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FAQs

 

The following information is a guide on "how to claim" and does not replace the PPS Sickness and Permanent Incapacity Policy document which contains all the terms and conditions applicable to claims.

 

Sickness and Permanent Incapacity

 

When can I claim for the sickness cover under this benefit?

When you are sick and unable to perform any of your usual occupational duties due to that sickness or a condition;

The SPPI product has two waiting periods, namely, seven (7) days or thirty (30) days. Thus depending on the waiting period you have chosen, the benefit will pay as follows:

  • 7-day waiting period: A Total Sick Pay Benefit will be considered if you were totally unable to perform any of your usual professional duties for at least seven consecutive days, due to sickness or a condition and will pay retrospectively, from day one. Once this initial requirement for a minimum period of seven consecutive days of total incapacity is met, on-going claims can be submitted for continuing total or partial claims. If not totally unable for 7 consecutive days but totally / partially unable for at least 30 consecutive days, the benefit will pay from day 31.
  • 30-day waiting period: A Sick Pay Benefit will be considered if you are unable, either totally or partially, to carry out your usual professional duties for at least 30 consecutive days due to sickness. The Sick Pay Benefit will be paid on either a Total or a Partial basis, whichever is applicable, prospectively from day 31.

Please refer to your policy certificate to confirm if you have a 7 day or 30 day waiting period.

Admission benefits - do I need to be sick and unable to perform my usual occupational duties due to that sickness for a total consecutive period of 7 days or more to claim Admission benefits?

No, to claim the Admission Rider Benefit you only have to be in hospital for four consecutive days (3 consecutive nights) or more. The benefit is payable from day one.

Are exclusions applicable to the hospital benefit?

If you have existing exclusions on the sickness benefit these will also apply to the Admission Rider Benefit (hospital claim).

What is required for me to submit a claim?

  • A claim form completed by you (Declaration by Member Form);
  • A claim form completed by your treating Medical Doctor (Declaration by Medical Doctor Form);
  • For admission rider benefits we require proof of hospitalisation showing admission and discharge dates.
  • For claims relating to your spouse or child, we require a marriage certificate, unabridged birth certificate of the child and proof of medical aid.
  • For adopted children we require a copy of the official adoption court order and/or official proof of the registration of the adoption with the Registrar of Adoptions, a copy of the marriage certificate pertaining to the Spouse and proof of medical aid for the child.
  • For the Child Terminal Illness and Death benefit, we require the respective benefit claim forms completed by the member and treating Medical Doctor, the unabridged birth certificate or proof of adoption papers, marriage certificate and a death certificate where applicable.

What are Standard Recovery days?

  • To enable PPS Insurance (Namibia) to manage claims and to ensure that all valid claims are paid, the Standard Recovery times provide a guideline to assessors of what is considered a reasonable period to recover from a specific illness or procedure. The concept of 'Standard Recovery time' considers current clinical practice and relevant medical literature in conjunction with PPS's claims experience. PPS will approve the sick pay period which is in line with this current clinical practice.

What happens if my claim period is longer than the Standard Recovery time?

  • Should this period have been extended by the treating specialist/ doctor, the doctor will be asked to provide additional supporting information based on his/her medical examination. Based on this additional supporting information, PPS Insurance (Namibia) will be able to make an informed decision on the remainder of the claim period considering the illness and effect thereof on your ability to perform your nominated profession.

Why would additional information be required?

The assessor may request additional information to determine when your illness started and to get a history of your illness. We may also require a general medical history questionnaire. There may be other reasons why the assessor may call for additional information, for example, to determine the effect the condition has on your ability to attend to your activities of daily living and how the sickness affects your ability to do your work. This could include an Independent Medical Evaluation by a Specialist chosen by PPS or an Occupational Therapy Evaluation.

Special protocol for certain medical conditions:

Special protocol for certain medical conditions:

Mental and Behavioural disorders, fibromyalgia, chronic fatigue syndrome, on-going chronic auto-immune and connective tissue disorders, back conditions, conditions that may have started prior to the business being granted, that could become chronic conditions or are already classified as chronic conditions.

Assessor may ask for:

  1. Copies of clinical notes from your treating doctor, or usual doctor or the doctor who completed the medical reports at application for the policy.
  2. Mental and behavioural questionnaire from the doctor who booked you off – Psychiatric claims.
  3. Medical History Questionnaire from the doctor who booked you off (fibromyalgia/chronic Fatigue Syndrome/ME/Post Viral Fatigue) - Any chronic fatigue/myalgicencephalitis/connective tissue/auto immune claims.
  4. General claims Questionnaire completed by yourself.
  5. The assessor may verify your medical aid records or any other information pertinent to the medical history of your condition. In order to finalise the claim the assessor may request further information directly from members or their treating doctors.
  6. You may be asked to consult a medical specialist who is an expert in that particular field of medicine relating to your claim.

Where do I send my claim forms to?

How long will it take for my claim to be assessed?

  • The entire process should not take more than 8 working days to finalise, once we have received all the required documentation.
  • The process will take longer if additional information is required or if the standard forms have not been completed correctly. If the forms have been incompletely filled in by either yourself or your doctor, this will lead to delays.

Is there a limit to the number of claims I can submit?

  • No, there is no limit to the number of claims you can submit. However, claims for a condition that is regarded as the same or similar or as a result of an existing condition or related to an existing condition, will be limited to 728 days.

How much will I be paid?

  • Your benefit will depend on the sickness cover amount reflected on your Policy Certificate and will be calculated based on the approved number of claim days.

What will be paid out if I am in hospital?

  • If you elected to have the Admission Rider Benefit, you will be paid an additional benefit that will be calculated based on the number of days in hospital, multiplied by the cover amount for Admission benefits. Provided that you were admitted for at least 4 consecutive days.

Which hospitals are covered?

  • District, regional and provincial hospitals
  • Private hospitals
  • Spinal rehabilitation units
  • Infectious Diseases hospitals
  • Rehabilitation Step down facilities (e.g. Life Rehab)
  • Step Down Institutions
  • Frail care facilities

Which hospitals are not covered?

  • Alcohol and substance abuse rehabilitation centres.

Will I get paid if my child or spouse is hospitalised?

  • If you elected to have the Family Responsibility Rider Benefit as a Rider Benefit, you will be paid a benefit if your spouse or child is hospitalised for four consecutive days (3 nights) or more.

What is meant by ‘partial’ incapacity?

You may qualify for a Partial Sick Pay Benefit if you are unable to carry out all your normal duties or normal work hours compared to a normal working day, due to the sickness, but you are able to attend to some of your usual professional duties.

‘Some of your usual professional duties’ means that you have spent time during the working day attending to some of your duties and applying your knowledge and skill related to your nominated occupation. Should you be able to attend to duties related to a different occupation, you must advise PPS Insurance (Namibia) of such change of occupation.

You may submit a claim for being able to work on a partial basis which will be considered and paid a partial benefit rate. Calculations will depend on the cover that you have.

What are my 'usual professional duties'?

Usual Professional Duties are those occupational tasks which you carry out as part of your occupation prior to claim. This includes any administrative duties related to your business or occupation.

What is Gross Professional Income (GPI) and how does this affect my claim?

Gross Professional Income is personal income and actual expenses derived before tax. As per the terms of the Policy Document, a member cannot receive sick pay benefits in excess of two-thirds of his gross professional income or total cost to company salary at time of claim. Thus, PPS Insurance (Namibia) can perform a financial review when a sick-pay benefit claim has been submitted to determine whether a member has the appropriate amount of cover.

What happens if I need to claim for a number of months? What information will PPS require?

PPS Insurance (Namibia) will require:

  • Monthly claim forms will be required, a Declaration by Member from you and a Declaration by Doctor from your doctor;
  • You will be required to consult your doctor monthly;
  • If claims are not submitted regularly on a monthly basis there will be delays in the future payment of benefits. The claims management team are required to request information regularly for long term claimants, and if they are not able to do this there will be delays in the assessment of your claim.
  • Completion of forms based on Telephonic consultations are not accepted by PPS;
  • Fully completed and signed claim forms (Declaration by Member and Declaration by Doctor Forms) should be submitted to PPS on the 25th of the month you are claiming for;
  • The Doctor’s Declaration form must be completed by your treating appropriate or relevant Specialist, that is, a doctor who has specialised in the field of medicine related to your condition.
  • Additional requirements will be communicated to you and may include:
  • Progress reports/questionnaires from your attending specialist(at PPS’s cost);
  • Questionnaires to be completed by you (to determine the effect the condition has on your daily activities of living and your ability to perform your usual professional duties);
  • You may be required to go for an independent assessment at PPS’s cost.

Can I claim for public holidays and weekends?

  • Yes, your claim may include public holidays and weekends.

 

Accelerated Disability

 

When can I claim this benefit?

A claim for this benefit can be submitted when you suffer from a permanent condition (illness/injury) that may prevent you from using your professional training and knowledge to carry out your own occupation or any other occupation that could be carried out by someone with similar qualifications.

What is required to submit a claim?

  • Professional Disability Provider claim form (member);
  • Professional Disability Provider claim form (doctor);
  • Comprehensive medical report from your treating specialist/doctor.(if possible please include copies of all relevant test results inclusive of blood test results and x-rays)

Would I be required to submit any additional information once the claim forms have been submitted?

You may be required to submit a report from an Independent specialist (e.g. Occupational Therapist, Neurologist, etc.).Once the initial documentation has been reviewed, PPS will inform you of any additional requirements.

Who will pay for these reports?

Independent Specialist reports will be paid for by PPS.

Why would additional information be required?

This will assist us in ensuring that we make a fair and informed decision regarding your claim.

How long will it take for my claim to be assessed?

  1. This will depend on whether or not we have enough information with which to assess your claim.
  2. Once we have all the necessary information your claim will be prepared for discussion by the Medical Officers Committee. Your claim will be assessed by the Committee within 15 days of receipt of the last piece of information and you will be informed via e-mail of the date on which your assessment will take place.
  3. You will receive a letter detailing the decision on your claim within 5 working days of the meeting.

Is there a limit to the number of claims I can submit?

Yes, once the full sum assured has been paid the benefit ends.

How much will I be paid?

The benefit amount is reflected on your PPS Policy Certificate. You can also ask your Financial Advisor for this information.