Access to essential healthcare

Healthcare costs increase at rates which are substantially higher than the general inflation rate and that may require member contributions to increase each

year. The financing available for healthcare expenditure is not infinite, therefore one

of the measures employed by medical aid funds to mitigate the threat of affordability,

is exclusions on benefits covered for certain medicines, treatments and procedures.

Medical aid funds must nonetheless ensure that there are good reasons for these exclusions, otherwise they may lead to the unreasonable denial of healthcare benefits to the members of medical aid funds.

All medical aid funds have a list of treatments, medicines and procedures that they will not cover. Therefore, to ensure that all members have a fair and equitable rationing of healthcare benefits, medical aid funds have limits to the items and treatments covered for members. The principles that are considered by medical aid funds when deciding whether exclusion is justified or not are:

best practice, evidence-based healthcare, clinical protocol, cost-effectiveness (affordability), and the prevailing laws of the country. It would, for example, be inappropriate to exclude the treatment of acute appendicitis because of its life threatening nature, while exclusion for cosmetic surgery in the absence of clinical indications would be appropriate.

Each medical aid fund’s benefit exclusions are listed in detail in the respective Fund Rules. Excluded products or services as stipulated in the exclusion lists will not be paid for by the medical aid funds. It is thus the responsibility of members to ensure that they are familiar

with the products and services that are excluded from their medical aid fund cover. Members should ensure that the medicines, treatments and procedures they receive or require, will be paid for by their medical aid fund before obtaining the service. Otherwise, they will be solely responsible for paying the costs of the said products or services. Examples of medical benefits that are generally excluded by most of the registered medical aid funds in Namibia include, but are not limited to: 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; Nutritional supplements including patent foodstuffs, baby food and special formulas; Preparations used specifically to treat and/or prevent obesity or overweight or any slimming preparations; 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; Patent and secret medicines and preparations, household remedies and preventative preparations; Medicines used specifically for the treatment of sterility, impotence and infertility; Vitamins and multivitamins alone or in combination with stimulants (tonics); Medicines used specifically to treat alcohol or drug addiction; Treatment of an illness or injury sustained by a member or a dependent 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 dependent; Suicide, attempted suicide or intentional self-inflicted injury whether the patient concerned is of sound mind or not; Plastic surgery and cosmetic treatments of a member’s own choice or which are recommended for psychological reasons or surgery directly or indirectly caused by

or related to or in consequence of cosmetic surgery; Medical expenses for any planned or non-emergency consultations, examinations, procedures and treatment incurred in foreign countries other than in South Africa. The above examples are not a complete list of medical aid funds exclusions. To read the full list of exclusions, one should request it from their medical aid fund. Some medical aid funds have also put the exclusion list on their respective websites. – www.namfisa.com.na

Did you know?

Wellness programs

It has shown to help employees alleviate and better manage the symptoms of depression, improving their overall wellbeing.

Health tip

Wellness programs are good at helping people adopt and maintain healthy behaviors.

Health precaution tip

Healthy behaviors lead to lower health risks, and lower health risks lead to less chronic disease.

STATS:

Medical insurance:

• May be used as a gap cover in conjunction with your medical aid

• Protects your financial assets and promotes wellness and health

• Covers certain accidental injuries such as disability

• Can cover your salary when you’re unable to work due to an accidental injury

• Gives you the option of including death and/or funeral cover to your plan

• Covers health events at fixed or stated amounts paid directly to the member as opposed to a medical service provider.