GROUP HEALTHCARE AND LIFE INSURANCE

PT NOKIA SOLUTIONS AND

NETWORKS INDONESIA
(Policy No. 2011100103)
Period : 1 January 2019 – 31 December 2019
HEALTHCARE
01
INSURANCE PROGRAM
Policy Period : 1 January 2019 to 31 December 2019

Eligibility :
- ACTIVE EMPLOYEE
- Entry Age : 16 – 60 years old
- Renewal : Up to 65 years old

- DEPENDENTS
- Spouse : 16 – 60 years old
- Children : 0 days up to 23 years old*
*Student, unmarried, unemployed
HOSPITAL & SURGICAL BENEFITS
Hospitalization (100% Provider / Reimbursement) Plan
Room & Board per day 900,000
Intensive Care Unit (ICU), per day
Private Nurse, per day
In Hospital Physician’s Visits, per day
Pre-Hospital & In-Hospital Specialist Consultation, per confinement
Miscellaneous Hospital Supplies, per confinement
Ambulance Service, per confinement
As Charged
Surgery, per operation
Anesthesia, per operation
Operating Theatre, per operation
Emergency Outpatient treatment, per year
Emergency Dental treatment, per year
Post – Hospital Specialist Consultations, per confinement

OVERALL ANNUAL LIMIT, per policy year 180,000,000

Term Life Benefit (Employee & Dependants) 7,200,000
HOSPITAL & SURGICAL BENEFITS
SPECIAL CONDITIONS :
1. Room Tolerance :
✓ No vacancy according to the entitled room :
Upgrade 1 class above the entitled room, max. 2 days
✓ The hospital does not have room rate as the entitled room :
Upgrade max. Rp. 975.000,- , unlimited days
✓ Own request : Will be covered by prorated calculation, see the provided prorated
calculation examples on page 9-11. Any excess claims would need to be settled
directly to the hospital at time of discharge, by the respective employee.
2. No waiting period (pre existing conditions is waived)
3. No restoration period for the same illness

4. No pro-rata benefit for new participant

5. Cover pregnancy complication, as long as hospitalized in hospital and the

pregnancy can still be maintained when she check out from hospital
 HOSPITAL & SURGICAL BENEFITS
SPECIAL CONDITIONS :

6. Pre-Hospital and In-hospital Specialist Consultations, 31 days before hospitalization.

7. Post-Hospital Specialist Consultations, per confinement, 90 days after hospitalization.

8. Hospitalization must take place for minimum 6 hours as a registered patient

9. Pre & Post Hospitalization, Emergency Outpatient and Emergency Dental Benefit will be
covered by reimbursement systems. Cashless system will use Outpatient limit

10.Bed-paying patient in a Hospital and not in a Clinic or Maternity Hospital (except for
female and children)

11.All surgery must be performed in hospital otherwise it not covered.

12.Cover wisdom teeth surgery as long as performed in hospital Should the surgery
performed in clinic, the claim will be posted in Outpatient limit.

13.Cover congenital condition, mental disorder and psychosomatic

HOSPITAL & SURGICAL BENEFITS

EXCLUSION :
1. Injuries arising directly or indirectly from war, declared or undeclared.
2. Treatments or services which are not consistent with the diagnosis, or not
medically necessary, or not medically customary, or not in accordance with
good medical practice standards.
3. Cosmetic surgery treatment and/or medication relating to cosmetic such as
plastic surgery except for reconstructive plastic surgery due to accident carried
out within 30 ( thirty ) days as of the accident.
4. Routine physical examinations and health check ups.
5. Communicable diseases requiring isolation or quarantine under the law.
6. Eye refraction, fitting of glasses, contact lenses or hearing aids, gingivitis, any
dental or oral care, treatment or surgery of any nature what so ever except
procedure necessitated by damage to sound natural teeth as a result of an
accidental injury occurring during the period of insurance
HOSPITAL & SURGICAL BENEFITS

EXCLUSION :
7. Injuries due to insanity or self-infliction; conditions related to functional
disorders of the mind; rest cure or sanitary care (e.g. neurasthenia, anxiety
state, anemia ) ; treatment of an optimal nature (e.g. anorexia, indigestion or
dyspepsia, constipation, acne ); drug addiction or alcoholism.
8. Treatment relating to birth control, sterilization of either sex, treatments
pertaining to infertility.
9. All costs arising as a consequence of the donation of body organs and/or blood
by the insured member, but if the insured member is the recipient of a donated
body organ and/or blood, the cost paid will be the hospitalization and surgical
benefits in accordance with the maximum limit received by the insured member,
but not including the cost for obtaining the body organs and /or the total pre
examination cost
HOSPITAL & SURGICAL BENEFITS
ROOM TOLERANCE ILLUSTRATION :

CASE 1 = NO VACANCY ACCORDING TO THE ENTITLED ROOM :

Upgrade 1 class above the entitled room, max. 2 days
HOSPITAL & SURGICAL BENEFITS
ROOM TOLERANCE ILLUSTRATION :

CASE 2 = THE HOSPITAL DOES NOT HAVE ROOM RATE AS THE ENTITLED ROOM :
Upgrade max. Rp. 975.000,- , unlimited days
HOSPITAL & SURGICAL BENEFITS
ROOM TOLERANCE ILLUSTRATION :
CASE 3 = OWN REQUEST : Will be covered by prorated calculation from 1st day
MATERNITY BENEFITS
Hospitalization (100% Provider / Reimbursement) Plan
Normal Delivery (Physician), per pregnancy 15,000,000
Normal Delivery (Midwife), per pregnancy 15,000,000
Caesarian Section, per pregnancy 25,000,000
Abortion, per pregnancy 10,000,000
Pre & Post Natal, per policy year 5,000,000

•Pre Natal covered since the doctor announce positive pregnancy & post natal
covered up to 40 days after delivery
•If the patient has reach maximum limit pre & post natal under Maternity Benefit, the
medical bill can be covered in Outpatient Benefit as long as the limit in Outpatient
Benefit still available (Applied with reimbursement system)
 OUTPATIENT, GLASSES & DENTAL BENEFITS
Benefits (100% Provider / Reimbursement) Plan

Outpatient Physician’s Visit

Outpatient Specialist Consultation
Outpatient Diagnostic & Lab Test
Outpatient Physiotherapy Services
Outpatient Prescription Drugs, include : AS CHARGED
-Immunization
-Family Planning

Routine Medical Check Up for Adults

Pre & Post Natal Care (top up limit from Pre & Post Natal in Maternity Benefit)
Optical :
- Employee, per policy year 3,000,000
- Dependent, per policy year 1,500,000
 OUTPATIENT, GLASSES & DENTAL BENEFITS
Benefits (100% Provider / Reimbursement) Plan

Dental Basic Treatment

Dental Preventive Treatment
Dental Rehabilitative Treatment
AS CHARGED
Dental Complex Treatment
Gum Treatment
Prosthetic Treatment
Reimbursement Percentage :
-Employee 100%
- Dependant 80%
OVERALL LIMIT PER FAMILY, PER POLICY YEAR IDR 10,000,000 or 1xMonthly
Salary (whichever higher)
OUTPATIENT, GLASSES & DENTAL BENEFITS
SPECIAL CONDITIONS :
1. Outpatient Specialist Consultation :
• Without referral letter from General Practitioner
2. Outpatient Diagnostic / Lab Services :
• Without referral letter from Doctor
• No need to submit copy of test result
3. Outpatient Physiotherapy Treatment :
• Without referral letter from Doctor
4. Outpatient Prescription Drug :
• Covered vitamin & food supplement as long as recommended by doctor
• Medicine must be bought in Pharmacy (both for medicine with doctor’s
prescription or OTC (Over The Counter)
• All kind of immunization for children & adult
5. Routine Medical Check Up :
• Covered without doctor referral
• Only for adult (employee & spouse)
• Children are not covered
OUTPATIENT, GLASSES & DENTAL BENEFITS
SPECIAL CONDITIONS :
7. Pre & Post Natal Care :
• Top up limit from Pre & Post Natal in Maternity Benefit
• Should be on reimbursement basis to avoid wrong cost / benefit posting
8. Glasses :
• Cashless / reimbursement system
• Could use refraction size from the optic
• For all member with specific limit
• Contact lenses (with refraction size) is covered
• No need to provide breakdown on frame & lens
• Sunglasses is not covered

9. Dental Treatment should be performed in Dentist

10. Hormonal treatment could be covered as long as not related with anti aging &
cosmetic treatment
OUTPATIENT, GLASSES & DENTAL BENEFITS

EXCLUSION :
1. Vitamin and food supplement without doctor prescription.

2. AIDS, sexual infectious diseases, drug addiction therapy, eye Lasik, milk,
medical diagnostics equipments (blood test equipment, tensi meter,
nebulizer, etc), other non health reason treatment.

3. Anti aging treatment such as hormone treatment, plastic surgery, hair

dyeing, hair loss prevention, etc.

4. Chiropractic, hypnotherapy, autism, orthodontist related to aesthetic.

5. Treatment containing cosmetic nature in order to beautify the body such

as skin improvement, braces, etc.

6. Alternative/traditional treatments.
OUTPATIENT, GLASSES & DENTAL BENEFITS

EXCLUSION :
7. Therapy Bekam, Holistic. Acupuncture should be performed by doctor.
8. Treatment of disease caused by the employee himself/his family such as
suicide attempt, crimes/violations, participation in dangerous sports,
carelessness in work accident prevention, abortion without physician’s
recommendation.
9. Treatment in traditional orthopedist, midwife without official registration
number from the Ministry of Health, or other alternative treatments.
10. Treatment for weight loss or obesity/weight gain treatment.
11. If the medical practitioner is a main family member and or parent/parent in
law of the related employee.
Claims Procedure
FLOW OF INPATIENT and MATERNITY PROCESS (ON-LINE)
(ADMISSION, VERIFICATION & INITIAL GUARANTEE)
Member showing :

AdMedika
Card Member go to hospital
to get hospitalized

5 Member get hospitalization

Member should sign letter of guarantee

4 Printed from EDC terminal.

BAGIAN PENDAFTARAN
RAWAT INAP

Swipe ADMEDIKA card to EDC Terminal and

2 input the diagnose terminal code
Letter of Guarantee / Rejection Letter will
3 Printed from EDC terminal as the eligible ADMEDIKA DATA
benefit (within 30 seconds) CENTER
Member data will be sent through
phone line to
 VALIDATION PROCESS
(BEFORE CHECK OUT)
4 Patient check Out after pay the excess charges

BAGIANPEMBAYARAN
(KASIR)
BAGIAN JAMINAN
RAWAT INAP

Before check out from the hospital, Cashier

should fax detail of invoice and The hospital will receive Inpatient
medical resume to AIA/Admedika 3 Validation Letter from AIA/Admedika
by fax

BAGIAN OPERASI
ADMEDIKA

AIA will verify final diagnose and invoice

2 within 30 minutes
 FLOW OF OUTPATIENT PROCESS (ON-LINE)
(ADMISSION & VERIFICATION)
Member showed

Medical Card
Member go to
Provider Clinic /
Hospital
1

Doing doctor’s consultation

4

Outpatient Admission

2 Swipe the card to

EDC Terminal
LoA will be printed from EDC Terminal
3 within 30 second

Deliver the member data by online ADMEDIKA DATA

system through phone line to CENTER
Admedika
 VALIDATION PROCESS

Validation process (by signing the LoA)

4

CASHIER

2
ADMEDIKA card swiped to EDC
Terminal & input : Approved LoA and Excess Claim Amount
1) Diagnose Code will be printed from EDC Terminal within 30
2) Detail Amount second
3
3) Amount of Absent Day

DATA LINK
DATA CENTRE
All data will be delivered by online
system (through phone line)
 Reimbursement Procedure

Reported on EOB by e-
mail (Payment Direct
to Employee Account
within 14 working days
after complete
document received )
 Reimbursement Inpatient and Maternity Document
❖ Claim Form
▪ Page 1 : Signed by employee
▪ Page 2 : Filled and signed by doctor, completed with medical diagnose + hospital
stamp.
▪ Page 2 could be substituted by medical resume
Note : Diagnose must be filled by the doctor
❖ Attach the original hospital receipt
▪ Completed with billing detail.
▪ The original receipt of the charges for the treatment with stamp IDR 6.000,-
(Indonesian Tax Regulation)
❖ Copy of the laboratory test report, diagnosis test report, Rontgen, X-ray and other
reports relating to the treatment as recommended by the registered medical
Practitioner.
❖ Copy of medicines and medical equipments as recommended by the registered
medical practitioner.
❖ Reference letter from the registered medical practitioner or specialist for
hospitalization, laboratory and diagnose examinations and or physiotherapy.
 Reimbursement Inpatient and Maternity Document

❖ For emergency outpatient claim, member should provide a chronology of the

accident, complete with date, time and detail of the accident

❖ For pre and post inpatient, member should give an information that the claim
is a pre & post inpatient consultation (also complete with date of hospitalized
and hospital name). Pre & post inpatient claim could be process after the
inpatient claim received from hospital, therefore the TAT for claim might be
more than 14 working days.

The Policy Holder have to submit claim documents within 90 (ninety) days
after the receipt date.
 Reimbursement Outpatient Document

❖ Claim Form
▪ Part 1 : Signed by employee
▪ Part 2 : Filled and signed by doctor, completed with medical diagnose + hospital
stamp.
▪ Part 2 could be substituted by diagnose in receipt
Note : Diagnose must be filled by the doctor
❖ Original Doctor’s fee Receipt
▪ The original receipt of the charges for the treatment with stamp IDR 6.000,-
(Indonesian Tax Regulation) for transaction above Rp. 1.000.000,- or deducted Rp.
6000,- from the claim if does not completed with stamp.
❖ Original Medicine & Laboratory Receipt
❖ Copy of medicines as recommended by the registered medical practitioner.
 Important Notes

When using the cashless system / Provider :

• All the excess claim occurred is to be paid on the spot (when discharge)

• There is still possibility of additional excess charge later, which will be

charged to member through the Company
EXCESS CLAIM

WHY THERE ARE ANY EXCESS CLAIM?

1. If member is using R&B higher than the entitlement

2. If the medical treatment expenses is higher than the benefit
maximum limit
3. If the diagnose / treatment is included in Policy Exclusion
4. No medical indication
5. Non medis, such as TV rental, pampers, newspaper
Example of Claims
Document
INPATIENT AND MATERNITY CLAIM FORM
OUTPATIENT & DENTAL CLAIM FORM
 Medical Resume and Laboratory Result

Resume Medis Rawat Inap Hasil Laboratorium

Inpatient Receipt
Inpatient Billing Detail
 Outpatient – Receipt
Patient Name

Stamp & Doctor’s

Signature
Medical Diagnose is Mandatory
 Outpatient – Pharmacy Receipt
Patient Name
Clear
Name &
Address
of the
Pharmacy
Pharmacy Stamp

Copy of Recipe
GROUP TERM LIFE
02
INSURANCE PROGRAM
Policy Period : 1 January 2019 to 31 December 2019

1. Group Term Life

2. Total Permanent Disability
3. Personal Accident
GROUP TERM LIFE

What does Group Term Life Insurance cover?

Death due to any cause.
Who is eligible?
Permanent employee (17 to 64 / 65 years old for renewal)

• Maximum benefit at 24 x monthly base salary

• It offers 24-hour protection regardless of geographical location
(worldwide coverage), during or after working hours.
• Any employee whose sum assured exceeds free cover limit
(FCL) will be required to undergo further Medical Examination
• FCL = IDR1,500,000,000
TOTAL PERMANENT DISABILITY

What does Total Permanent Disability cover?

Disability resulting from accident or sickness or both, that after a waiting
period of 6 (six) consecutive months, and upon being certified by a
registered medical practitioner, renders the member unlikely ever to
resume working or engaging in any occupation.
Who is eligible?
Permanent employee (17 to 64 / 65 years old for renewal)

• Maximum benefit at 24 x monthly base salary

• It offers 24-hour protection regardless of geographical location
(worldwide coverage), during or after working hours.
• Lumpsum payment after 6 month waiting period
TOTAL PERMANENT DISABILITY

Exclusion :
1. Member preparing himself for or participate in a race or
competition and other, using a motor vehicle, bicycle, boat,
horse, aircraft or the like, parachuting, mountain climbing, water
skiing, ice skiing, or other winter sports not mentioned herein,
professional: football (soccer), boxing, karate, judo, or other
branches or self-defense alike.
2. Self injury on the part of the Member’s; or
3. The Member’s being in military service during a period of war,
either declared or undeclared; or
4. The Member’s being under orders from the government to
restore public order ; or
5. Handling the reaction of nucleus of an atom and nuclear; or
6. The Member as the passenger of aircraft, except as the
passenger of aircraft having permanent flight schedule.
ACCIDENTAL DEATH & DISMEMBERMENT

What does Accidental Death & Dismemberment cover?

Death or disability as a result of an accident.
Who is eligible?
Permanent employee (17 to 59 / 60 years old for renewal)

• Accident is events that occur suddenly in the insurance, unexpected,

coming from outside, is violence, not desired and there is no intentional
elements, which is a direct and major cause of injury or body injury
• Maximum benefit at 24 x Basic Monthly Salary
• It offers 24-hour protection regardless of geographical location
(worldwide coverage), during or after working hours
ACCIDENTAL DEATH & DISMEMBERMENT
PERCENTAGE TABLE ON THE LOST OF FUNCTION FROM :
•Total permanent disability of both hands or both feet or both eyes, or one hand and one foot, or one hand and one 100%
eye, or one foot and one eye
• Permanent disability partly:

• Right hand from shoulder 75%

• Left hand from shoulder 56%
• Right hand from the knee 65%
• Left hand from the knee 52%
• Right hand from the wrist 60%
• Left hand from the wrist 50%
• One foot..... 50%
• One eye 50%
• Two ears 50%
• One ears 15%
• Right thumb 25%
• Left thumb 20%
• Right pointer 15%
• Left pointer 12%
• Right little finger. 12%
• Left little finger 7%
• Middle finger or right ring finger 10%
• Middle finger or left ring finger 8%
• One foot finger 5%
ACCIDENTAL DEATH & DISMEMBERMENT
Exclusion :

1. War and the laws of war (whether declared or not), invasion of

another country, the military operations which are hostile or
resembling a war (whether declared or not), acts of terrorism but
as victims who are not directly involved in these circumstances,
civil war, insurrection, civil commotion or riots as part of or which
is the resurrection/resistance to the government in general, the
resistance/insurgency military, social revolution except as a
victim who was not directly involved in such circumstances; or
2. Participation in aviation other than as a commercial passenger
aircraft that has a business license from the aviation authorities
and institutions that have a fixed flight schedules and regular; or
3. The involvement of participants in the use of drugs, narcotics,
psychotropic or illicit drugs, and/or under the influence of drink; or
ACCIDENTAL DEATH & DISMEMBERMENT
Exclusion :

4. The involvement of participants in conducting, or participating in

a criminal act or violation of both the crime or the like; or
5. The involvement of participants in sporting activities such as
sports martial dangerous, parachuting, diving, hiking, rock
climbing (both rock and the cliff is made), white water rafting,
bungee jumping or base, match the speed of the vehicle
(whether motorized or not), cycling , horseback riding, boating
(both with the screen or not), aircraft, flying kites and/or other
aerospace sports; or
6. Natural disaster or a reaction to the atomic nucleus / nuclear; or
7. Disorders/mental retardation and/or psychological Participants
suffered; or
8. Participants efforts to hurt themselves on purpose, or tried to
commit suicide or other acts that way whether committed in a
state of insanity or not.
CONTACT US
 Admedika 24 Hour Call Center
Hotline 021 1-500-811 (all insurance)
AIA Financial 021 1-500-433 (AIA Financial only)

 Customer Service - AIA Financial

AIA Central
Jl. Jend. Sudirman Kav. 48A, Jakarta

24 Hour Hotline : 1-500-980

E-mail : id.nsn@aia.com
Fax : 021 57957434
OUR SERVICES
E-BENEFITS (www.aia-financial.co.id)
MOBILE APPS (Android / iPhone)
Thank you.