NAMAF is the legislated entity authorised to set benchmark tariff structures on behalf of all medical aid funds. These benchmark tariffs are commonly referred to as the “NAMAF benchmark tariffs”, “scale of benefits” or “medical aid tariffs”. The NAMAF benchmark tariffs used by medical aid funds represent a specific threshold according to which the medical aid fund is willing to reimburse for healthcare treatment and services rendered to the member but in no way limits the healthcare provider to charge more or less than the benchmark tariff, subject to their preference.

As such, the Fund pays claims on behalf of its members 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.

Members will remain responsible for settling the full account to the healthcare providers and as such may be required to settle any outstanding amounts. 

In the case of hospitalisation and treatment while in hospital, it is often the case that members may run up a significant bill for expenses that are 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 be paid to the healthcare provider as per the benefit allowed per benefit option.

Members with accumulated Roll-Over benefits may also request that such co-payments in respect of out-of-hospital treatment be refunded from their accumulated Roll-Over benefit account or may alternatively also contact NHP for further advice.

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. Risks are managed by providing good value for money regarding the fit between membership contributions and the need for comprehensive benefits.

Medscheme Namibia established a forensic unit in 2018 to help combat fraud, waste and abuse. In an effort to further manage the risk of the Fund, a Roll-Over Benefit 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 profile of the Fund or an employer group.

Members living in remote and outlying regions of Namibia, in need of specialist treatment referred by their local healthcare provider, provided the particular treatment is not available in their town of residence and thus need to travel to Windhoek for treatment, may apply to the Fund for assistance in defraying some of the transportation costs to and from their town of residence.

The following conditions will apply:

• No referrals within a radius of 150km outside of Windhoek shall qualify for consideration.
• Transportation costs for specialist treatment, required in Windhoek.
• No travelling costs granted for specialist referrals to Swakopmund or any other place in Namibia, unless Swakopmund is the closest town with such specialist services.
• 80% of the transportation cost for the first and all subsequent visits for the same medical condition will be paid.
• All claims for reimbursement are subject to pre-authorisation.
• The Fund will not pay for claims submitted, if there is no pre-authorisation number.
• Members travelling in their own vehicle must submit a detailed log sheet and attach all supporting fuel slips.
• Members must submit a referral letter from a healthcare provider to a specialist when services are not available in their town of residence.
• The Fund will only allow one fill-up in the town of residence.
• Members must attach a confirmation of the appointment with the specialist to the travelling claim.
• No fill-up will be refunded on departure from town of residence.
• Benefits exclude orthodontic treatment. Only the travelling cost for the first consultation will be paid.
• All travelling costs for auxiliary services are excluded.

Please Note:

• Failure to obtain prior authorisation will result in the Fund not accepting any liability in respect of such costs, unless in the case of a medical emergency.
• Members travelling with their own vehicles must note that a detailed log sheet and supporting fuel slips must be submitted.
• Members must submit a referral letter from a specialist or another healthcare provider in Namibia when services are not available in Namibia.
• Members must submit a confirmation of an appointment at a specialist in South Africa.
• No claim will be considered if the member did not receive prior authorisation to claim such expenses from the Fund.
• Members travelling with their own vehicles must note that a detailed log sheet and supporting fuel slips must be submitted.
• Members must submit a referral letter from a healthcare provider to a specialist when services are not available in their hometown. The Fund will allow only one fill-up in the hometown and not both on departure and arrival.
• Members must attach a confirmation of the appointment with the specialist to the travelling claim.
• Benefits exclude orthodontic treatment (only the first consultations travelling costs will be paid)

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 profile 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 financial year will determine the age category and therefore the monthly contributions for the remainder of that financial year. Monthly contributions are not increased in accordance with the principal member’s birthday during the course of the year.

Use our online contribution calculator to determine you monthly contribution.

Pre-existing conditions refer to any diagnosed medical condition from which either the principal member or any of their dependants may suffer or sustained prior to or at the date of joining the fund. 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.

Any failure to disclose any conditions, whether intentionally or unintentionally, which manifested or originated from the causes prior to admission as a member, or within 120 days from the date of such admission (“the underwriting review period”), will at the sole discretion of the NHP, be met with the following consequences:

• If NHP, in its sole discretion believes any condition for which benefits claimed during the underwriting period, may have existed or originated before commencement of membership, benefits will be put on hold until submission of such proof.
• If the member cannot prove beyond reasonable doubt that such medical condition was not present at the time of commencement of membership, then NHP, at its sole discretion, reserves the right to withhold benefits relating to the treatment required.
• NHP may exclude or limit any benefits in respect of the undisclosed condition and/or NHP may unilaterally terminate membership.

Upon joining the Medical Aid Fund, it will not be necessary for a new employer group to submit medical certificates 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 certificate 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 Fund’s 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 certificate 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 identified at that stage
• The submission of a medical certificate 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 identified at that stage
• A medical certificate will be compulsory for any member wishing to enroll their aged parents as special dependants onto the Fund either immediately upon joining the Fund or at a later stage.

Medical declarations/certificates are compulsory for all individual members when applying for membership to the Fund, irrespective of whether or not they have previously belonged to another medical aid fund. Proof of previous medical aid fund membership (membership declaration/certificate) alone will not be sufficient.

• Routine medical costs.
• Outstanding member’s portions.
• Treatment normally excluded from your benefits.
• Medical expenses with a valid chargeable Tariff or Nappi Code which are usually excluded by the Fund. These medical services must be provided by a registered healthcare provider.
• The difference between the actual medical costs and the NAMAF benchmark tariff for medical services covered by the rules of the Fund.
• Medical aid contributions.
• Claims in respect of benefits for sickness conditions, medical procedures or medicines excluded (Including exclusions from the Optical and Dental benefits) may be paid from a positive balance on the accumulated Roll-Over benefit.
• Medical expenses in respect of new dependants where a waiting period may apply. Claims not eligible for payment from the Roll-Over benefit:
• Non-medical expenses without a valid chargeable code and Nappi code which is not rendered by a registered healthcare provider.
• Any medical or non-medical expenses claimed for beneficiaries not actively registered as dependants of the main member.

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 benefits for services rendered during the period of suspension.

Monthly contributions are payable in advance before or on the 7th day of each calendar month. The first payment needs to be made by cheque or alternatively electronic funds transfer (EFT). Debit orders will only be processed as from the 2nd calendar month of membership. Non payment of contributions will result in suspension.

Students who are not regarded as dependants on their parent’s 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 first confirm with the university if this prerequisite is enforced before applying for medical aid within the Republic of South Africa.

With the exception of refractive surgery on all benefit options and optical benefits on the Blue Diamond and Litunga benefit options, there is no defined waiting period in respect of benefits 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 satisfied that all conditions for membership have been met. The effective date of membership may be postponed until all supporting documentation in respect of marriage certificates, birth certificate(s) or medical declaration/certificate(s) have been submitted. The Fund applies waiting periods in certain conditions:

Individual members:

• A general waiting period of 3 months will apply for all Day-to-Day and Major Medical Expense claims excluding emergencies on all new individual members joining NHP. This means that members, within their first 3 months as new members to the Fund, will only qualify for emergency in-hospital treatment and emergency procedures performed in emergency rooms/ casualty wards.
• A general waiting period of 6 months will apply for the optical benefit on the Blue Diamond and Litunga benefit options.
• A general waiting period of 3 months for all Day-to-Day and Major Medical Expense claims will apply in respect of aged parents joining the Fund as a dependant, in addition to a 12 month condition specific waiting period for pre-existing conditions.
• A condition specific waiting period of 12 months will apply to Day-to-Day and Major Medical Expense claims relating to maternity.

Employer group members:

• All new employer group members joining the Fund will normally be exempt from the waiting period unless the member/dependants joins the Fund 3 months after becoming eligible for membership.
• The 3 month general waiting period applies to‑ all Day-to-Day and Major Medical Expense claims, excluding emergencies. In the event of an employer group member only joining after the 3 month window period then, a general waiting period of 3 months will apply for all Day-to-Day and Major Medical Expense claims excluding emergency in-hospital treatment and emergency procedures performed in emergency rooms/casualty wards.
• The 12 month condition specific period for maternity related claims. All dependants of employer group members joining as from the 4th month after the principal member or 3 months after becoming eligible to qualify as a dependant will be subjected to a 3 month general waiting period on all Day-to-Day and Major Medical Expense claims, excluding emergencies, as well as a 12 month condition specific waiting period for maternity related claims.

Condition-specific:

• If a principal member and/or dependant suffers from a specific illness, the Fund has the right to exclude benefits for this specific condition for a period of up to 12 months.
• A condition-specific waiting period will apply if the previous medical aid fund had imposed such waiting period and it had not expired at the time of termination.

Non-disclosure consequences:

• If found that false information has been submitted or that any relevant information has deliberately been omitted on an application, the Fund may correct this in terms of its rules, which may include re-underwriting or termination of membership. 

Refractive surgery:

• A 12 month waiting period will apply on all members across all benefit options where the benefit is available, including members previously covered by other medical aid funds.

Maternity:

• All new employer group members joining the Fund will normally be exempt from the following unless the member/dependants join the Fund 3 months after becoming eligible for membership.
• A condition-specific waiting period of 12 months will apply to new individual members and to a member who joins NHP already pregnant, until and including delivery.  All maternity related treatment falls under the 12 month waiting period. This also applies to members previously covered by other medical aid funds.

Newborn:

• The principal member is required to register a newborn as a child dependant within 30 days from the date of birth.
• If a member applies to register a newborn or newly adopted child as a dependant after 3 months following the date of birth or adoption of the child, the Fund may subject the child dependant to a general waiting period.  A medical declaration completed by a doctor will be required for the child dependant.

An aged parent of a principal member, not younger than 60 years, who has no income and is totally and financially dependent on the principal member. Proof of no income will be required. A direct biological relationship between the member and the aged parent must be proven. Aged parents are limited to a maximum of two per member. Approval of the application to enrol aged parents onto the medical aid fund is subject to the discretion and approval of the Board of Trustees. The decision of the Board of Trustees will be final and cannot be appealed.

Please note: If approved, a 3 month general waiting period will be applied in respect of aged parents, in addition to a 12 month specific waiting period for pre-existing conditions.

A company or business wishing to obtain membership with the Fund should apply in writing to the Board of Trustees for employer group status, provided that at least 10 of its employees, who qualify for membership, join the Fund.

If part of an umbrella body, continued employer group status is conditional to companies or their members renewing their membership with the relevant umbrella bodies as applicable, on an annual basis and that proof of such updated subscriber status is provided 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.

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 benefits from any other medical aid fund. In the case of an individual member, the monthly contribution is calculated according to their age and number of dependants, as well as the benefit option chosen. If one of the individual member’s dependants is older than the principal member, the monthly contribution will be calculated according to the age of the oldest person.

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 a new individual member.

Major Medical Expenses, or MME’s are normally regarded as the various types of treatments rendered while the beneficiary is hospitalised or requires a period of hospitalisation for treatment. In the case of MME’s, benefits 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.

The financial year of the Fund runs concurrently with the benefit year from 1 January until 31 December of each consecutive calendar year. The Fund announces its new monthly contributions and benefits structure that will apply for the following financial 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 Benefit is a low claims incentive through which unused day-to-day benefits below the threshold value will be transferred from one financial year to another. At the start of each new financial year, new benefits are thus allocated to members in accordance with the benefit structure that will apply for the particular year.

Pre-authorisation is not a guarantee of payment for hospital treatment. You as the member are responsible for confirming whether the cost of your treatment is within the limits of your selected benefit option. If you are unsure whether your treatment will be covered in part or in full, please contact NHP.

In the case of membership being for a period of less than 12-months, pro-rated annual benefits will apply and will be adjusted accordingly. Pro-rated annual benefits are not only applicable on termination, but also when joining the Fund during the course of any financial 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 benefits 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.

The overall annual limit is a specific amount allocated and defined by either an individual member or per family unit. The OAL is the maximum amount that may be claimed by either member or the family unit. Different sub-limits apply in respect of major medical expenses and day-to-day out-of-hospital expenses. The Gold and Platinum have an unlimited overall annual limit.

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 benefit options during his/her period of membership with the Fund.

Medscheme Namibia is the appointed 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 themselves 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 financial management, sound corporate governance principles and excellent service levels.

• Members Roll-Over benefit accumulates in their name for as long as they are members of NHP.
• A Roll-Over benefit instruction claims form for manual Roll-Over refunds must be completed and can be sent via fax 061 223 904 or emailed to claims@nhp.com.na.
• If members select the automated claims process, the completed form can be sent via fax 061 230 465 or emailed to members@nhp.com.na.

If you claim less than a certain threshold amount included in your day-to-day benefits, you will build up a Roll-Over benefit which you can use to pay for healthcare treatment and medical costs. Claims paid in accordance to the day-to-day benefits of each benefit option, taking into account the threshold level, will first be debited against the Roll-Over benefit after which the normal day-to-day risk benefits will be used.

At the end of April, in the following benefit year, if your previous year’s day-to-day claims excluding costs for chronic medication are less than the Roll-Over benefit, the remaining balance will be transferred into your accumulated Roll-Over benefit account, which you can use to pay for additional medical expenses normally excluded in terms of the Rules of the Fund.

The Fund is a member of the Namibian Association of Medical Aid Funds (NAMAF), the controlling body for medical aid funds in Namibia. Private medical aid funds must register with the Registrar of Medical Aid Funds in Namibia. NAMFISA is the registrar of non-banking financial institutions and is responsible for the supervision of these institutions in terms of the NAMFISA Act, 2001 (Act 3 of 2001).

On an annual basis, NAMAF publishes benchmark tariffs for specific healthcare treatment, services and procedures performed in-or-out of hospital. These NAMAF benchmark tariffs are only a guideline for any healthcare provider e.g. general practitioners, specialists and anaesthetists, to follow when they consider billing the portion for which the Fund will be accountable in respect of treatment provided. 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.

Members can approach NAMAF should they feel their claims or membership status are being unfairly treated by a medical aid fund. Members are encouraged to exercise the above option only if they fail to resolve the situation directly with their medical aid fund. If NAMAF finds the complaint to be valid, they will aim at rectifying the issue with the member and medical aid fund in question.

Pro-rated annual benefits will apply to membership that is shorter than one calendar year. Pro-rated annual benefits will also apply to beneficiaries that may be enrolled during the course of a benefit year. On joining the Fund a member will have the option of paying back-dated monthly contributions to the start of the financial year in order to increase his/her benefits to the full annual limit.

If a member joins the Fund after the 1st day of the financial 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 benefits for all services under the day-today benefits are decreased for such financial year in the same ratio as the number of calendar months already expired up to 12. Pro-rated annual benefits apply for all day-to-day benefits, chronic medication, and oral surgery.

Similarly if a member terminates his/her membership from the Fund before the last day of the financial 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 benefits applicable to such member’s membership at the date of termination of membership.

Pro-rated annual benefits 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 financial year.

At NHP, we take pride in offering a range of benefit options that meet everyone’s needs:

• Comprehensive benefits allow members to choose a level of comprehensive cover that best suits their needs and budget and include the Gold, Platinum, Titanium, Silver and Bronze benefit options.
• Hospital benefit 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.
• Primary Healthcare benefits options provide access to affordable healthcare to employees who have not previously had access to medical treatment and membership with a medical aid fund and include the Blue Diamond and Litunga benefit options.

To make it easier for you to decide which option is best for you, you can use the handy tools on this website to Compare Options or help you Choose an Option. If you’re still not sure, please contact us so we can advise you.

In the case of Individual members with and / or without dependants, the principal member is the person with the highest age and therefore responsible for payment of the monthly contributions.

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 or main 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 benefits from any other medical aid fund.

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 flexibility in the utilisation of benefits, 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 benefits available within your selected option.

A membership application form must be completed and submitted to the administrator offices 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 filled 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 doctor’s certificate, relating to the member’s health and family medical history, from either the member or medical practitioner. Pro-rated day-to-day benefits will apply as from the date of joining, unless the joining date is 1 January.

Any failure to disclose any conditions, whether intentionally or unintentionally, which manifested or originated from the causes prior to admission as a member, or within 120 days from the date of such admission (“the underwriting review period”), will at the sole discretion of the NHP, be met with the following consequences:

• If NHP, in its sole discretion believes any condition for which benefits claimed during the underwriting period, may have existed or originated before commencement of membership, benefits will be put on hold until submission of such proof.
• If the member cannot prove beyond reasonable doubt that such medical condition was not present at the time of commencement of membership, then NHP, at its sole discretion, reserves the right to withhold benefits relating to the treatment required.
• NHP may exclude or limit any benefits in respect of the undisclosed condition and/or NHP may unilaterally terminate membership.

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 patient’s 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 financial benefit 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.

In order for any healthcare provider to claim from any medical aid fund both the facility and the individual provider must be registered with NAMAF. Members are at risk to the extent that should they have used the services of any healthcare providers with a suspended practice number during such time, then such services are deemed not to be eligible for processing against a person’s medical aid benefits.

We respect your privacy and understand that to facilitate your medical needs we need to handle your data.

To manage/delete your data please contact our call centre on 061 285 5400 and we will gladly assist you.

Members with an accumulated Roll-Over balance can now also make use of an automated function for payment of claim co-payments. In the past members with positive Roll-Over balances had to inform the Fund if they wanted to have payment towards their medical accounts and expenses deducted from their accumulated Roll-Over balances. This feature has now been automated and members have the luxury of choosing whether they want to have their co-payments deducted automatically or whether they want to continue with the manual nomination process.

Members are requested to indicate whether they want to make use of the automated payment function or continue with the manual process of nominating for the accumulated Roll-Over benefit to be paid by filling out a claim form. Members opting for the manual option must attach proof of purchase and the payment will be reimbursed from the accumulated Roll-Over benefit account.

The Fund offers its members a major medical expense benefit that automatically covers a certain percentage on top of the NAMAF benchmark tariff, depending on the benefit option chosen, for services provided in hospital by healthcare providers.

This cover is over and above the normal benefits.

Benefits 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

The Gold, Platinum, Silver, Bronze, Titanium and the Hospital benefit options cover is 225% of the NAMAF tariff allowed for services provided in hospital by healthcare providers. This cover is included in the normal benefits.

Benefits excluded:

• HIV/AIDS
• National epidemics
• Organ transplants
• Post-hospitalisation and rehabilitation medication
• Pre-existing conditions
• Refractive surgery
• Dental surgery, but for children under 10-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.

In order to qualify for additional in-hospital 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 benefit limit in respect of surgical prostheses will not qualify for the additional in-hospital cover benefit in respect of the additional in-hospital cover. No additional in-hospital cover will be granted in respect of any set benefits, for example in the case of oral surgery where a benefit for the full procedure has been granted.

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.

At the beginning of every financial year and in conjunction with the annual monthly contribution increases, existing members are afforded the opportunity to change from one benefit option to another, based on their need. Benefit 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 benefit option to another during the course of a benefit 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 benefit option to another:

• An application for change of benefit option form must be filled out and sent via fax 061 230 465 or emailed to members@nhp.com.na, please contact NHP, tel 061 285 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 benefit option will be indicated as selected
• The personal details and beneficiary details will remain the same unless instructed to effect changes

Download the Member record amendment request form

Adults may be registered as dependents of a principal member upon the following conditions:

• 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.

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.

The Maxillo-facial and oral surgery benefit is subject to prior approval and provides cover for the following treatment:

• Oral surgery: Planned surgery benefit for all services, with regards to doctor, an 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 tumors and neoplasm’s, 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
• Benefits 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

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 verified.

Please note: Pre-authorisation is not a guarantee of payment.

Pre-authorisation for treatment in hospital is only valid and restricted to conditions for which such pre-authorisation has been requested 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.

Benefits 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

Fraudulent and abusive behaviour against the Fund will not be tolerated. The Board of Trustees may exclude from benefits or terminate the membership of a member or dependant whom the Board of Trustees finds 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 employee’s 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

Fraud hotline – Confidential

Tel: 0800 647 000

Email: medschemenamibia@whistleblowing.co.za

All benefit options on the Fund are specifically designed to cater for the needs of its members based on their medical needs and affordability.

The range of benefits includes three traditional benefit options; namely the Gold and Platinum and Titanium benefit options, as well as three new generation benefit options; namely the Silver, Bronze and Hospital benefit options. . Two of the benefit options offered to members, the Blue Diamond and the Litunga benefit option, are primary healthcare benefit options.

The Fund’s product range has been developed in conjunction with consulting actuaries who specialise in healthcare financing. This has been done in order to create a flexible range of legislatively compliant, sustainable, actuarially sound and cost effective benefit options, designed to meet the needs of both employers and individuals in all spheres of employment.

You can download the form here or alternatively obtain an application form from any of the NHP call centres throughout Namibia. The completed application form should be accompanied by the following documentation and handed in at one of our branches:

• A medical certificate – 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 certificate(s), except in the case of children with different surnames, in which case a full birth certificate will be required
• A copy of the marriage certificate – If applicable
• In the case of a common-law spouse – A certified 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
• Bank confirmation letter, dated and stamped within a 3 month time-period.

After submitting the membership application form and supporting documentation to the administrator offices, your application will be processed, and you will be notified as to whether your application was successful via e-mail or sms.

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 benefits and contributions will be announced in the summary of changes document annually. You will also receive a new copy of the Benefit 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 the User Guide, please do not hesitate to contact NHP or your Client Liaison Officer.

NHP produces an annual Benefit 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 Benefit Guide contains the benefits and contributions as approved by the Board of Trustees and will apply for the specific benefit year. The changes for the specific benefit year 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 benefit and contributions offered there under.

Monthly contributions are payable in advance before or on the 7th day of each calendar month. The first payment needs to be made by electronic fund transfer. Debit orders will only be processed as from the 2nd calendar month of membership.

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 benefits or withdraw or refuse payment of benefits.

A principal member may register child dependants if:

• Children are under the age of 21, and are totally dependent on the principal member, unemployed and are unmarried.
• Children are 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 financially 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 financially dependent on the appointed guardian. A copy of the death certificate of such parents must be handed in as proof.
• Members should notify the Fund within 30 days of the birth of a child to qualify for immediate benefits and submit a copy of the birth certificate with the dependant registration form. Members’ monthly contributions increase when registering a new dependant, due from the 1st day of the month following the birth. The Fund will not impose any restrictions on congenital ailments and conditions on a newborn, if registered in accordance with the rules of the Fund.

This benefit provides cover for a patient’s accommodation according to a specific amount per day for accommodation other than a recognised hospital or medical institution. This benefit is aimed solely at members who are not hospitalised, but are required to attend treatment, consultations or examinations in-and-out of hospital, while referred to South Africa for treatment.

• Available on Gold, Platinum, Titanium, Silver, Bronze and Hospital plan, subject to Overall Annual Limits.
• Daily rate of N$ 835.00
• Only applies to treatment offered in South Africa on special referral nd is subject to pre-authorisation.
• In cases where the patient is a minor, 18 years and younger, the Fund will cover the accommodation for an accompanying guardian

The Fund’s age-based contribution tables offer value for money by ensuring that the Fund’s 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 influence each other.

Through the Nexus Administration Platform, 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 benefits as well as changes regarding their membership status.

Typical events include notification 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.

If you would like to access the NHP Members portal to view your account details online at any time, simply register or login via the page on this website.

Preventative care helps keep your medical costs down by allowing members access to preventative care treatment for specific health conditions. This benefit is available on Gold, Platinum,Titanium, Silver and the Bronze benefit options.

We encourage members to be pro-active in taking responsibility for their healthcare needs, enabling them to make the best use of the benefits available within their selected Benefit 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:

• On Gold, Platinum, Titanium, Hospital, Silver and Bronze options: N$ 835.00 per night, Maximum of 2 nights per family per anum, refer to Benefit Guide;
• 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.

Available on Gold, Platinum, Titanium, Hospital, Silver and Bronze options.

Subject to availability of Overall Annual Limit.

The Fund may make use of the services of any accredited locally registered emergency service provider with the appropriate infrastructure in place to provide adequate cover and peace of mind.

NHP emergency numbers: Download List

If you need us to know about any changes of address, employer or banking details, please download the membership update form for membership record amendment. Please fill out the form and return it to us via fax or email. Alternatively, please feel free to give NHP a call on 061 285 5400.

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 member’s 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 member’s failure to furnish and update his/her latest contact details, inclusive of banking details.

After hour emergency related procedures will be covered as long as the Managed Care department is notified on the 1st working day following the procedure and the patient is admitted in Hospital.

Accommodation other than a recognised hospital/medical institution in the Republic of South Africa is a benefit restricted to the Gold, Platinum, Titanium, Silver, Bronze and Hospital benefit options. This benefit is subject to the overall annual benefit. A specific amount will be paid per day per patient for accommodation other than a recognised hospital or medical institution.The benefit will not be paid while the member/patient is still in hospital.

This benefit 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 benefit will only apply to treatment received in the Republic of South Africa and is subject to prior approval.

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 registered umbrella body, may also join the Fund, but will not be eligible for the reduced monthly contributions.

Replace with-Employees of a new employer group joining NHP from another medical aid fund with 10 or more employees are entitled to join the Fund. Such members have a window period of 3 months to apply for membership. Thereafter, the normal rules of the Fund as defined 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 defined 3 month period. A special application to waive this condition may, however, be made to the Board of Trustees in writing.

Members and dependants transferring from another medical aid fund will enjoy benefits from day one, with the same terms and conditions (state of health) as accepted by the previous medical aid fund, provided that such member and dependants were members of the previous medical aid fund for a minimum period of 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.

A surviving dependant must have been registered as a dependant of a principal member at the time of death of the principal member in order to enjoy continued membership with the Fund. For the continuation as a principal member, a death certificate 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 confirmation 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 qualifies for membership as a dependant, is eligible for individual membership.

Your Roll-Over Benefit accumulates in your name for as long as you are a member of the Fund. If you resign from NHP and become a member of another medical aid fund, the positive balance in the Roll-Over Benefit account will be transferred to the NHP reserves.

A termination request form must be filled out and returned to NHP via email to members@nhp.com.na or fax 061 230 465 it with a minimum of thirty days prior to the effective termination date.

An employer wishing to terminate its contract with the Fund must provide the Board of Trustees with one calendar month’s written notice of such intention. Failing to do this, the employer will be held liable for one calendar month’s contributions, based on the average, calculated over the last 6 calendar month’s 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 month’s 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 re-join subject to the discretion and approval of the Board of Trustees at the beginning of a new financial 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 benefits utilised within such period.

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.