Frequently Asked Questions (FAQs)
What are my responsibilities in relation to the scheme?
Members must understand their selected cover and the benefits associated with it, as outlined in the product brochure.
It is the member’s responsibility to inform the scheme of any changes to their personal details or dependents.
Members must also obtain the required pre-authorisations and keep their membership card secure to prevent fraudulent use.
How will I know when my benefits take effect?
Benefits are aligned with the scheme’s benefit year, which runs annually from 1 June to 31 May.
Members joining after the benefit year has started will receive monthly pro-rated benefits for the remainder of that benefit year.
Who can utilize my medical aid cover?
Only registered beneficiaries are permitted to use your medical aid cover to access private healthcare services.
Who qualifies as a dependent?
Dependents may include:
- Spouse or partner
- Children
- Other relatives (assessed individually and must be below 55 years of age)
How do I register child dependents?
Newborn or newly adopted children must be registered within 30 days of birth or adoption.
The following documentation is required:
- Birth certificate
- Registration receipt or child welfare card
- Legal adoption papers (where applicable)
How do I terminate my membership?
One month’s written notice is required from either the member or employer.
Membership may also terminate due to:
- Death of the member
- Outstanding contributions
- Fraudulent claims
- Misrepresentation
- Non-disclosure of information
Note: Benefits will be prorated during the notice period.
Will option changes be allowed?
Yes. Option changes become effective every June.
- 30 days’ notice is required for downgrades.
- 60 days’ notice is required for upgrades.
What should I do if I lose my membership card?
Request a replacement through the mobile app, where you can also access a digital membership card.
Alternatively, contact the customer service team for assistance.
Will contributions be adjusted during the year?
Yes. Contributions may change due to:
- Addition or removal of dependents
- Salary changes (for salary-banded premiums)
- Age changes (for age-banded premiums)
- Annual product option changes
Note: Premiums are reviewed annually at the beginning of the benefit year.
What happens when the principal member passes away?
The Premium Health Waiver benefit allows registered dependents to remain covered for
12 months from the principal member’s date of death.
Which medical expenses are covered?
- Hospital and related expenses (pre-authorisation required)
- Day-to-day outpatient treatment
- Chronic medication through the Disease Management Programme
Members must register for the Disease Management Programme to access chronic medication benefits.
What is pre-authorisation and when do I need it?
Pre-authorisation confirms benefit eligibility and available cover before treatment.
Contact:
- Phone: +267 73014111
- Email: preauthorization@metropolitan.co.bw
Pre-authorisation is required for:
- Hospital admission (including psychiatric admission)
- Dread disease treatment
- Rehabilitation
- Procedures performed in a doctor’s room
- Maternity benefits
- MRI / CT scans
- Radio isotope studies
- Interventional and specialised radiology
- Advanced dentistry
- Refractive surgery
- In-hospital dentistry for children under seven years
How do I submit a claim?
Most healthcare providers submit claims directly to the scheme.
If you pay cash for treatment, submit:
- Original detailed invoice
- Proof of payment (receipt)
Note: Claims must be submitted within 4 months from the date of treatment.
What is Balance Billing?
Balance Billing occurs when a healthcare provider charges above the agreed scheme tariff.
Members are responsible for paying the difference directly to the provider, and this amount
cannot be claimed from the scheme.
How long does it take to process a claim?
Claims are generally processed within 30 working days from the submission date.
Members can track claims through the member portal or customer service.
What happens if my claim is rejected?
You will receive a remittance explaining the reason for rejection.
You may appeal by providing any required supporting documentation or requesting a review through customer service.
Can I claim for medical expenses incurred outside Botswana?
South Africa – Emergency
- The hospital submits the claim directly to Botsogo Health Plan.
- Payment is made directly to the provider according to scheme tariffs.
South Africa – Non-Emergency
- Members pay first and submit a reimbursement claim.
Other Countries
- Only emergency claims are reimbursed.
- Non-emergency claims are not covered.
- Claims are reimbursed according to scheme tariffs in Botswana Pula (BWP).
What constitutes an emergency?
An emergency is the sudden onset of a serious medical condition requiring immediate medical or surgical treatment
to prevent severe impairment, organ dysfunction, or loss of life.
How will the scheme reimburse me?
The scheme reimburses KYC-compliant members via Electronic Funds Transfer (EFT).
How can I check my available benefits and claims history?
Log in to your member account using the mobile app or online portal to view your benefits,
claims history, and coverage details.
Does the scheme cover occupational injuries and diseases?
No. Occupational injuries and diseases fall under Workmen’s Compensation and are the responsibility of the employer.
Points to remember
- Keep copies of all submitted documents.
- Ensure your claims have been submitted and paid, even if your healthcare provider submits them on your behalf.
- If your claim is rejected, you have 60 days to resubmit the correct claim or raise a query.
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