General Provisions
·
Benefits with individual limit.
·
Adult participants are guaranteed a maximum of
up to the age of 65 years at the time of policy closure.
·
Reimbursement claim document expiration:
ü The initial
filing of the claim is 60 calendar days from the date of the receipt.
ü Re-filing of
the claim is 60 calendar days.
·
Reprints of damaged or lost participant card
will be charged a replacement fee of IDR 20.000 per card.
·
Providing telemedicine services for the benefit
of general practitioners, specialists and medicines and excluding medicine
delivery costs for outpatient benefit.
·
Excess claim:
ü Excess claim
will be bailed and directly paid by participant before leaving the hospital.
ü The number of
excess claims paid by Participants at the Hospital / Clinic is not yet a final
amount and there is still a possibility of a lack or an over payment of excess
claims.
ü The final
amount of excess claim is based on verification of the claim documents received
by BNI Life.
ü If based on the
verification of claims by BNI Life, there is a lack of payment for the excess
claim value that has been paid at the Hospital/Clinic, the participant must pay
the difference to BNI Life and vice versa.
Inpatient Benefit
·
Reimbursement of 100% of the receipt with the
maximum limit per participant as follows:
Term and Condition – Inpatient benefit
Coverage of Inpatient Benefits:
1. Recovery
benefit for the same disease and surgery is 14 Days.
2. The minimum
limit of the duration of treatment for categorized hospitalization is 6
consecutive hours of treatment.
3. Room class
tolerance:
BNI Life provides Room
Class Tolerance with conditions if the room whose rate is the same as the
participant's insurance benefit guarantee is not available or full (stated in a
cover letter from the hospital) then:
a. During the
first 2 days, participants are allowed to take a room with a room rate that is
1 level higher than the room and board fee according to the participant's card
(whichever is lower). From day 3 (three) onwards, the difference between room
and board costs and maintenance costs that occur with room and meal costs and
treatment costs according to the participant's card is the responsibility of
the participant.
b. In addition to
room and board costs, the maximum covered costs are in accordance with the
participant's insurance benefit guarantee limit stated on the participant's
card.
c. Participants
who upgrade to a room class at their own request (APS) will still be
guaranteed, but the tolerance of the above room will not apply. Participants
will only be guaranteed according to the benefits, and the excesses will be
borne by the participants.
4. Auxiliary tools
such as rings, pens, plates, screws, k-wire, stent, pacemaker, IOL (which is
implanted in the body) per case is covered by the Hospital Cost benefit.
5. One Day Surgery
Treatment without hospitalization (ODS), per case, is covered on Surgical
benefit.
6. Endometriosis,
Cysts, and Myom that are not related to Hormonal and Infertility.
7. Hernia that is
not related to congenital conditions, for participants over the age of 10
years.
8. Organ
transplantation services exclude the purchase of the organ.
9. Equipment
rental per case is covered on the Miscellaneous Hospital cost benefit.
10. Vitamin,
Multivitamin, Food Supplement recommended by doctors as long as it is in
accordance with medical indications, does not stand alone, for the healing
stage (not prevention), in reasonable quantities and is not an MLM product.
11. Compensation
Benefit of Daily Room Cost for Participants Using BPIS Provider, with limit =
room and board fee per day 60-day frequency limit").
12. Wisdom Tooth
Surgery is covered on Surgical benefits.
13. Compensation
for non-medical costs, including: washcloth, thermometers, under pads, and
gloves (but do not guarantee supporting equipment that is not directly related
to the patient's healing process such as entertainment equipment or equipment
communication), is covered on the Miscellaneous Hospital cost benefit.
14. Excess Claim
will be bailed and directly paid by Participant before leaving the Hospital.
15. The following
benefits are replaced only by REIMBURSEMENT:
a. Pre (Max. 30
Days) and Post (Max. 30 Days) Inpatient Treatment.
b. One Day
Surgical Treatment without hospitalization (ODS).
c. Emergency
Treatment and Special Dental Care Costs without Hospitalization due to
Accident.
d. Special
Benefits.
Annual
claim limit: 5,500,000
Term & Conditions – Outpatient Benefits
Coverage of Outpatient Benefits:
1. Physician/General
Practitioner (consultation, diagnose, treatment), per visit, per day.
2. Specialist/Expert
(consultation, diagnose, treatment), per visit, per day (with/without
Recommendation Letter from General Practitioner).
3. Acupuncture
services performed by certified Acupuncture Physicians. Consultation is covered
on Specialist limit, Treatment is covered on Physiotherapy, Medicines
prescribed (as long on medical indication) is covered on Prescribed Medicines
limit.
4. Laboratory/Diagnostic
Test with limit per year.
5. Physiotherapy
per visit.
6. Eye refraction
examination is covered on Specialist/Expert benefit, per visit per day.
7. Telemedicine
services for the benefit of general practitioners, specialist, and medicines,
exclude cost of the delivery of medicines.
8. Excess claim
will be bailed and directly paid by Participant before leaving the hospital.
Reimbursement of 100% of the Receipt with the Maximum limit per
Participant as follows:
Term & Conditions – Dental Care Benefit
Coverage of Dental Care Benefit:
-
Benefits above are including Dentist +
Medicines + Administration (if any).
-
Basic dental treatment is costs of medicines
prescribed by dentist, dental x-rays required before dental treatment, dental
fillings, extraction, and root canal treatment.
-
Gum care is costs of gum care including
curettage.
-
Preventive care is replacing costs of teeth
cleaning, polishing, and prophylaxis.
-
Complex dental treatment which includes dental
tissue surgery, gold plating, apicoectomy of the small molars and revocation
that needs surgery on a wisdom tooth.
-
Repair maintenance costs involving caping,
crowns, and bridges in the form of plastic or gold coated porcelain.
-
Excess claim will be bailed and directly paid
by participant before leaving the hospital.
Exclusion
The
following are the categories of illnesses or situations that cannot be
tolerated.
Coverage
for the following treatment, services, circumstances, matters or activities as
well as all medical care costs and related costs arising therefrom:
·
Treatment that has not been authorized by the
Ministry of Health, including alternative non-medical treatment.
·
Treatment related to mental and mental health,
as well as drug and/or alcohol addiction.
·
All treatments related to:
Ø Infertility,
including artificial insemination, IVF, and fertility return.
Ø Impotence.
Ø Premenopausal
syndrome and menopause.
·
Treatment for obesity, weight loss or weight
gain.
·
Treatments related to cosmetics.
·
Treatment related to:
Ø Hernias under
the age of 10 years.
Ø Congenital,
hereditary and/or growth abnormalities (congenital).
·
Treatment related to:
Ø HIV/AIDS,
including diseases or conditions related to HIV/AIDS.
Ø Sexually
transmitted diseases.
·
Non-medical expenses other than washcloths,
thermometers, under-pads, and gloves.
·
Vitamin, multivitamin and complementary food
substances (food supplements) without recommendation from a doctor or medical
indication.
·
Over the counter medicines (medicines purchases
without prescription from a doctor).
·
Treatment due to:
·
Treatment due to participation in dangerous
activities or sports:
·
Treatment caused by participants flying using
chartered aircraft, military/police, or helicopters.
·
All treatments and/or treatments that have
received 100% coverage of the total costs paid by BPJS and/or other insurance
companies outside the insurer.
·
Treatment related to pregnancy, childbirth, and
miscarriage/abortion for/or without medical indication.
·
Glasses, contact lenses and those related to
reading ability, eye examinations including eye surgery to diagnose
astigmatism, myopia, hyperopia, or presbyopia.
·
Natural disasters are disasters that if
declared by the government as national disasters.
·
Blood screening from Indonesian red cross
(PMI).
·
Suicide or death penalty by court.
·
Crimes conducted by insurance participants or
other interested parties.
Claim Procedure
1. Cashless: AD
Medika (Swipe card)
2. Reimbursement:
email, mobile apps & regular
Cashless – Swipe Card
Inpatient Procedure
·
Participants showed the card and identity card
to the registration officer.
·
The registration officer will swipe the card to the
EDC machine.
·
Denied/delayed or approved/benefits available.
·
A confirmation letter with details of the
guaranteed limit and eligibility of participants will be sent to the hospital.
·
Participant gets the health services.
·
The provider will send a final bill and medical
summary to AdMedika by fax.
·
AdMedika will check the feasibility of the bill
and the medical summary.
·
Benefits available or if any excess claim will
be covered in advance at the hospital by insurance.
·
Participants may return.
Outpatient/Dental Care Procedure
·
Participants showed the card and identity card
to the registration officer.
·
The registration officer will swipe the card to the
EDC machine.
·
Denied/delayed or approved/benefits available.
·
Participant gets the health services.
·
Participants showed the card and identity card
to the discharge counter officer.
·
Discharge counter officer swipes the member card
and inputs the ICD code and billing cost to the EDC terminal.
·
EDC machine will print the letter of
confirmation (LoC).
·
Benefits available or if any excess claim will
be covered in advance at the hospital by insurance.
Reimbursement Claim Procedure
·
Reimbursement claims document expiration:
ü The initial
filling of the claim is 60 calendar days from the date of the receipt.
ü Re-filling of a
60-day claim.
·
Worldwide guarantee (overseas treatment is
subject to reimbursement).
Reimbursement Claim Document
Ø Inpatient
ü Original
official receipt with stamp and details of medical costs (tax invoice).
ü Medical resumes
signed by the doctor.
ü Diagnostic
examination report (laboratory, Rontgen, USG)
Ø Outpatient,
Dental
ü Original
official receipt with stamp and details of medical costs (tax invoice).
ü Medical resumes
signed by the doctor.
ü Medical
diagnosis.
ü Copy of
prescribed medicine by doctor recommendation.
ü Diagnostic
examination report (laboratory, Rontgen, USG, CT scan, MRI, Panoramic, etc.).
Ø Pharmacy and
Diagnostics
ü Official
receipt.
ü Copy of
prescribed medicine by doctor recommendation.
ü Medical
diagnostic by doctor recommendation.
ü Diagnostic
examination report.
Ø BPJS cash Plan
(daily compensation)
ü Medical resume.
ü An inpatient
form filled out and signed by a hospital officer with the original stamp from the hospital/BNI Life BPJS form.
Reimbursement Claim Requirements
Ø Copy of
participant card.
Ø The receipt
mandatory stated the full name of the doctor according to the name listed in
the Konsil Kedokteran Indonesia (Indonesian Medical Disciplinary Board). See: http://www.kki.go.id/cekdokter/form
Ø Referring to
the terms of policy in clause number 20 sections 1 and 2, if BNI Life requires
additional supporting data or further verification from the doctor/clinic, BNI Life
has the right to request additional documents or authority to visit directly to
the doctor/clinic.
Ø Submission of odontectomy
and denture claim requires panoramic results and dental region information.
Ø More info
please contact: care.eb@bni-life.co.id
Call Center Service
·
Call centre 1-500-045
·
For information about provider hospitals, claim
submission status, remaining insurance benefits.
Email Service
·
Email: care.eb@bni-life.co.id
·
For information about provider hospitals, claim
submission status, remaining insurance benefits and submission of reimbursement
claims.
Reimbursement Claim Metod
·
Regular
Claims with an amount above
Rp. 10,000,000 should be submitted by sending a hard copy to BNI Life Insurance,
with an SLA of 14 working days since the claim submission file is complete and
received by BNI Life.
·
Digiclaim
Claims with amounts up to
Rp. 5,000,000 can be submitted using the BNI Mobile application it can be accessed
on Android and IOS with an SLA of 4 working days since the claim notification
has been successfully received by the BNI Life system. The H+1 payment process for
claims maximum of 500 thousand. Public holidays/holidays are not counted.
·
E-mail
1) The maximum amount
for claims submission is Rp. 5,000,001 – Rp. 10,000,000 per claim per
participant.
2) SLA claims
process 14 working days (with conditions: BNI Life received the completed document).
3) 1 email only
for 1 claim submission per participant with mail subject “Pengajuan klaim by
email atas nama (fill with participant's name) & nomor kartu (fill with
participant number).
4) The original claim
document must be kept for 90 calendar days (can’t be lost), but no need to send it to BNI Life Insurance if not requested by BNI Life.
5) The claim
expiration period is 60 calendar days from the date of receipt was issued.
6) Maximum
attachment email size is 4 mb, if the email attachment is more than 4 mb, can
be sent partially, by writing in the email subject part 1 etc.
Telemedicine (Cashless) – Good Doctor
·
Fill in your detailed information “Admedika card
number and personal information”.
·
Click “validasi” if the data is complete.
·
Your insurance benefits at BNI Life are
connected to Good Doctor Telemedicine.
Telemedicine – Reimbursement
·
Online consultations can be guaranteed by using
all telemedicine platforms such as HaloDoc, YesDok, and others.
·
Submission of claims by reimbursement.
·
Can be guaranteed according to the limit of
participant’s outpatient benefits.
·
The username in the application must match the
participant’s name recorded in BNI Life system.
·
Medicine delivery costs are not guaranteed.
Telemedicine Claim Requirements
1. Medical resume
(name of doctor, patient & medical diagnosis stated).
2. Receipt/invoice
(name of patient & physician stated).
3. Telemedicine
user profile.
4. Copy of
doctor’s prescription.
PT BNI Life Insurance
Centennial Tower, 9th
Floor.
Jl. Gatot Subroto Kav. 24-25,
Jakarta 12930
Phone: +62 21 2953 9999
Fax: +62 21 2953 9998
Fax: +62 21 5366 7688
SMS Center: +62 811 117 626
Email: care.eb@bni-life.co.id
Website: www.bni-life.co.id
Costumer Care: 1-500-045
Costumer Line Admedika – BNI Life: 1-500-246