1. What is the coverage for the Social Health benefit for WESTADI Insured members` dependants?

  • Health benefit for WESTADI beneficiaries covers any four dependants (living in Tanzania) selected by WESTADI member.
  • Health services will be covered under Social Health Insurance Benefits (SHIB) in Tanzania.

2. What is the health benefit services covered?

  • SHIB covers both out-patient and in-patient health services as summarized below

 Outpatient Services

  • Consultation with clinical/medical officer, specialist or consultant
  • Basic and specialized investigations
  • Minor surgical procedures
  • Dispensing of medicines in the National Essential Medicine list
  • Referral to higher levels and special hospitals

In-Patient services

  • Accommodation (excluding meals)
  • Consultation with clinical/medical officer, specialist or consultant
  • Basic and specialized investigations
  • Minor and major surgeries
  • Dispensing of medicine in the National essential medicine list
  • Dispensing medicines on discharge
  • Referral to higher levels and special hospitals.

3. Are there any limits or exclusions in the health package?

Yes, Social Health Insurance Benefit has limitations and exclusions as follows:

Exclusions:

  • Diseases or services covered under Maternity Benefits
  • Free services/treatment provided by the Government such as immunization, Tuberculosis and Leprosy, Cancer, HIV/AIDS, epidemics, Mental illness, Diabetic Mellitus.
  • Injuries where a third party is involved such as road accident where the vehicle is covered by insurance.
  • Cosmetics and cosmetics surgery.
  • Services/treatment for self inflicted diseases/injuries like alcohol, drug and tobacco abuse, attempted suicide and criminal abortion.
  • Physiotherapy services at home.
  • Psychiatric diseases, except during acute illness within 7 days of care.
  • Medical examination for employment, schooling and travel purposes.
  • Treatment due to diseases/condition arising from participating in an experimental study.
  • Therapeutic trials.
  • Expensive specialized investigation procedures like MRI and DNA Typing.
  • Services/treatment for injuries/conditions arising from active participation in riots, demonstration, unrest and civil strife.

Limitations:

  • Emergency services for mobile members (Traveling outside their place of residence);
  • Outpatient – not more than 4 times/year and
  • Inpatient (48 hours) – not more than 2 times a year
  • Hospitalization for a maximum period of 42 days of Inpatient care for 4 dependants per year

4. Does NSSF have its own Health Facilities? If No, which Health Facilities participate in the Scheme?

NSSF does not have its own Health Facilities the scheme has accredited health Facilities to provide medical services to the beneficiaries. These will include Public, Private, Religious and where necessary Employers’ health facilities are accredited. Accreditation incorporate health facilities of different levels including:-

Dispensaries

  • Health Centres
  • Hospital level I – district and other hospital
  • Hospital level II – regional and other hospitals
  • Hospital level III – referral and special hospital

5. Is there a cap amount for Health Benefit?

NSSF Social Health Insurance benefit applies a Capitation mode of payment or Fee per visit system for referral hospitals accredited by the Fund. The capitation system operates under insurance principles and therefore beneficiaries are not obliged to pay for their treatment except for services not covered in the benefit package.

6. When will a WESTADI beneficiary start/cease to enjoy health benefits?

WESTADI health services starts immediately after confirmation of premium remittance by the insured person.

However, health services for WESTADI beneficiary will stop once the insured WESTADI member's membership expires and he/she ceases to remit premium.

7. What is the process for beneficiary enrolment for health insurance benefit?

  • Dependants will have to go to the nearest NSSF office for enrolment.
  • At NSSF they will need to fill WESTADI dependant enrolment form in triplicate, together with the following documents:-
  • Three passport size photos
  • PIN number they have received from the Insured WESTADI member.
  • Photostat copies for IDs of either the following documents: - Tanzania Voter’s card, Bank card, employee card, birth certificate, etc.
  • Dependant will have to choose a health facility of his/her preference from a list of SHIB accredited health facilities present in NSSF office.
  • Once the above is completed, NSSF will inform the dependant the time for commencement of health services.
  • Dependant will have to re-enroll him/herself any period a premium is renewed.

8. Can the beneficiary change hospitals/dependants after enrolment?

  • Yes, member can change any active dependant as in the WESTADI Guidelines.
  • Yes, Dependant can change Medical Provider as per provided SHIB Guidelines.
  • Member changing a dependant has to follow WESTADI guidelines.