Exclusions

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.

 

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. Click on the link below to download the complete User Guide which contains the rules of the fund and a detailed explanation of all exclusions.

Download: 2018 User Guide

What medical benefits 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, 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 Mabthera (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, and
    • Herceptin (Trastuzumab) for the treatment of HER2-positive early breast cancer that exceeds the dose and duration of the 9 week regimen and used in the FinHer protocol; and
    • Any specialised drugs that have not convincingly demonstrated a survival advantage of more than 3 months used for treatment of metastatic solid organ malignant tumours, e.g. Nexavar (Sorafenib) for Hepatocellular carcinoma, Avastin (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 defined 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 classified.
  • Slimming preparations for obesity.
  • Tonics, evening primrose oil, fish liver oils, except for registered products that include haematinics and products for use of:
    • Supplementation to pregnant mothers and infants during lactation,
    • Malabsorption disorders,
    • HIV positive patients registered on the relevant Managed
    • Healthcare Programme,
    • Adults aged older than 50 years,
    • Children 5 years and younger
    • Injections, unless prescribed for the treatment of obesity
    • Haematinics,
    • Vitamin C 500mg or more prescribed together with cold and flu treatments,
    • Not more than 30 days supply of Vitamin C 500mg or more prescribed together with cold and flu treatments, and
    • 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 for non-oncology treatment, including Betaferon for the treatment of multiple sclerosis and Enbrel (Etanercept), Humira (Adalimumab) and Pegasys (Peg interferon alfa) unless pre-authorised.
  • All benefits for clinical trials unless pre-authorised by the relevant Managed Healthcare Programme.
  • Diagnostic agents, unless pre-authorised.
  • Growth hormones, unless pre-authorised.
  • Immunoglobulin’s and immune stimulants, oral and parenteral, unless pre-authorised.
  • Erythropoietin, unless pre-authorised.
  • Medicines used specifically to treat alcohol or 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 South Africa.
  • Services rendered by any person not registered under his/her applicable statutory body, either in Namibia or South Africa.
  • Treatment of ailments from which the member was specifically excluded at the date of membership.
  • 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 satisfied 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 benefits 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 specifically excluded by the Rules of the Fund.
  • Holidays for recuperative purposes.
  • Insurance and physical examinations i.e. flight medical examinations, fitness test, etc.
  • Operations, medicines and treatments of a cosmetic nature,
  • The treatment of obesity.
  • Wilfully self-inflicted injuries or attempt to commit suicide.
  • Dysfunctional family and social problem counselling.
  • 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, reflexology.
  • Hyperbaric oxygen treatment.
  • Hyperbaric oxygen treatment.
  • Appliances, devices and procedures not scientifically 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.
  • Humidifiers, lonisers and air purifiers.
  • Orthopaedic shoes and boots, unless specifically authorised,
  • Pain relieving machines, e.g. TENS and APS.
  • Stethoscopes.
  • The hire of oxygen or purchase thereof, unless authorised.
  • The treatment and diagnosis of infertility and any related expenses.
  • Artificial insemination of a person as defined in the Human Tissue Act, 1993.

 

Alternative healthcare providers

  • Acupuncture,
  • Aromatherapy,
  • Ayurvedics,
  • Herbalists,
  • Homeopathy for Blue Diamond and Litunga Primary Care,
  • Iridology,
  • Naturopathy,
  • Osteopathy,
  • Phytotherapy for Blue Diamond and Litunga Primary Care,
  • Reflexology,
  • Therapeutic massage therapy (masseurs),
  • Traditional healing, and
  • Forensics.

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