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.

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

• Medicines or chemotherapeutic agents not approved by the Namibia Medicines Regulatory Council (NMRC) unless approval is obtained and pre-authorised by the relevant Managed Healthcare Programme.
• Anabolic steroids and immunostimulants and remedies for body building purposes or exercise and sport specific enhances.
• Growth hormones, unless prescribed.
• Immunoglobulins and immune stimulants, oral and parenteral, unless pre-authorised.
• Erythropoietin, unless pre-authorised.
•  Slimming preparations for obesity.
• Treatment for loss of libido.
• Injection and infusion material, except for out-patient parenteral treatment and diabetes as prescribed by a registered medical practitioner.
• The following medicines, unless they are authorised by the relevant Managed Healthcare Programme:
  • Liposomal Ampthotericin B for fungal infections;
  • Protein C inhibitors such as Xigris, for septic shock and septicaemia;
  • Cancer treatments outside managed care protocols;
  • Herceptin (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 median overall survival advantage of more than 3 months in advanced or metastatic solid organ malignant tumours, unless deemed cost effective for the specific setting, compared to standard therapy (excluding specialised drugs) as defined in established and generally accepted treatment protocols, for example Nexavar (Sorafenib) for hepatocellular carcinoma, Avastin (Bevacizumab) for colorectal and metastatic breast cancer.
• Erectile dysfunction medical treatment.
• Biological drugs for non-oncology treatment, unless pre-authorised.
• Medicines not included in a prescription from a healthcare 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 not authorised or defined as exclusions by the relevant Managed Healthcare Programme. 
• New medicines or those with additional registered indications, that have not been reviewed by the relevant Managed Healthcare Programme.
• 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.
• Patent medicines, household remedies and proprietary preparations and preparations not otherwise classified.
• Traditional and Indigenous Medicines, except Chinese medicines as prescribed by a registered Chinese Medicine Practitioner
• Anti-habit-forming drugs and medicines for alcohol or drug addiction.
• Medication and clinical services as advertised directly to the public.
• Appliances, devices and procedures not scientifically proven or appropriate.
• Continuous Glucose Monitoring Systems unless provided for in the option benefit schedule and pre-authorised.
• Cardiac assist devices, e.g. Berlin heart
• Custom made compression garments.
• Diagnostic kits, agents and appliances unless otherwise stated, except for diabetic accessories.
• Pain relieving machines, e.g. TENS and APS.
• Repair of hearing aids, spectacle frames or lenses and medical apparatus beyond available benefits.
• Breast pumps and baby/apnoea monitors.
• Orthopaedic shoes and boots, unless specifically authorised.
• Pulse oximeters.
• The hire or purchase of oxygen apparatus of gases, unless authorised.

Medical expenses

• Services not considered appropriate in terms of Managed Healthcare Principles, or that are not lifesaving, life sustaining or life supporting.  The Fund reserves the right to determine such instances in general or for specific instances at any time, at its discretion;
• All costs which are not:
  • medically necessary and appropriate to meet the health care needs of the beneficiary;
  • consistent with the diagnosis or condition;
  • rendered in a cost-effective manner and type of setting appropriate to the supply of the service required for purposes other than comfort or convenience;
  • appropriate and necessary for the symptoms, diagnosis or treatment of the medical condition at an affordable level of service and cost;
  • All costs for treatment, if its efficacy and safety cannot be proved to the satisfaction of the Fund or have not been published in scientific peer-reviewed journals or in standard medical texts.
• Compensation for pain and suffering, loss of income, funeral expenses or claims for damages.

Alternative healthcare providers

• Acupuncture – except as provided by a registered Chinese Medicine Practitioner;
• Aromatherapy;
• Ayurvedics;
• Herbalist;
• Homeopathy;
• Iridology;
• Naturopathy ;
• Osteopathy;
• Phytotherapy; 
• Reflexology;
• Therapeutic massage therapy (masseurs), including massage or relaxation therapy for the relief of general, chronic and acute muscular discomforts or stress relief;
• Traditional/indigenous healing therapies and medicines except Chinese medicines as prescribed by a registered Chinese Medicine Practitioner;
• Bloodtests requested by beneficiaries or Homeopaths, Naturopaths and Physiotherapists or other alternative medicine providers.

Travelling assistance

• Transport costs to and from South Africa if the services are available in Namibia, unless specific exemption has been received from the Managed Care department.
• International medical expenses and air ambulance repatriation costs outside the borders of Namibia and South Africa, unless pre-authorised.
• Travelling costs within Namibia, if such travelling is done without a valid referral letter to a specialist or specialist service and no approval received from the Managed Care department.
• Ambulance services not authorised, unless provided in circumstances of emergency medical condition as determined by the Fund, or ambulance services not registered as a accredited medical transport service provider.
• Ambulance services requested by a hospital for the purpose of transporting a patient to and from an x-ray facility, unless provided in circumstances of emergency medical condition as determined by the Fund.