A problem with a healthcare insurance company

[jstar]

The court rejected that particular argument when finding against the insurance company.

I wonder what an Indonesian court would rule when a Bule challenges a contract (s)he signed which states the polis was read, understood and all information provided benar adanya?

 

[fastpitch17]

I wonder what an Indonesian court would rule when a Bule challenges a contract (s)he signed which states the polis was read, understood and all information provided benar adanya?

Let's just say that by the time you got into a courtroom you would have paid out twice the amount you wanted refunded or what a denied procedure would have cost and then find out you lose. Even the Hotman would probably stay away from this unless of course he counts the rupiah win or lose.

 

[Samoerai]

I wonder what an Indonesian court would rule when a Bule challenges a contract (s)he signed which states the polis was read, understood and all information provided benar adanya?

Well, there are 2 parts I had to sign. One being the formulir with the questionnaire and one being the formulir where Prudential asks if I understand the projections of the growth of the unit/fund. That second formulir has the 'small prints' with

Jika ditemukan kondisi yang telah ada sebelumnya (pre-existing condition) yang tidak diberitahukan oleh Pemegang Polis atau Tertanggung sesuai ketentuan Polis Asuransi Dasar atau Asuransi Tambahan (jika ada). Pre-existing condition adalah kondisi di mana segala jenis penyakit, cedera atau ketidakmampuan yang tanda atau gejalanya diketahui atau tidak diketahui oleh Pemegang Polis atau Tertanggung, baik telah ataupun belum didiagnosis oleh Dokter, baik telah ataupun belum mendapatkan perawatan/pengobatan/saran/konsultasi dari Dokter, terlepas dari pengobatan sebenarnya telah ataupun belum dilakukan, yang terjadi sebelum Tanggal Mulai Pertanggungan, atau tanggal Pemulihan Polis yang terakhir, tergantung pada ..

In my opinion these small prints are stated in the wrong place on the wrong form.

 

[SamR]

3. The agent didn't ask me this during the application when he visit me.

You've discussed the steps that you've taken to appeal the decision but what I'm curious is what has been this agent's role since the problem started with the insurance company? Has he helped or has he just disappeared?

I've had longtime friends who have become Pru agents and tried to sell insurance to me. It's always unsettling for me that they are always trying to speed things along and that when I ask to read any piece of information (contracts, policies, etc.) in detail so that I'm aware of what I'm signing up to and ask further questions, they become uncomfortable and their manner suggests that they're worried I might not end up signing if given the details. I can only attribute this to them merely chasing the sale and their commission but forgetting completely about the service they're suppose to provide.

My insurance agent happens to be an extended family member so not only did I feel more comfortable disclosing various health information, they also feel a bit tidak enak to speed things along and refuse when I ask to read contracts or whatever I have to sign in detail.

 

[Samoerai]

what I'm curious is what has been this agent's role since the problem started with the insurance company? Has he helped or has he just disappeared?

He did file an appeal a couple of days ago, but I didn't read the appeal. As I understand he asked also for a medical test to prove that I am healthy. Who is going to pay for the test, I asked him? He doesn't know. Prudential sent me a message that it takes 5 working days to give an answer. So I am waiting for that.

The rol of the agent is the application proces?
Yes, looking back ... his mistake was: he didn't ask me if I have pre-existing conditions and explain what this means. He should have asked me, even there is no standard question in the questionnaire about this.
It's a big mistake in my opinion, because this has a huge impact. And I am probably not the first customer in this situation.

Anyway ... this thread might also be information/warnings to others (e.g. newbies) who want to apply for health insurances.

 

[jstar]

Well, there are 2 parts I had to sign. One being the formulir with the questionnaire and one being the formulir where Prudential asks if I understand the projections of the growth of the unit/fund. That second formulir has the 'small prints' with

Jika ditemukan kondisi yang telah ada sebelumnya (pre-existing condition) yang tidak diberitahukan oleh Pemegang Polis atau Tertanggung sesuai ketentuan Polis Asuransi Dasar atau Asuransi Tambahan (jika ada). Pre-existing condition adalah kondisi di mana segala jenis penyakit, cedera atau ketidakmampuan yang tanda atau gejalanya diketahui atau tidak diketahui oleh Pemegang Polis atau Tertanggung, baik telah ataupun belum didiagnosis oleh Dokter, baik telah ataupun belum mendapatkan perawatan/pengobatan/saran/konsultasi dari Dokter, terlepas dari pengobatan sebenarnya telah ataupun belum dilakukan, yang terjadi sebelum Tanggal Mulai Pertanggungan, atau tanggal Pemulihan Polis yang terakhir, tergantung pada ..

In my opinion these small prints are stated in the wrong place on the wrong form.

With this wording….

If a pre-existing condition is found that has not been notified by the Policy Holder or the Insured in accordance with the provisions of the Basic Insurance Policy or Additional Insurance (if any). Pre-existing condition is a condition where all kinds of illness, injury or disability whose signs or symptoms are known or not known by the Policyholder or the Insured, whether or not they have been diagnosed by a Doctor, whether or not they have received treatment/medication/advice/consultation from Doctor, regardless of whether the actual treatment has been carried out or not, which occurred before the Coverage Start Date, or the last Policy Recovery date, depending on..

….obviously they never have to cover and pay for any disease which is not completely ‘new’ and has been present in the body in one form or another. Can you imagine having an auto-immune defect or so? Think of those from lupus, rheumatoid arthritis etc. Or anemia. They can always make the case this was present long before the contract started. And not coincidently these illnesses are very expensive to treat.

.

 

[kripik-pisang]

Are you sure that you really need insurance? If you can pay that kind of premium then you can probably pay for pretty much any medical treatment that you might need.

Remember your premium pays for a success bonus for the agent (not insignificant), the chairman's bonus, and company profit. Between them they may take up 75% or more of your premium. Why hand them all that money when you could create your own insurance by putting the money in a high interest account.

 

[Jaime C]

I have BPJS insurance plan, so I’ll be fine, right?

 

[Dave70]

I have BPJS insurance plan, so I’ll be fine, right?

AFAIK, BPJS doesn't cover treatment for injuries sustained in road accidents and by victims of rape (among other things).

BTW, I remember you posted somewhere that your mother-in-law was operated for cataract using BPJS. Did she get a Lens Implant ID card?

 

[Samoerai]

Are you sure that you really need insurance? If you can pay that kind of premium then you can probably pay for pretty much any medical treatment that you might need.

Remember your premium pays for a success bonus for the agent (not insignificant), the chairman's bonus, and company profit. Between them they may take up 75% or more of your premium. Why hand them all that money when you could create your own insurance by putting the money in a high interest account.

Yes, that's what I am going to do .. now that I had this bad experience with Prudential. I will cancel this health insurance, and the one I have in Holland (that's even more expensive: 400 euro per month).

 

[jstar]

BPJS doesn't cover treatment for injuries sustained in road accidents

I think it’s a bit more nuanced; the occasions where a vehicle insurance would normally interfere.

 

[Jaime C]

AFAIK, BPJS doesn't cover treatment for injuries sustained in road accidents and by victims of rape (among other things).

BTW, I remember you posted somewhere that your mother-in-law was operated for cataract using BPJS. Did she get a Lens Implant ID card?

I don’t know anything about a lens implant ID card.

I have a decent auto policy, I think. Plus 6 airbags.

 

[Dave70]

I don’t know anything about a lens implant ID card.

It looks like this

your mother-in-law should be given one for each eye.

 

[pantaiema]

The problem with a healthcare insurance and other insurance in Indonesia is corruption, which is already routed in Indonesian society like a sub culture.
In the wrong hand an insurance could turn into one of the oldest scam on earth e.g "advance fees payment".

An Insurance company operates by assessing risks and using actuarial methods to calculate premiums based on the likelihood and severity of potential losses. If large chunk of the money is already spent to recruit con artists, to pay agent to get the victim, heavy advertisement spending where will the money be coming from to pay the claim If there are simultaneous unfortunate case which might result many major claims. BY that time the insurance bosses have escaped to other countries.

Do not forget the case like Jiwasraya, Asabri, Taspen, Bumiputra, PT Asuransi Jiwa Mega Indonesia, etc. I personally believe that Indonesia might be one the most extreme cases when comes to insurance, pension / welfare funds. ASABRI for instance is a welfare and pension fund intended for Indonesian Army, police, associates army/police staffs and the member of their family, yet people still have courage to embezzle it. Also most parties collude and take their cuts from the insurance company, the regulators, the police, the justice system, etc so what left. Just imagine what will happen if the Indonesian government do not take quick action to cover all of liabilities, cover all of the losses.

IMHO the only safest insurance in Indonesia is probably only BPJS as they keep having deficit in their balance sheet most of the time. There are not not much money left to be embezzled each year and they keep getting subsidy from the government to cover the deficit.

 

[jstar]

Hmm. It’s much more the business model.

I have never seen an insurance company, in any country, willing to pay out without a struggle or sending at least an expert whose task seems to be to lowball the financial damage. On car and house insurances the companies often make a loss and offer these to have the complete package; the real profit is in life insurances.

And on health insurance; I personally encountered in a western country they prohibited to undergo a treatment even after the specialist wrote a letter about its necessity, their own ‘doctor’ knew better

 

[pantaiema]

Hmm. It’s much more the business model.

I have never seen an insurance company, in any country, willing to pay out without a struggle or sending at least an expert whose task seems to be to lowball the financial damage. On car and house insurances the companies often make a loss and offer these to have the complete package; the real profit is in life insurances.

And on health insurance; I personally encountered in a western country they prohibited to undergo a treatment even after the specialist wrote a letter about its necessity, their own ‘doctor’ knew better

Yes, but there is a massive difference with Indonesia, e.g the existence of a strong watchdog, regulator and ombudsman. The insurance will be thinking twice avoiding their obligation if they know that the claim is genuine due to the existence of strong evidence. It is not uncommon if the victim take it to the ombudsman they will be ordered to pay. In addition, they might also get fined involving a huge amount of money.
In Indonesia, it is the opposite, the insurers might even get protected. There are already a lot of cases. The new case involving insurance is "Sinarmas MSIG life"
The main problem with insurance is you pay in advance. In the wrong hand the insurance could easily turn up to be one of the oldest scam on earth, e.g advance-fee scam.

 

[jstar]

The new case involving insurance is "Sinarmas MSIG life"

Come on, that’s a case of a bad and stealing staff member! Who was sentenced by the Manado court to 4,5 years of jail time (you would probably get a community service sentence in Europe for something like that.

Of course Sinarmas should have better checks on their personnel and procedures in place and they are trying to avoid payment of the damages, that is something you can blame them for. But they are definitely not protected by the government, they are still negotiating with the OJK since it’s a big mess.

It is a struggle of every firm here; I don’t know any company run by my f-i-l where people don’t embezzle. But they don’t get fired because it will take a big investment and a lot of effort to train new staff who will probably also steal after some time.

It’s somewhat simplistic to blame Toyota and the government if an Astra salesman sells you a lemon.

 

[pantaiema]

The case has been going since two years ago and finally, confirmed the another Life insurance. Kresna Life Insurance licenced is cancelled to avoid a Ponzi / pyramid scheme to continue.


Kresna Life defaulting IDR6.4T of their customers.

In the hand of a criminal insurance could easily turn to become one of the oldest scam on earth "Advance Fee"

Insurance in Indonesia is one of the most profitable business as it is very easy to recruit people and pay them commission used them to recruit other people, family members, friends. After getting enough money collected from the premium just run with your money.

 

[pantaiema]

A unit-link healthcare insurance has some advantages compared to a classic healthcare insurance. One of them is that (unless the stock market dips) the premium will not increase. The premium of the classic insurance, i.e. without unit-link, is lower in the first years than the 'unit-link' insurance, but will increase every year by about 12 - 15 %. So after about 6 years, the premium you have to pay has doubled.

@Samoerai. For health insurance why do not you just find a way to enrol to BPJS ? For a more serious illness such as in need of major surgery you could still do it in Holland using state healthcare system free of charge? With BPJS you will not be disappointed as the premium for the 1st class is almost nothing, just Rp150.000.

With so many cases involving unit-link insurance in the past, I would personally not touch this type of insurance; not even with a barge pole.

 

[Samoerai]

@Samoerai. For health insurance why do not you just find a way to enrol to BPJS ? For a more serious illness such as in need of major surgery you could still do it in Holland using state healthcare system free of charge? With BPJS you will not be disappointed as the premium for the 1st class is almost nothing, just Rp150.000.

With so many cases involving unit-link insurance in the past, I would personally not touch this type of insurance; not even with a barge pole.

Yes, I will try to enroll to BPJS here in Jakarta Senayan. Maybe they will accept me as WNA on the karta keluarga with my wife (WNI).