www.nhp.com.na after a
password and login has been issued to the member. In order to
view claims via the internet, members need to contact NHP for
assistance. Please contact NHP to be registered as such.
What medical benets are excluded?
Any injuries suffered as a result of recklessness or intentional
self-injury while participating in lifestyle or sports activities of
choice will be excluded. Injuries resulting from attempted suicide
are also excluded.
Medicines and appliances
Anabolic steroids and immunostimulants
Cosmetic preparations, emollients, moisturisers, medicated
or otherwise, soaps, scrubs and other cleansers, sun-tanning
preparations, medicated shampoos and conditioners,
except for the treatment of lice, scabies and other microbial
infections and coal tar products for the treatment of psoriasis
Erectile dysfunction and loss of libido medical treatment
Food and nutritional supplements including baby food and
special milk preparations unless prescribed for malabsorptive
disorders and if registered on the relevant Managed
Healthcare Programme, or for mother to child transmission,
prophylaxis and if registered on the relevant Managed
Healthcare Programme
Injection and infusion material, except for out-patient
parenteral treatment and diabetes
The following medicines, unless they are authorised by
the relevant Managed Healthcare Programme:
- Maintenance Rituximeb or other monoclonal antibodies
for haematological malignancies
- Liposomal Ampthotericin B for fungal infections
- Protein C inhibitors such as Xigris, for septic shock and
septicaemia
- Trastuzumab for the treatment of HER2-positive early
breast cancer that exceeds the dose and duration of the
9-week regimen as used in the FinHer protocol
- Any specialised drugs that have not convincingly
demonstrated a survival advantage of more than
3-months in metastatic solid organ malignant tumours,
e.g. Sorafenib for Hepatocellular carcinoma, Bevacizumab
for colorectal and metastatic breast cancer
Medicines not included in a prescription from a medical
practitioner or other healthcare provider who is legally
entitled to prescribe such medicines, except for schedule
0, 1 and 2 medicines supplied by a registered pharmacist
Medicines for intestinal ora
Medicines dened as exclusions by the relevant Managed
Healthcare Programme
Medicines or chemotherapeutic agents not approved by the
Medicine Control Council unless approval is obtained and pre-
authorised by the relevant Managed Healthcare Programme
Medicines not authorised by the relevant Managed
Healthcare Programme
New medicines that have not been reviewed by the relevant
Managed Healthcare Programme
Patent medicines, household remedies and proprietary
preparations and preparations not otherwise classied
Slimming preparations for obesity
Tonics, evening primrose oil, sh liver oils, except
for registered products that include haematinics and
products for use for:
- Prescribed for supplementation to pregnant mothers and
infants during lactation
- Malabsorption disorders
- HIV positive patients registered on the relevant Managed
Healthcare Programme
- Prescribed for adults aged older than 50-years
- Prescribed for children 5-years and younger
- Injections, unless prescribed for the treatment of obesity
- Haematinics
- Vitamin C 500mg or more prescribed together with cold
and u treatments
- Not more than 30 days supply of Vitamin C 500mg or
more prescribed together with cold and u treatments
- Claimed as self-medication
New indications for existing medicines that have not been
reviewed by the relevant Managed Healthcare Programme
Products that are not listed in MIMS, e.g. Golden Products,
Sportron
Biological drugs including Beta Interferon for the treatment
of Multiple Sclerosis
All benets for clinical trials unless pre-authorised by the
relevant Managed Healthcare Programme
Diagnostic agents, unless authorised
Growth hormones, unless pre-authorised
Immunoglobulins and immune stimulants, oral and
parenteral, unless pre-authorised
Erythropoietin, unless pre-authorised
Medicines used specically to treat alcohol and drug
addiction
Medication and clinical services as advertised directly to
the public
Medical expenses
Intentional medical expenses and air ambulance repatriation
costs outside the borders of Namibia and the Republic of
South Africa
Services rendered by any person not registered under his/her
applicable statutory body, either in Namibia or the Republic
of South Africa
Treatment of ailments from which the member was
specically excluded at the date of membership
21
Treatment of ailments or injuries sustained by a member or a
dependant and for which another party may be liable, unless
the Board of Trustees is satised that there is no reasonable
prospect that the member or dependant will recover such
cost from the other party
Treatment of an illness or injury sustained by a member
or a dependant of a member where such illness or injury is
directly attributable to failure to carry out the instructions
of a healthcare provider or to negligence on the part of the
member or dependant
Treatments that are in excess of your annual maximum
benets or applicable sub-limits, to which a member is
entitled to in terms of the Rules of the Fund
The cost of treatment for complications that resulted from a
procedure specically excluded by the Rules of the Fund
Holidays for recuperative purposes
Insurance and physical examinations (i.e. ight medical
examinations, tness test, etc.)
Operations, medicines and treatments of a cosmetic nature
The treatment of obesity
Wilfully self-inicted injuries or attempt to commit suicide
Dysfunctional family and social problem counselling
Family, family support or family environment counselling
Marital counselling and/or therapy
Assessment for children or tests to determine school
readiness
Sex therapy and counselling
Stress management courses/service level boosters and study
tips
Life and business coaching
Career guidance counselling
Employee Assistance Programmes
Sleep therapy
Hypnotherapy
Acupuncture, reexology
Hyperbaric oxygen treatment
Biological drugs for oncology treatment unless authorised via
Ex-Gratia
Pilates training
Appliances, devices and procedures not scientically proven
or appropriate
Back rests, chair seats and pillows
Bandages and dressings, except for medicated dressings or
bandages applied after a procedure
Beds and mattresses
Cardiac assist devices - e.g. Berlin Heart
Diagnostic kits, agents and appliances unless otherwise
stated, except for diabetic accessories
Electric tooth brushes
Humidiers
Ionizers and air puriers
Orthopaedic shoes and boots, unless specically authorised
Pain relieving machines, e.g. TENS and APS
Stethoscopes
The hire of oxygen or purchase thereof, unless authorised
Alternative healthcare providers
Acupuncture
Aromatherapy
Ayurvedics
Herbalists
Homeopathy for Blue Diamond and Litunga
Iridology
Naturopathy
Osteopathy
Phytotherapy for Blue Diamond and Litunga
Reexology
Therapeutic massage therapy (Masseurs)
Traditional healing
Forensics
Physiotherapy
Massage or relaxation therapy for the relief of general,
chronic and acute muscular discomforts or stress relief
Travelling assistance
Transport costs for Excimer laser or Lasik treatment
Consultations
A telephonic consultation or an appointment arranged with
a healthcare provider which has not been honoured by the
member or any of the members dependants
22
The NHP Wellness Programme
A rapid increase in chronic conditions fuelled by lifestyle choices
has resulted in an increased focus on preventative strategies
to counteract their negative effects. NHP has identied
preventative care as a key focus area going into the future
and has incorporated a preventative care benet into the
benet design without inuencing your day-to-day benets or
impacting on your Roll-Over Benet. The intention is to shift the
focus from curative, to primary and preventative care. The NHP
Wellness Programme forms part of a greater effort to support
the focus on preventative treatment.
Becoming aware of your health risks can lead to specic
goals and planning to reduce the risks of certain diseases
and sicknesses, enhance health, improve productivity in the
organisation, increase job satisfaction, and reduce absenteeism.
Our NHP Wellness Programme is a practical programme aimed
at empowering you to take ownership of your own health and
well-being. The Beneciary Risk Management (BRM) programme
targets key lifestyle factors that inuence your healthcare risks.
These life-style factors include stress, weight control, smoking,
diet, nutrition and exercise. The BRM Programme is a tool to
manage your healthcare risk in order to start early intervention
and active engagement. NHP provides clinical expertise and
guidance that equips you with vital information necessary to
benchmark your health.
For more information, contact NHP, tel +264 61 285 5400.
NHP Lifestyle
Management Programme
As a member of the Fund you are entitled to make use of
the exclusive NHP Lifestyle Management Programme, where
benets can be enjoyed at no additional cost. The purpose of
the Lifestyle Management Programme is to you and your family
by offering discounted services and rebates. In addition, the
programme promotes a healthy lifestyle through benets such
as providing credits with our Lifestyle partners.
Please note For more information on rebates that members can
claim when exercising regularly and living a healthy
lifestyle please revert to the Benet Guide for
more information.
Introduction 3
About NHP 3
How NHP is managed 3
Introducing your Principal Ofcer 3
Introducing your NHP Board of Trustees 3
Your Guides as a tool to understanding the Rules
of the Fund 3
What role does NAMAF and NAMFISA play in the
medical aid industry? 3
What is meant by medical aid tariff? 3
About Medscheme Namibia 4
What is the relationship between Medscheme Namibia and NHP? 4
How do I become a member of NHP? 4
Application requirements for NHP membership 4
Monthly contributions 4
Dual membership 4
Individual members 5
Student members 5
Employer groups 5
Distinguishing between the principal member
and an aged dependant 6
Principal members 6
Registering an adult as a dependant 6
Registering a special/adult as a dependant 6
Registering a child as a dependant 6
Acceptance of membership 7
Pre-existing conditions 7
Medical certicate requirements for employer groups 7
Medical declaration/certicates requirements for
individual members 7
Important to know once membership is approved 7
Proof of membership - Membership number and card 7
1Number4Life 7
Can my exclusions be waived? 8
What is meant by a nancial year/benet year? 8
What about benet option changes? 8
Pro-rated annual benets 8
Waiting periods 8
Termination of membership 8
Fraud and abuse against the Fund 9
What is my liability as a member? 9
Change of address 9
Understanding your Medical Aid Fund 9
How are benets allocated? 9
Benet options to suit your needs 10
Nexus Administration System 10
Roll-Over Benet 10
Value for money contribution tables 10
Overall Annual Limit (OAL) 10
Family focused benets 10
Management of risk/Managed care 10
Preventative care benet 11
Case management 11
Pre-authorisation for treatment in hospital 11
Major medical expenses (MMEs) 11
Accommodation other than a recognised hospital/medical
institution in the Republic of South Africa 11
Accommodation other than a recognised
hospital/medical institution within Namibia 11
Travelling costs for specic medical treatment not available
in Namibia 11
Travelling costs for specialist treatment within Namibia 11
Dentistry in-hospital 12
Additional in-hospital cover 12
Emergency evacuation 12
International travel benet 13
Repatriation benet 13
Premium waiver 13
Optional benets 13
Ex-Gratia applications for additional benets 13
Sports injuries 13
Foreign accounts 13
Injuries on duty 13
Motor vehicle accident claims 15
Connements 15
Oncology Disease Management Programme 15
How to register? 15
Treatment and medication 15
Surgery and hospitalisation 15
Stoma therapy 15
Wigs and external breast prosthesis 15
Hospice care and private nursing 15
Oncology claims 15
Aid for AIDS (AfA) Programme 15
Help is available to manage your medical condition 16
Your condition will stay condential 16
You must register on the AfA programme 16
After you have registered 16
Day-to-day medical expenses 16
Generic industry medicine reference pricelist 16
Generic medicines 16
Why are generic medicines cheaper than ethical drugs? 17
Are generic medicines as reliable as ethical products? 17
Chronic medication benet 17
Automated chronic application process 17
Acute medicines 18
Self-medication 18
Dentistry out-of-hospital 18
Orthodontics 18
Dental implants 18
Optical 19
Auxiliary services 19
Quit Smoking Programme 19
Weight Management Programme 19
How do I claim? 19
How do I know that my account has been paid? 20
What medical benets are excluded? 20
Medicines and appliances 20
Medical expenses 20
Alternative healthcare providers 21
Physiotherapy 21
Travelling assistance 21
Consultations 21
The NHP Wellness Programme 22
NHP Lifestyle Management Programme 22
Appendix
23
Windhoek
tel + 264 61 285 5400
fax + 264 61 223 904
1st Floor, Hidas Centre
21 Nelson Mandela Avenue
PO Box 23064, Windhoek
Oshakati
tel + 264 65 221 721
fax + 264 61 277 412
Medical Complex, Main Street
PO Box 23064, Windhoek
Swakopmund
tel + 264 64 405 714
fax + 264 64 403 715
7 Daniel Tjongarero Street
PO Box 2081, Swakopmund
Keetmanshoop
tel + 264 63 225 141
fax + 264 61 277 419
Birds Mansion Hotel, 6th Avenue
PO Box 1541, Keetmanshoop
Walvis Bay
tel +264 64 205 534
fax + 264 64 209 959
Ofce Number 7,
Welwitschia Hospital Centre
PO Box 653, Walvis Bay
Emergency medical number
tel + 264 61 222 223
After hours emergency
cell + 264 81 129 1709
In-hospital emergency
cell + 264 81 246 8436

www.nhp.com.na