Microsoft word - nmc exclusions 2006.doc

EXCLUSIONS NMC 2007

Notwithstanding any contrary provision contained elsewhere in the Rules, the provisions of
paragraphs 1 and 2 shall apply to all MEMBERS and their DEPENDANTS.
1.
Unless the BOARD determines otherwise, costs in respect of the following medicines are Preparations used specifically to treat and/or prevent obesity or overweight or Patent and secret medicines and preparations, household remedies, and preventative preparations generally promoted to the public to increase consumption unless prescribed in the form of a mixture together with any medicated cream or ointment e.g. a topical steroid. Household type bandages and dressings, cotton wool and similar requisites unless supplied to or used in a clinic or doctor's room or during the patient's stay in a hospital or a nursing home. Nutritional supplements including patent foodstuffs, baby food and special Medicines used specifically for the treatment of sterility, impotence and infertility. Aphrodisiacs: Preparations generally purported to improve or increase libido, or Medicines used specifically to treat alcoholism and drug addiction on all BENEFIT OPTIONS other than Protector Health. Anti-smoking preparations: All preparations designed specifically to treat or stop Soaps, shampoos, and other topical applications (of a cosmetic nature) medicated or otherwise: Items other than those intended for the treatment of lice, scabies and other parasitic infestations or fungal infections, as indicated by the doctor's diagnosis. 1.10.1 Sun screening and sun tanning agents, unless prescribed by a dermatologist in the form of a mixture together with any medicated cream or ointment e.g. a topical steroid. 1.10.2 Sun screening and sun tanning agents, unless prescribed by a dermatologist for medical reasons (full motivation letter required). 1.10.3 Products used to relieve or treat sunburn unless prescribed by a doctor. Anabolic Steroids, unless prescribed for medical reasons (full motivation letter Vitamins, multivitamins, vitamin combinations and tonics, unless: 1.12.1 prescribed for adults aged older than 50, 1.12.2 prescribed for children aged 5 and younger, 1.12.3 Vitamin B supplementation prescribed as an adjunct to antibiotic therapy, 1.12.4 not more than thirty (30) days' supply of vitamin B supplementation prescribed as an adjunct to antibiotic therapy, 1.12.5 prescribed for supplementation during pregnancy and lactation, 1.12.6 injections other Neurobion injections prescribed for the treatment of obesity, 1.12.8 Vitamin C 500mg or more prescribed together with cold and flu treatments, 1.12.9 not more than thirty (30) days' supply of vitamin C 500mg or more prescribed together with cold and flu treatments, Products that are not listed in MIMS (for example, Golden Products, Single or combined mineral preparations and electrolytes: Oral preparations intended as dietary supplements when intake is considered inadequate unless prescribed together with diuretics e.g. Slow K (full motivation required): prescribed for Electrolyte replacement therapy with diarrhea (full motivation required): prescribed together with hormonal replacement therapy in the case of calcium supplements: prescribed for osteoporosis in the case of calcium supplements or prescribed for patients older than 50 years of age (full motivation required). Contact lens preparations specifically used for the care and cleaning process of contact lenses, including wetting agents. Cosmetic and toilet preparations, medicated or otherwise. Immunosuppressives unless prescribed by a medical specialist. Medicines used specifically to treat Acquired Immune Deficiency Syndrome (AIDS), unless the patient is registered for Case Management. Contraceptive Devices: Foam preparations, jellies, condoms, or any other contraceptive devices apart from IUCD's. Preparations not easily classified if not prescribed for medical reasons (full motivation letter required). For example, Evening Primrose or Efamol G. Unless the BOARD determines otherwise, direct or indirect costs in respect of the following treatment are excluded from BENEFITS: Suicide, attempted suicide or intentional self-inflicted injury, whether the patient Medical examinations for insurance purposes, for and with regard to employment Medical examinations and/or treatments where no actual or presumed illness Physical fitness tests, other than for MEMBERS or DEPENDANTS registered under any wellness program offered by the FUND. Plastic surgery and cosmetic treatments (excluding mamma reductions, dental implants and refractive surgeries) of a member's own choice or which are recommended for psychological reasons only. Examinations for and/or treatment of infertility, sterility, impotence and artificial insemination, and obesity and overweight. Appointments with a supplier of services not kept by the patient and charged for Acupuncture, Acupressure, Reflexology and Masseurs. Accommodation in old age homes and similar institutions. Hospitalisation or accommodation in an institution similar to a hospital for breastfeeding mothers for the sole benefit of their newborn babies. All costs pertaining to pregnancies for the first 12 months of membership in the case of members who are registered as individuals. All costs incurred for treatment of injuries, where such costs are the responsibility of another party unless the Rules provide otherwise. Ophthalmic examinations by anyone other than an eye specialist or registered Any instrument to correct or enhance vision other than a pair of spectacles or Operations to correct vision defects, where the lack of refraction is less than: * In the case of myopia, (-) 3,00 dioptre; * In the case of hyperopia, (+) 6 dioptre; * In the case of astigmatism, (-) 2,50 dioptre; * In the case of combined myopia and astigmatism, (+) 4,00 dioptre unless preceded by keratoconus. Tinting of prescription lenses by 35% or more. Dental devices and materials such as dental floss, tooth brushes and tooth paste. Any dental procedures that are recommended for cosmetic purposes. Costs incurred in respect of injuries sustained by a MEMBER or DEPENDANT participating in a sport as a professional or any hazardous sport or activity which is inherently hazardous, including, but not limited to, active voluntary service in any military or paramilitary organisation or the Namibian Police Services, Namibian Defence Force, well as other activities where the MEMBER or DEPENDANT deliberately exposes himself/herself to substantial danger. Any procedure or device intended to induce, enhance, maintain and promote penile erection or to address erectile dysfunction, such as erectile appliances, auto injectors, and including, but not limited to, drugs such as Viagra. Unless the BOARD determines otherwise, direct or indirect costs in respect of the undermentioned treatment are excluded from the BENEFITS set out in paragraph 3.2 of Annexures B1, B2, B3, B4, B5 and B6. 3.1 For exposure to Nuclear weapons or nuclear material or by ionising radiation or contamination by radioactivity from any nuclear fuel or from any nuclear waste form the combustion of nuclear fuel. For the purpose of this exclusion, "combustion" shall include any self-sustaining process of nuclear fission. 3.2 The contraction of Venereal or sexually transmitted diseases or any condition that, in the opinion of a medical practitioner appointed by the FUND, is in any way due to or arises directly or indirectly from the MEMBER or DEPENDANT having contracted AIDS or HIV infection, unless proved by or on behalf of the MEMBER or DEPENDANT that he/she contracted such condition solely and directly as a result of a normal medical blood transfusion. 3.3 Investigations, treatment or surgery for obesity or its sequelae, cosmetic surgery or surgery directly or indirectly caused by or related to or in consequence of cosmetic surgery, other than because of the following: 3.3.1 Bodily injury caused by violent accidental and external physical means, or, 3.3.2 any somatic illness or disease that manifests itself during the period of insurance and includes premature senile degenerative changes, but not an illness that is of such a nature as to be incapable of diagnosis by objective evidence or which though capable of diagnosis by such evidence has not been so diagnosed. 3.4 Artificial insemination or hormone treatment for infertility. 3.5 Routine physical examinations or procedures, any procedure of a purely diagnostic nature, any other examination where there is no objective indication of impairment in normal health, and laboratory diagnostics or x-ray examinations, except in the course of a disability establishment by prior call or attendance of a physician. 3.6 Depression, insanity, mental conditions or mental stress-related conditions. 3.7 Suicide, attempted suicide or intentional self-injury. 3.8 The taking of any drug or narcotic unless prescribed by and taken in accordance with the instructions of a medical practitioner (other than the MEMBER or DEPENDANT) or any illness caused by the use of alcohol. 3.10 An event directly attributable to the MEMBER or DEPENDANT having a blood alcohol content exceeding eighty milligrams per one hundred milliliters of blood or the MEMBER or DEPENDANT suffering from alcoholism. 3.11 Any medical or surgical procedure not listed in the SCALE OF BENEFITS. 3.12 Costs incurred in respect of injuries sustained by a MEMBER or DEPENDANT participating in a sport as a professional or any hazardous sport or activity which is inherently hazardous, including but not limited to participation in active military duty, police duty, police reservist duty, civil commotion, as well as other activities where the MEMBER or DEPENDANT deliberately exposes him/herself to substantial damages; Costs incurred in respect of any medical condition (whether chronic or otherwise) or a combination thereof, which in the exclusive opinion of the BOARD, warrants to be excluded from BENEFITS. Notwithstanding the provisions of paragraphs 1, 2 and 3 hereof, the BOARD may, upon application by a MEMBER to have a BENEFIT paid in respect of an EXCLUSION (other than a SPECIFIC EXCLUSION) and after consideration of such motivation/other information as it deems relevant, grant such MEMBER'S application if the BOARD, in its discretion, deems such excluded procedure, material or requisite to have been medically necessary.

Source: http://www.methealth.com.na/nmc2007/NMC%20Exclusions%202007.pdf