Medical Insurance Claim Form

Medical Insurance Claim Form Template for Indonesia

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Key Requirements PROMPT example:

"I need a Medical Insurance Claim Form in Bahasa Indonesia and English for our new hospital chain that handles both local and international patients, with sections for direct billing and reimbursement options, compliant with 2025 OJK regulations."

Document background

The Medical Insurance Claim Form is a crucial document used in the Indonesian insurance sector for processing healthcare-related insurance claims. It serves as the primary mechanism for policyholders to request reimbursement or direct payment for medical expenses covered under their insurance policies. The form must comply with Indonesian regulations, particularly Law No. 40 of 2014 on Insurance and OJK Regulation No. 69/POJK.05/2016, which govern insurance operations and claim procedures. This document is typically used following medical treatment or hospitalization and requires detailed information about the treatment received, associated costs, and healthcare provider verification. It includes provisions for both routine medical claims and specialized situations such as overseas treatment or emergency care, ensuring comprehensive coverage of various claim scenarios while maintaining regulatory compliance.

Suggested Sections

1. 1. Policyholder Information: Basic details of the insurance policy holder including policy number, name, ID number, contact information

2. 2. Patient Information: Details of the patient receiving treatment (if different from policyholder), including relationship to policyholder

3. 3. Medical Treatment Details: Information about the medical condition, treatment dates, healthcare provider details, and diagnosis

4. 4. Claim Details: Breakdown of expenses being claimed, including treatment costs, medication, and other related expenses

5. 5. Payment Information: Preferred payment method and bank account details for claim reimbursement

6. 6. Declaration and Authorization: Legal declaration of truth and authorization for insurers to access medical records

7. 7. Healthcare Provider Confirmation: Section for healthcare provider's signature, stamp, and confirmation of treatment provided

Optional Sections

1. Accident Details: Additional section required when claim is related to an accident, including date, location, and circumstances

2. Third Party Insurance Information: Required when another insurance policy may cover part of the claim

3. Overseas Treatment Declaration: Required for claims involving medical treatment received outside Indonesia

4. Chronic Condition History: Additional information required for claims related to ongoing or chronic conditions

5. Emergency Treatment Justification: Required when claiming for emergency treatment outside network hospitals

Suggested Schedules

1. Medical Bills and Receipts Checklist: Itemized list of all submitted medical bills and receipts

2. Supporting Documents List: Checklist of required supporting documents such as medical reports, prescriptions, and referral letters

3. Medical Report Form: Standardized form for detailed medical report to be filled by attending physician

4. Claim Processing Timeline: Information about expected processing times and claim status tracking

5. Network Hospital List: Reference list of network hospitals and clinics for direct billing arrangements

Authors

Alex Denne

Head of Growth (Open Source Law) @ tiktok��˰� | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

alex.den.21@genieai.co

Relevant legal definitions

Clauses

Relevant Industries

Insurance

Healthcare

Medical Services

Hospital Administration

Financial Services

Healthcare Technology

Regulatory Compliance

Risk Management

Relevant Teams

Claims Processing

Medical Assessment

Customer Support

Compliance

Risk Management

Healthcare Relations

Policy Administration

Operations

Document Management

Quality Assurance

Relevant Roles

Insurance Claims Manager

Medical Claims Assessor

Healthcare Administrator

Insurance Underwriter

Compliance Officer

Risk Manager

Medical Director

Insurance Operations Manager

Claims Processing Officer

Healthcare Relations Manager

Policy Administration Officer

Customer Service Representative

Medical Records Officer

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Authors

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