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:
Please refer to your policy certificate to confirm if you have a 7 day or 30 day waiting period.
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.
If you have existing exclusions on the sickness benefit these will also apply to the Admission Rider Benefit (hospital claim).
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:
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:
Which hospitals are not covered?
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.
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.
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.
PPS Insurance (Namibia) will require:
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.
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.
Independent Specialist reports will be paid for by PPS.
This will assist us in ensuring that we make a fair and informed decision regarding your claim.
Yes, once the full sum assured has been paid the benefit ends.
The benefit amount is reflected on your PPS Policy Certificate. You can also ask your Financial Advisor for this information.
Given that most patients who test positive for COVID-19 have a good prognosis and a relatively short acute illness period, PPS anticipates that most potential claims will be for the Sickness Benefit (in particular our 7-day Sickness Benefit).
With respect to the other PPS products and benefits, claims will be assessed in accordance with existing claim definitions and processes that apply to our disability, critical illness, and death products and benefits.
You do not need to have a positive COVID-19 test result to submit a valid claim to PPS.
You need to be Suspected of having COVID-19 or have a Confirmed diagnosis of COVID-19. If you present with an acute respiratory tract infection or other clinical illness
compatible with COVID-19 or you test positive for COVID-19 with laboratory confirmation of SARS-CoV-2 infection, you can submit a Sickness Benefit claim.
If you are asymptomatic (not currently ill with COVID-19 related symptoms) you need to have been quarantined;
by a Namibian government authority (e.g. Namibian Minister of Health) or the Ministry of Health and Social Services (MHSS) following confirmed exposure to COVID-19. These claims will be limited to a maximum of 10 days per claim event and will exclude the period of
national or regional lockdown unless the individual person was specifically quarantined during this period by a Namibian government authority or the MHSS. Policyholders will be limited to a maximum of 1 asymptomatic claim event.
by a Medical Practitioner following close contact1 with a confirmed2 COVID-19 case. In these instances, the claimant will be required to make disclosures of the confirmed COVID-19 person that they were exposed to,
and the circumstances of this exposure. These claims will be limited to a maximum of 10 days per claim event and will exclude the period of national or regional lockdown unless the individual person was specifically
quarantined during this period by a Medical Practitioner. Policyholders will be limited to a maximum of 1 asymptomatic claim event.
For Suspected and Confirmed COVID-19 cases A Declaration by Member (DBM) claim form completed by the member. A Declaration by Doctor (DBD) claim form completed by the treating medical practitioner. Copies of all COVID-19 test results (whether negative or positive).
For Asymptomatic cases quarantined by a Namibian government authority A Declaration by Member (DBM) claim form completed by the member.
Evidence of government quarantine instruction naming the exposed claimant, that is acceptable to PPS. For Asymptomatic cases quarantined by a Medical Practitioner. Declaration by Member (DBM) claims form completed by the member. Disclosures by Member of the confirmed COVID-19 person that they were exposed to and the circumstances of this exposure, that is acceptable to PPS. A Declaration by Doctor (DBD) claim form completed by the treating medical practitioner.
1.Close contact: A person having had face-to-face contact (1 meter) or in a closed space with a confirmed case for at least 15 minutes. This includes, among others, all persons living in the same household as a case and, people working closely in the same environment as a case. Healthcare workers or other people
providing direct care for a case, while not wearing recommended personal protective equipment or PPE (e.g., gowns, gloves, N95 respirator, eye protection). Contact in an aircraft sitting within two seats (in any direction) of the case travel companions or persons providing care, and crew members serving in the section of the aircraft where the case was seated.
2.Confirmed case: A person with laboratory confirmation of SARS-CoV-2 infection (using an RT-PCR assay), irrespective of clinical signs and symptoms. Symptomatic cases are considered infectious from 2 - 3 days before symptom onset to 14 days after symptoms onset.
If you are symptomatic and test positive for COVID-19 you can claim for both the acutely ill period plus the isolation period as advised by your medical practitioner. The isolation period will be subject to a maximum of 10 days.
If you are symptomatic and test negative for COVID-19 you can claim for the acutely ill period as per the provisions of your normal Sickness Benefits as contained in the Provider Policy. If the claimant is placed in isolation after the acutely ill period by a medical practitioner despite testing negative, PPS will also consider the additional isolation period. The number of isolation days will be subject to a
maximum of 10 days.
If you are asymptomatic following exposure to a known COVID-19 case and test positive for COVID-19 you can claim for the quarantine period as advised by your medical practitioner, a government authority, or the MHSS subject to a maximum of 10 days.
If you are asymptomatic following exposure to a known COVID-19 case and you are not tested, you can claim for the quarantine period as advised by your medical practitioner, government authority, or the MHSS subject to a maximum of 10 days. If you stay at home as a precautionary measure or on the direction of your employer without being confirmed as a Suspected or Confirmed COVID-19 case or being quarantined by a Namibian
government authority, the MHSS or a Medical Practitioner as an Asymptomatic person with exposure to COVID-19, you would not have a valid claim.
PPS will not pay any Sickness Benefit claim or COVID-19 related claim where a claimant was asymptomatic but placed in isolation or quarantine following international travel.
The only exception to this is where, despite being asymptomatic, you are tested and confirmed to have COVID-19 during the quarantine period.
If you are not displaying symptoms, you will not be classified as a Suspected or Confirmed COVID-19 case and would not be able to submit a Sickness Benefit claim to PPS.
The only exception to this is where you are quarantined by a Namibian government authority, the MHSS or a Medical Practitioner.
PPS will consider all claims where a member is partially unable to perform their usual professional duties if the total claim period is greater than the
waiting periods that apply to your policy. Partial Sick Pay Benefits will be paid for the days that you are not able to carry out at least some of your
professional duties while you are ill or in isolation. If you are able to perform all of your usual professional duties, this would not be a valid
Isolation and quarantine are public health practices used to stop or limit the spread of disease. There are different interpretations of these concepts, so PPS has assigned the following meaning to these terms for the purposes of this document.
Isolation is where a person has been tested and confirmed to have COVID-19, and they are separated from those that are healthy.
Quarantine is where a person is asymptomatic (not ill) but may have been exposed to COVID-19 and a government authority (e.g. Namibian Minister of Health), the MHSS, or a medical practitioner has mandated that the person be quarantined or
a person is identified as a Suspected COVID-19 case and is awaiting test results and is advised by their treating medical practitioner to home quarantine until the results are known and the appropriate steps followed.
PPS will consider a member to have been in close contact where the member had face-to-face contact (1 meter) or in a closed space with a confirmed COVID-19 case for at least 15 minutes.
If a medical practitioner can make the appropriate diagnosis following a tele-consult, PPS accepts this as a method of consultation during the pandemic. The member must still submit a completed Declaration by Doctor form in support of the claim