The definition of health insurance according to Law No. 40 of 2014 concerning Insurance is an agreement between two parties, namely the insurance company and the policy holder which is the basis for receiving premiums by the insurance company in return for:
- Provide reimbursement to policyholders due to unexpected health losses
- Provide payments based on the value that has been set on the results of fund management
The basic benefit is the primary coverage. This means that when enrolling in a policy, the insurance company will automatically cover the following treatment costs:
- Hospitalization: The cost of hospital rooms, doctor visits, medicines, and other costs associated with hospitalization.
- Surgery: The cost of surgery, such as resection, amputation, or reconstructive surgery. The health insurance policy also covers operating room costs, surgeons, and anesthesiologists.
- Outpatient: Expenses for medical procedures that do not require hospital stay. Either pre-hospital or post-hospital or simply outpatient diagnosis and treatment.
Additional benefits, also known as riders, are the expansion of health insurance policy coverage. This means, to get this rider, customers will be charged an additional fee.
For example, if you have received basic benefits in the form of inpatient, outpatient, and surgery, then the customer wants to get other additional benefits such as medical check-up (MCU), maternity insurance, health insurance covering dental care, and eye care.
- Medical check-up: Usually, MCU fees are only borne at the beginning of insurance registration in order to measure the health risk of potential customers.
- Maternity insurance: The cost of giving birth, starting from check-ups, caesarean delivery or normal delivery, and aftercare.
- Dental care: The cost of dental health insurance coverage, starting from an examination, cleaning, filling, or tooth extraction.
- Eye care: The cost of eye health care, starting from the examination and including glasses.
- Suicide or self-inflicted injury
- Organ transplants, including related treatments and medications
- Supporting equipment such as wheelchairs, prosthetic limbs, heart trigger devices, hearing aids, vision aids, and the like
- Dialysis or dialysis and other related
- Experimental, traditional, or alternative treatments and remedies
- Psychosomatic, mental or nervous disorders and addiction
- Weight-related care and/or treatment
- Treatment and/or treatment related to plastic surgery
- Periodic physical examination or medical check-up (MCU)
- Treatment and/or treatment related to hernia or developmental delay
- Circumcision that is not related to illness or accident
- Treatment and/or treatment related to HIV/AIDS to sexually transmitted diseases
- Coverage for the cost of vitamins and supplements without medical indication
- Family planning costs
- It should be understood that each insurance company has different exclusion clauses.
Health Insurance Claim
Health insurance claims are divided into two categories, namely cashless (non-cash) and reimbursement (cash).
Cashless claims are the most practical option, because the insured only needs to show the insurance participant card to the partner hospital. Then you can immediately get health services.
Meanwhile, reimbursement requires the insured to pay hospital bills with personal funds first. After that, submit a claim to the related insurance company, then the hospital bill will be replaced. The advantage of this claim method is that it can be used in non-partner hospitals of insurance companies.
Minimum Data Requirement
- Company’s detail
- Census data such as name, occupation/position, gender, date of birth and plan needed.
- Health Declaration (If required)
- Existing and proposed Term & Conditions
- Loss history