Understanding Medical Aid Exclusions
Medical aid funds are designed to guarantee access to essential healthcare for their members. However, rising healthcare costs—often exceeding inflation—threaten the affordability and sustainability of private healthcare. To manage this, medical aid funds implement exclusions on certain medicines, treatments, and procedures.
Why Exclusions Exist to:
- Maintain affordability for all members
- Ensure benefits are evidence-based and clinically justified
- Align with best practice and the laws of Namibia
- Avoid covering services with little or no medical necessity
For example, emergency surgery for acute appendicitis is covered, while elective cosmetic procedures may not be, unless clinically necessary.
What Members Should Know
Each fund outlines its exclusions in its Fund Rules, which are legally binding. It is the member’s responsibility to:
- Know what is not covered
- Confirm whether a treatment or medicine is included before undergoing it
Failure to do so means the member must cover those costs out-of-pocket.
Why Exclusions Exist to:
- Maintain affordability for all members
- Ensure benefits are evidence-based and clinically justified
- Align with best practice and the laws of Namibia
- Avoid covering services with little or no medical necessity
For example, emergency surgery for acute appendicitis is covered, while elective cosmetic procedures may not be, unless clinically necessary.
What Members Should Know
Each fund outlines its exclusions in its Fund Rules, which are legally binding. It is the member’s responsibility to:
- Know what is not covered
- Confirm whether a treatment or medicine is included before undergoing it
Failure to do so means the member must cover those costs out-of-pocket.
Common Medical Aid Exclusions in Namibia
Below are examples of services and products generally not covered by most registered medical aid funds:
Note: This list is not exhaustive. Members should request the full list of exclusions from their fund or check the official website.
