Healthcare expenditures that medical aid funds do not cover

The objective of medical aid
cover is to guarantee access to
essential healthcare, for fund
members. However, there are threats to
the sustainability of private healthcare
coverage, such as affordability.
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 dependant 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;
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.

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