The Importance of Understanding Insurance Policies to Avoid Claim Rejections

In the midst of rising medical service costs and health risk uncertainties, owning health insurance has become an essential part of the public’s financial planning. Insurance policies serve as financial protection against various treatment expenses, from doctor consultations to hospital stays, in accordance with the benefits listed in the contract. For many people, health insurance is often regarded as a lifesaver in medical emergencies. They contain provisions regarding the rights and obligations of both parties, including coverage benefits, costs, risks, claim procedures, and exclusion clauses. By reading and understanding the terms and conditions in the policy, customers can clearly know the protection benefits they possess. This also helps ensure that future claim processes run in accordance with the applicable provisions. Several conditions commonly included in exclusions include illnesses not covered by the policy benefits, claims during the waiting period, injuries due to criminal acts, congenital abnormalities or hereditary diseases, and medical procedures not related to medical needs such as cosmetic surgery. In Prudential Indonesia’s health insurance products, one exclusion that draws attention is experimental treatment or therapy. It is stated that experimental treatment involves actions using methods, procedures, technologies, or substances that have not been proven effective based on Western medical science and/or have not obtained approval from the relevant authorities in the country where the action is performed. Assessment of therapy also considers several aspects, such as approval status by authorities like BPOM, FDA, or EMA, the strength of scientific evidence, clinical objectives, and the level of recognition in the healthcare system. For example, in breast cancer treatment, Immune Cell Therapy (ICT) which uses the patient’s blood to be processed and returned, falls into the experimental category and is thus not covered under Prudential Indonesia’s health insurance policy benefits. In addition to understanding the policy contents, customers also need to provide complete and factual information when applying for insurance. Such information includes health history, hobbies, and lifestyle such as alcohol consumption.