CONTRACT AGREEMENT OF

GUARANTEED HEALTH MAINTENANCE FOR THE MEDICAL SERVICE

between
GRACE KLINIK
and
PT. MATSUSHITA KOTOBUKI ELECTRONIC PRRIPHERALS INDONESIA
(PT. MKPI)

Number : GK/CA-018/I-02
Number :

Today, Tuesday, 1 January 2002, the undersigned below :

1. Dr. Florence Wati :

act for and on behalf of Grace Klinik as Director, located at Jl. Imam Bonjol
No.3, Nagoya - Batam, hereinafter called as FIRST PARTY.

2. Koichiro Ota :
as Finance and Administration Director of PT. Matsushita Kotobuki Electronics
Peripherals Indonesia, act for and on behalf of PT. Matsushita Kotobuki
Electronics Peripherals Indonesia, located at Kawasan Industri Batamindo,
Muka Kuning, Batam - Indonesia, further called as THE SECOND PARTY.

Each party previously explained:

1. THE FIRST PARTY is a corporation that build up under Indonesian Law of

Medical Service which consist of : Group of General Practitioner, Group of
Medical Specialist, Maternity Hospital, Minor Surgery Service, Physiotherapy,
Laboratories, Radiology and Pharmacy.

2. THE SECOND PARTY is a company of Electronics Devices Manufacturing.

3. Both FIRST & SECOND PARTY are agreed to make an agreement as things
that arrange in the following articles:

Article 1
Aim and Goal

THE SECOND PARTY appoints THE FIRST PARTY and THE FIRST PARTY
accept the appointment and binds it self as the provider of “MEDICAL FACILITY”
health package.
 Article 2
Scope and Service Procedure

Scope and service procedure, which are given according to Article 1, are attached
in this letter which is a non-separately part of this agreement.

Article 3
Health Services

THE FIRST PARTY provides medical services to THE SECOND PARTY as far as
it is regarding to the process & procedure are agreed.

Article 4
Medical Service Cost

1. THE SECOND PARTY will not be charged for any additional cost, if the
medical services required are according to the process and procedure that
have been agreed.

2. For the cases that are not covered in the program, member / patient must pay
for the medical fee by him / herself.

Article 5
Membership Fee

1. Membership fee is charged according to the kind of health services chosen by

THE SECOND PARTY. The amount of membership fee for the above Medical
Services, shown as follows:

COMP “A” / VIP : Rp. 125.000,- / person / month

COMP “B” / I Class : Rp. 90.000,- / person / month
COMP “C” / II Class : Rp. 65.000,- / person / month
COMP “D” / II OB Class : Rp. 40.000,- / person / month
COMP “E” / III Class : Rp. 21.000,- / person / month

2. Membership fee is paid by SECOND PARTY to THE FIRST PARTY.

3. Reduction and addition of the number of Member should be informed oficially

at the latest by the date of 10th of the following month.

4. If THE FIRST PARTY does not receive any data / member list regarding to the
reduction and addition of the member by the agreed time, it is assumed that
there is no change of member list. Unlisted employees have no rights to be
served by THE FIRST PARTY.
 Article 6
Payment Procedure

1. Membership fee for Indirect Labor / Staffs (COMP “A”, “B”, “C” and “D”) should
be paid collectively 3 (three) months consecutively, where as for Direct Labor /
Operators (COMP “E”) is paid 1 (one) month consecutively according to the
invoice of the total chargeable fee.

2. The first payment is due 3 (three) days before initial date of the contract.

3. The second payment and onwards is due by the latest of 14 days from the
date stated on the invoice receiving from the THE FIRST PARTY.

4. Penalty payment is 3% of the total invoice per month.

Article 7
Member Administration

1. In order to have proper administration procedure, THE SECOND PARTY has

obligation to give to THE FIRST PARTY monthly report, shown as follows:

 Any employee who has resigned or has been recruited in that month
 Complete data of new members / employees and their family if the
employee is registered as married.

2. Employee who is not discipline in administration will be served only once and
the next service will not be served before he / she administered his / her full
data.

3. If registered member resigns or is terminated by PT. MKPI by the 10 th of the

stating month, then FIRST PARTY has to return the membership fee on that
month to THE SECOND PARTY and he / she is no longer under PT. MKPI
employee / GRACE COMP member.

4. If registered member resigns or is terminated by PT. MKPI on or after the 10 th

of the stating month, then the membership fee on that month is not return to
THE SECOND PARTY and he / she does not have any rights to be served by
THE FIRST PARTY since he / she is no longer under PT .MKPI employee /
GRACE COMP member.
 Article 8
Services received Outside Batam

1. Outside Batam in Indonesia area

The Member who is on duty or leave outside Batam in the area of Indonesia
can be served by any medical unit / provider in that area with the condition of
payment in advanced and would then be reimbursed by FIRST PARTY after
being standardised the chargeable fee according to the rate of Rumah Sakit
Budi Kemuliaan. This condition is applied for any medical services which are
includes in the GRACE COMP program.

2. Outside Batam in Singapore

The Member who is on duty in Singapore (e.g. training, meeting) can be
served by the oppointed provider in Singapore free of charge, with the
condition of : FIRST PARTY has to be informed by THE SECOND PARTY with
official letter latest by 1 (one) day before they proceed to have the medical
services. Without such official letter, member is not served by THE FIRST
PARTY (provider in Singapore). This condition is only applied for outpatient
treatment.

Article 9
Duration of Agreement

1. This agreement is effective from 1 January 2002 until 31 December 2003 for
one-year contract.

2. Probation period is 3 (three) months. 1 (one) month before end of the

probation period, both of FIRST and the SECOND PARTY has obligation to
meet and discuss about the problem arised.

3. Termination / end of agreement by SECOND PARTY, the party has to inform

officially to THE FIRST PARTY at least 1 (one) month notice in advanced,
whereas the termination of agreement which is terminated by THE FIRST
PARTY, then THE FIRST PARTY has to inform officially to THE SECOND
PARTY at least 2 (two) months notice in advanced. In this case FIRST PARTY
has obligation to give to THE SECOND PARTY another one month allowance
in order to select other Medical Provider.

4. Termination of this agreement does not release the responsibility for both
parties to keep fulfil on their pending obligation.
 Article 10
Disputes

1. For any disputes, which might be arise, as resulted by the agreement, both
parties will be agree to settle it amicably before to the court.

2. If both parties still unable to reach any consensus, then both of THE FIRST
PARTY and THE SECOND PARTY agreed to appoint Batam district court to
assist for agreeable consensus.

Article 11
Additional Prerequisites

1. Both parties should be agreeing for any amendment of this letter of

agreement.

2. Other issues that are not regulated in this agreement will be arranged
deliberately and concencussly by both parties, and put it into addendum,
which become an un-separated part of this agreement.

Article 12
Closing

This letter of agreement is made in two copies duly stamped, both have equal
content and legal force. Both are made and signed on the day, month and year
stated on the first page of this letter, and each party shall retain one copy of it.

SECOND PARTY FIRST PARTY

KOICHIRO OTA Dr. FLORENCE WATI

Finance and Admnistration Director Director
 CONTRACT AGREEMENT OF
GUARANTEED HEALTH MAINTENANCE FOR THE MEDICAL SERVICE
between
GRACE KLINIK
and
PT. MATSUSHITA KOTOBUKI ELECTRONIC PRRIPHERALS INDONESIA
(PT. MKPI)

Number :
Number :

SERVICES REQUIRED

Practical guidence of GRACE Comprehensive Out Patient Medical Package

(COMP) health services requirement for the employee and family of PT.
Matsushita Kotobuki Peripherals Indonesia

A. Medical Services
B. Partly covered Medical Service
C. In House Clinic
D. Regulation for Reimbursement
E. Uncovered Medical Service
F. Medical Service Procedure
G. Closing

A. MEDICAL SERVICES

Medical services which are given to the employees and their family of PT.
Matsushita Kotobuki Electronics Peripherals Indonesia are :

a. Fisrt Level Out-patient Treatment

b. Preventice Act Service
c. Immunisation for children under 5-year old
d. Family Planning Service
e. Dental Care
f. Minor Surgery
g. Emergency Service
h. Specialist Service
i. Maternity and Delivery Care
j. Hospitalisation
k. Diagnostic Support
l. Medicine
OUT-PATIENT HEALTH CARE

Provider Clinics and doctors are according to the clinics stated below :

1. Provider Clinics and doctors are :

1. In House Clinic PT. MKPI
2. Grace Klinik at Nagoya
3. Grace Klinik at Batu Aji
4. Grace klinik at Waterfront City
5. Puskesmas Sei. Pancur (Tg. Piayu)
6. Sagulung Memorial Clinic
7. RB. Nurudiniyah
8. Tiban Klinik Asih
9. Dr. Wilda Hayati Tg. Piayu
10. Dr. Hanny Bengkong
11. Dr. Christiana Tiban
12. RSBK Klinik umum

2. Provider clinics and Dentist are :

 Drg. Norma Grace Klinik Nagoya
 Drg. Fenny M at Pelita
 Drg. Tohap Wong at Gedung Jamsostek
 Drg. Vera at Bengkong
 Drg. Lidya at Tiban
 Dentist at Sagulung Memorial Clinic

Kind of Health Services :

 Medical consultation
 GP examination and simple minor surgery
 Dentist examination and minor surgery
 Medication indicated by the doctor according to the standard of Medical
health GRACE COMP services
 Simple laboratory test
 Mother and child health care
 Pregnancy care and Post natal care
 Family Planning, services provides are : Pregnancy test if necessary, Oral
contraceptive pill, Contraceptive injection, Insertion and extraction of IUD
 Referral service to Specialist
Referral letter is to Specialist is only issue by the appointed provider, shown as
follow :
1. In House Clinic at PT. MKPI
2. Grace Klinik at Nagoya
3. Grace Klinik at Batu Aji
4. Grace klinik at Waterfront City
5. Sagulung Memorial Clinic
6. Tiban Klinik Asih
7. Dr. Wilda Hayati Tg. Piayu
8. Dr. Hanny Bengkong
 Immunisation for children under 5-year old
 Basic immunisation for baby : BCG, DPT, Polio, Campak, Hepatitis B. The
basic immunisation mentioned above can be served only by General
Practitioner (non Specialist / non Peadetrician) at all appointed Medical
provider.
 Immunisation of HIB, MMR and Thy Pim are covered by Grace Klinik.
These services can only be served by the following appointed Medical
Provider :
1. Grace Klinik at Nagoya
2. Grace Klinik at Batu Aji
3. Grace klinik at Waterfront City

SPECIALIST OUTPATIENT HEALTH CARE

Provider Clinics and doctors are :

 Rumah Sakit Otorita Batam

 Rumah Sakit Budi Kemuliaan

Specialist OBGYN :
 Dr. Amuransyah at Grace Klinik Nagoya
 Dr. Jhonny Koesmadi at Penuin
 Dr. Adriyanti SpOG at BMC
 Dr. Juliansyah Badar, SpOG (Reimbursement system)
 Dr. Kusno, SpOG at RSHB (Fully covered or reimbursement system for 5
members listed in the ammendment

Peadetrician :
 Dr. Iman at Penuin
 Dr. Iman at Sungai Panas
 Dr. Rudi at RSBK
 Dr. Rudi (Praktek Pribadi) at Windsor
 Dr. Indrayanti at Pos Farma Batu Aji

For Specialist consultation referral letter is required except for Specialist OBGYN
and Peadetrician and emergency case.

Kind of Health Services :

 Specialist examination and medication

 Advanced Diagnostic Support tests with medically indicated
 Medication as indicated by doctor according to the standard of GRACE COMP
program
 Referral service for hospitalisation
 Surgery
MATERNITY AND DELIVERY CARE

Kind of Health Services :

 Normal Delivery
Is all covered, includes normal newborn baby and hospitalisation for maximal 2
(two) days at appointed hospital with agreeable standard of room / ward :

COMP “A” / VIP Class : VIP Class at Rumah Sakit Otorita Batam
VIP Class at Rumah Sakit Budi Kemuliaan

COMP “B” / I Class : I Class at Rumah Sakit Otorita Batam

I Class at Rumah Sakit Budi Kemuliaan

COMP “C” / II Class : II Class at Rumah Sakit Otorita Batam

IIClass at Rumah Sakit Budi Kemuliaan

COMP “D” / II OB Class : II Class at Rumah Sakit Otorita Batam

COMP “E” / III Class : II Class at Rumah Sakit Otorita Batam

IIIClass at Rumah Sakit Budi Kemuliaan

 Ante and Post natal Care

 Pathologic Delivery is any delivery that is terminated by forceps extraction,
vacuum extraction and section caesaria  all covered, includes normal
newborn baby and hospitalisation for maximal 3 (three) days at appointed
hospital with agreeable standard of room / ward :

COMP “A” / VIP Class : VIP Class at Rumah Sakit Otorita Batam
VIP Class at Rumah Sakit Budi Kemuliaan

COMP “B” / I Class : I Class at Rumah Sakit Otorita Batam

I Class at Rumah Sakit Budi Kemuliaan

COMP “C” / II Class : II Class at Rumah Sakit Otorita Batam

IIClass at Rumah Sakit Budi Kemuliaan

COMP “D” / II OB Class : II Class at Rumah Sakit Otorita Batam

COMP “E” / III Class : II Class at Rumah Sakit Otorita Batam

IIIClass at Rumah Sakit Budi Kemuliaan
Note :
 For the pregnancy period members are entitled being consulted by Specialist
OBGYN for maximum 8 (eight) times visit
 Special for the pregnancy will be given vitamin in the third month pregnancy
period until newborn baby
 Any medical service which has the connection with pregnancy is only given to
the member who has been registered as MARRIED.
 Delivery at Grace Klinik will be free of charge
 Delivery covered by Grace Klinik restricted to the first, second and third child,
whereas delivery of the fourth child and onwards will not be covered.
 Delivery of twin babies borne by Grace Klinik considered as twice or more
delivery.

HOSPITALISATION and IN-PATIENT CARE, and SURGERY

Provider hospital are :

COMP “A” / VIP Class : VIP Class at Rumah Sakit Otorita Batam
VIP Class at Rumah Sakit Budi Kemuliaan

COMP “B” / I Class : I Class at Rumah Sakit Otorita Batam

I Class at Rumah Sakit Budi Kemuliaan

COMP “C” / II Class : II Class at Rumah Sakit Otorita Batam

IIClass at Rumah Sakit Budi Kemuliaan

COMP “D” / II OB Class : II Class at Rumah Sakit Otorita Batam

COMP “E” / III Class : II Class at Rumah Sakit Otorita Batam

IIIClass at Rumah Sakit Budi Kemuliaan

Kind of Health Services :

 Bed (Room / Ward), but not personal laundry, meals provided by hospital
 Patient visite by Specialist, at least once a day
 Medication as indicated by the doctor according to the standard of GRACE
COMP program
 Special medical care such as health cathetherisation, vena section, etc
 Advanced diagnostic support tests as indicted by Specialist

Hospitalisation Procedure :

 Hospitalisation room / ward class is due to the agreeable level of health

package
 The maximum length of hospitalisation includes medication; diagnostic support
test and medical utilities; is 40 days, includes admitted in ICU / ICCU for each
kind of disease in the period of 1 (one) year
 Class Transfer for In-Patient:
1. The members will be transferred into a higher level of In-Patient Class in
case of the appointed ward / room (in accordance to each COMP package)
is fully occupied, and would then be transferred back to such appointed In-
Patient Class according to each of the COMP Package, if the ward / room
is available.

2. In case of the appointed hospital is fully occupied, Grace Klinik will arrange
/ referral to other hospital of the same standard / rate for In-Patient /
hospitalisation, with the condition : if such appointed hospital is available
then the patient will be transferred back according to the In-Patient class
that have been agreed.

SURGERY
Surgery is all covered as far as it is indicated by doctor, unless for the kind of
uncovered diseases

Uncoverd surgery :
Surgery which is caused by the Uncovered Diseases / Uncovered Medical
Services

DIAGNOSTIC SUPPORT

Provider Clinics are :

 Grace klinik
 Rumah Sakit Otorita Batam
 Rumah Sakit Budi Kemuliaan

Kind of health Services :

 Laboratory examination
 Radiology
 Pathology anatomy examination
 Parapsychology
 Other diagnostic support, such as : ECG, EEG, CT Scanning, Endoscopes,
Eco Cardiograph and USG

EMERGENCY CARE

Definition :
 Emergency case means that the patient has to being treated immediately by
doctors / nurses, otherwise it will causes fatalism to such patient.
 In the case of emergency, member is entitled to be served by any medical unit
and must inform to GRACE KLINIK within 24 hours. Further health care
services / medication will be arranged by family doctors at Grace Klinik
 Grace klinik covered ambulance fee for any amergency case
Criteria of emergency are stated below :
 Severe bleeding
 High fever (over 39 degrees Celsius)
 Diarrhoea vomiting and dehydration
 Severe Asthma attack
 Stroke
 Sick or defect resulted by accident or beating
 Heart attack
 Cramps
 Unconsciousness including; Epilepsy
 Renal colic and Abdominal colic

Provider Clinics are :

Any Emergency Unit  reimbursement system

Kind of Health Services :

 GP examination and medication
 Minor surgery as indicated by doctor
 Hospitalisation
 Special care

MEDICATION and MEDICAL UTILITIES

Provider clinic are :

 Appointed Primary Outpatient Health Care
 Appointed Specialist Outpatient Health Care Hospital, prescription taken at the
appointed dispensary
 Appointed hospital
 Appointed dispensary / Pharmacy :
 Budi Farma at Nagoya
 Kimia Farma at Sekupang
 Kimia Farma at Batu Aji
 Kimia Farma at Raden Patah
 Apotik Bengkong
 Mitra Fatma
 Vitka Farma

B. PARTLY COVERED HEALTH CARE / REHABILITATION SERVICES

Kind of Health Services :

 Spectacles / glasses
 Dental Prohtese
 Hearing aid accessory
Spectacles / glasses (Frame & Lenses)
The maximum amount paid by Grace Klinik is :

COMP “A” / VIP Class : Rp. 250.000,- / case / year

COMP “B” / I Class : Rp. 200.000,- / case / year

COMP “C” / II Class : Rp. 150.000,- / case / year

COMP “D” / II OB Class : Rp. 125.000,- / case / year

COMP “E” / III Class : Rp. 100.000,- / case / year

Note :
1. For the member who is wearing glasses (ever) at the moment, can be claim for
the charges of frame & lenses after 6 (six) months being GRACE COMP
member, whereas for the lense itself can be claim anytime as at medically
indicated.
2. For the member who is not wearing glasses (never) at the moment, can be
claim for the charges of frame & lenses anytime as at medically indicated.

 Dental Prothese
The maximum amount paid by Grace Klinik is :

COMP “A” / VIP Class : Rp. 250.000,- / year (for all teeth)

COMP “B” / I Class : Rp. 200.000,- / year (for all teeth)

COMP “C” / II Class : Rp. 150.000,- / year (for all teeth)

COMP “D” / II OB Class : Rp. 125.000,- / year (for all teeth)

COMP “E” / III Class : Rp. 100.000,- / year (for all teeth)

 Hearing aid accessory

The maximum amount paid by Grace Klinik is :

COMP “A” / VIP Class : Rp. 250.000,- / case / year

COMP “B” / I Class : Rp. 200.000,- / case / year

COMP “C” / II Class : Rp. 150.000,- / case / year

COMP “D” / II OB Class : Rp. 125.000,- / case / year

COMP “E” / III Class : Rp. 100.000,- / case / year

Compentiation for the diseases which are not covered by GRACE KLINIK

 Treatment for Cancer

The maximum amount paid by Grace Klinik for the reimbursement of treatment for
Cancer / operation is:
COMP “A” / VIP Class : Rp. 2.500.000,- / case / year

COMP “B” / I Class : Rp. 2.000.000,- / case / year

COMP “C” / II Class : Rp. 1.500.000,- / case / year

COMP “D” / II OB Class : Rp. 1.250.000,- / case / year

COMP “E” / III Class : Rp. 1.000.000,- / case / year

 Haemodialysis
The maximum amount paid by Grace Klinik for the reimbursement of Haemodialys
/ the diseases regards with is :
COMP “A” / VIP Class : Rp. 2.500.000,- / case / year

COMP “B” / I Class : Rp. 2.000.000,- / case / year

COMP “C” / II Class : Rp. 1.500.000,- / case / year

COMP “D” / II OB Class : Rp. 1.250.000,- / case / year

COMP “E” / III Class : Rp. 1.000.000,- / case / year

 Heart attack
The maximum amount paid by Grace Klinik for the reimbursement of Heart
Attack / operation is :
COMP “A” / VIP Class : Rp. 2.500.000,- / case / year

COMP “B” / I Class : Rp. 2.000.000,- / case / year

COMP “C” / II Class : Rp. 1.500.000,- / case / year

COMP “D” / II OB Class : Rp. 1.250.000,- / case / year

COMP “E” / III Class : Rp. 1.000.000,- / case / year

C. IN HOUSE CLINIC

In-House Clinic preparation

 Doctor stand-by 8 hours per-day, 6 days a week
In morning time == 09.00 to 13.00 WIB
In afternoon time == 15.00 to 19.00 WIB
 Nurses stand-by 24-hour (3 shifts)
 Provides medicines
 Provides clinic medical equipment: Blood preasure (BP set), stethoscope
and othoscope
 Provides medical equipment: nald hecting, kidney dish, pinset, scissors,
flashlight, weighing scale and hand gloves
 Additional medical equipment: nebulizer
 Dental unit, the dental unit in the In House Clinic will not be replaced until
GRACE KLINIK is setteled to have another one which is owned by GRACE
KLINIK at the lates by the month in February 2002. In the case of rental fee
for such unit is bear by GRACE KLINIK.

D. REGULATION FOR REIMBURSEMENT

Members of GRACE COMP can submit individual claim / request for

reimbursement of the medical services by fulfil the following reason:
1. Emergency care
2. Medical services received out of Batam (in the area of Indonesia)
3. Partly covered health care services
4. Medical services received from Dr. Juliyansyah Badar
5. Member is in the list of the 5 (five) patients who are being treated by Dr. Kusno
at RSHB .If the services / delivery : normal delivery / delivery with complication
(sectio caesar, vacuum extraction or forceps extraction) is received in Batam
then amount will be fully covered, with no standardisation to the rate of RSBK,
whereas if the medical service received outside Batam then the amount will be
standardised to the rate of RSBK.

The claim must be completed by :

1. Claim Form must be submitted
2. Copy of GRACE COMP ID Card
3. Original receipt of the medical service (the amount must be specify the
details of the medical service receives)
4. Copy of prescription
5. Copy of Birth Certificate issued by the clinic / doctor midwife (if it is a Delivery
Case)

 All reimbursement will be paid by Grace Klinik after standardised the amount
according to the rate of Rumah Sakit Budi Kemuliaan according to the
package / level that has been agreed, by the latest of 14 working days if the
requirement is complete.
 Any medical services received by the member, that does not serve / available
in Budi Kemuliaan Hospital, then the amount of reimbursement will be
standardised according to the rate of Otorita Batam Hospital.
E. UNCOVERED MEDICAL SERVICES

Medical services which are not covered / guaranteed by Grace Klinik :

1. Medical services which are not proceed according to GRACE COMP GUIDE
BOOK or according to the package that have been agreed.
2. Medical services received (non emergency case) from non Grace Klinik
Provider or medical received out of Batam (except for Outpatient treatment in
appointed provider in Singapore)
3. Haemolialysis, kidney operation (haemodialysis Pheritonial dialysis / CAPD,
kidney transplantation, ESWL)
4. Fertility intervention
5. Medical Check-Up / General Check-Up
6. Organ transplants
7. Treatment or illness due to drugs or alcoholism
8. Additional tools : wheels chair, walking stick, corset
9. Personal cost during In-Patient (additional laundry, additional meals, cost of
accompanying person, telephone, television, etc)
10. Immunisation which is not in the list of covered immunisation (see last point of
the kind of services in Outpatient treatment)
11. Dental treatment other than the Dental Benefits which is due to cosmetic
purposes / without medically indication (e.g. scaling)
12. Multivitamin which is without medically indicated (Enervon C, Subex T, etc)
13. Any medical services which is not medically indicated / services that are not in
medically necessitate
14. Treatment for illness related to AIDS / HIV
15. Treatment for congenital illness
16. Diagnostic Support e.g. CTG, CT Scanning, MRI, Memography, etc (without
medically indicated)
17. Pace maker, heart operation including cardiac actheterisation
18. Treatment for the diseases Heart attack
19. Alternative treatment, such as: given by a shaman, paranormal, etc
20. Services covered by other institutions, such as : Jamsostek, Askes, Jasa
Rahardja, Inemnity Insurance, etc.
21. Disease in defect internationally done (e.g. effort to commit suicide, revolution,
war (wether declared or not), Treatment as a result of natural disaster,
Disease caused by fighting / action against law, etc)
22. Home nursing / convalescence unless approved by the provider (hospital,
Family Doctor, Clinic)
23. Treatment for Cancer
24. Disease which is due to craziness
25. Diseases caused by radiation / chemistry
26. Abortion without medically indicated
27. Medical services received out of Indonesia (except Outpatient treatment in
appointed provider in Singapore)
28. Experimental treatment, i.e. services that are not recognised by the Ministry of
Health
29. Contact lenses and its fitting
30. Disease caused by dangerous sport (e.g. Bungy jumping, scuba diving,
parasailing, etc)
31. Transportation fees from patient residential to hospital except for emergency
cases
F. MEDICAL SERVICES PROCEDURE

General Condition

 Member / patient has to bring GRACE COMP ID Card and Medical Record
Book anytime when he / she visit to any clinic / any GP Private practice / any
Dentist private practice / any Peadetrician private practice & any Gynae private
practice as mentioned in the list of doctor.

 GRACE COMP Guide Book has to be distributed to every members. Member

has to proceed the medical procedure according to the GRACE COMP Guide
Book.

 Each member / patient has his / her own GRACE COMP ID Card. The card is
given / prepared by GRACE KLINIK according to the data received from PT.
MKPI.

 Patient who does not bring GRACE COMP ID Card will not be served by the
provider as member. Any charges arised has to be paid by the patient.

 Member / patient / child who can visit direct to Peadetrician without referral is
valid for the age below 6-year old.

Outpatient Health Care

 Member / patient who visits / consult to GP at appointed clinic or other

appointed private practice will be free of charge, as far as the member / patient
proceed according to the General Condition

 Member / patient who visits / consult to Dentist at appointed clinic or other

appointed private practice will be free of charge, as far as the member / patient
proceed according to the General Condition

 Member / patient who visits / consult to Obstetrician at appointed clinic or other

appointed private practice without referral will be free of charge, as far as the
member / patient proceed according to the General Condition and related to
the pregnancy cases.

 Member / patient who visits / consult to Peadetrician at appointed clinic or

other appointed private practice will be free of charge, as far as the member /
patient proceed according to the General Condition
Specialist Outpatient Health Care

 Member / patient who visits / consult to Specialist at appointed hospital / clinic

or other appointed private practice, referral letter issued by the appointed GP /
POHC (Primary Outpatient Health Care) is required.

 Member / patient who visits / consult to Obstetrician or Peadetrician at

appointed hospital / clinic or other appointed private practice, referral letter is
not required, as far as the member / patient proceed according to the General
Condition.

Hospitalisation / Inpatient Care

 Member / patient who need to be hospitalised has to inform GRACE KLINIK in

order to assist the patient accordingly.

Delivery Care

Normal Delivery
 Normal delivery is fully covered by GRACE KLINIK due to the agreeable
standard room / ward for hospitalisation (see Hospitalisation Procedure).

 Normal delivery which is done at other clinic where the clinic is not under the
list of GRACE COMP Medical Provider, member has to settled the amount
charges in advanced and would then be reimbursed by GRACE KLINIK after
standardised the amount submitted to the rate of Rumah Sakit Budi Kemuliaan
(see Regulation for Reimbursement).

Pathologic Delivery
 Pathologic delivery is any delivery terminated by sectio Caesar surgery,
forceps, extraction or vacuum extraction.

 Patient will be hospitalised. In this case member / patient must ask for a
Guarantee letter issued by GRACE KLINIK for the administration of
hospitalisation.

Emergency Care

 Patient can be served at any medical unit / clinic with the condition of payment
settled in advanced and GRACE KLINIK will reimbursed the amount after
standardised according to the rate of Rumah Sakit Budi Kemuliaan. The case
must be includes in the list of the Emergency Criteria (see Emergency
Criteria).
Diagnostic Support Tests

 Patient who needs diagnostic support test will be done by GRACE KLINIK or
sent to appointed hospital with the referral letter issued by the GP at appointed
POHC (Primary Outpatient Health Care) provider (see List of the Specialist
who can issue referral letter).

G. CLOSING

Every member is assumed that he / she known and understood this agreement of
GRACE COMP Health Service Package, thereby any violation due to unknown of
this agreement is unacceptable.

SECOND PARTY FIRST PARTY

KOICHIRO OTA Dr. FLORENCE WATI

Finance and Admnistration Director Director