5 Surgeries Not Covered by BPJS Kesehatan: Check Before Surgery

Jakarta, CNBC Indonesia - BPJS Kesehatan is part of the national social security system aimed at providing healthcare protection for all Indonesian citizens. Like typical insurance, BPJS Kesehatan requires monthly contributions from members. While membership is active, citizens are entitled to free healthcare services at accredited facilities, including clinics, health centres, and hospitals. One major benefit covered is surgical procedures. However, not all types of surgery fall under this coverage. Here are the five surgeries not covered by BPJS Kesehatan: 1. Accident-related surgeries Surgeries resulting from traffic or workplace accidents, which are covered by other agencies such as Jasa Raharja or BPJS Employment, are not included in BPJS Kesehatan’s coverage. 2. Cosmetic or aesthetic surgeries Procedures aimed solely at enhancing appearance without medical necessity must be fully paid by the patient. 3. Self-inflicted injury surgeries BPJS Kesehatan does not cover surgeries resulting from intentional self-harm, including those caused by negligence, recklessness, or attempted self-harm leading to injury. 4. Overseas hospital surgeries All medical procedures, including surgeries conducted outside Indonesia or in foreign hospitals, are automatically not covered. 5. Non-compliant procedure surgeries If patients undergo surgery without following proper procedures—such as visiting a hospital directly without a referral for non-emergency cases—BPJS Kesehatan will not cover the costs. Surgeries Covered by BPJS Kesehatan As a key note for the public, under the National Health Insurance (JKN) guidelines outlined in Health Minister Regulation No. 28 of 2014, BPJS Kesehatan fully covers 19 major surgeries, including: - Heart surgery - Caesarean section - Cyst surgery - Myomectomy - Tumour surgery - Odontectomy - Oral surgery - Appendectomy - Gallstone surgery - Eye surgery - Vascular surgery - Tonsillectomy - Cataract surgery - Hernia repair - Cancer surgery - Lymph node surgery - Implant removal - Knee replacement - Thyroidectomy How does the claims process work? To claim BPJS coverage for surgery, patients must follow the standard healthcare pathway. They must first seek treatment at a Primary Healthcare Facility (FKTP), such as a community health centre or registered clinic. If the FKTP doctor deems surgery necessary, the patient receives a referral to a higher-level facility (hospital) to schedule the procedure with a specialist. Generally, three key conditions must be met for full BPJS Kesehatan coverage: an active BPJS Kesehatan or Indonesia Health Card (KIS); a formal referral from a registered FKTP; and a patient card issued by the destination hospital.