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.

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).

• 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.

• 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.

• 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.

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:

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.

• Fully completed claim forms may be sent to [email protected].

• 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.

• 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.

• 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.

• 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.

• Public and 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.

• 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.

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:

• 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.

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

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.

• 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)

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.

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.

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.

OR

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
COVID-19 Claim.

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