Ajukan Klaim Kesehatan
Health Insurance Claim Form
Please fill out the form along with the required documents for claim review
Select an option
Authorization Statement and Customer Personal Data Agreement
I have read and agree to the following Authorization Statement By submitting this claim document, I understand, declare, and warrant that
- All information or data I provide, disclose, transmit, or attach to this Online Claim Submission is true, accurate, complete, and up-to-date as of the current circumstances, and I agree to guarantee and take responsibility for the accuracy of this information or data.
- All data I provide, disclose, transmit, or attach to this Online Claim Submission will form the basis and part of the Policy.
- If I am found to have provided data, statements, information, and answers that are intentionally or unintentionally untrue or incomplete, I am aware, understand, and agree that PT. AXA Insurance Indonesia has the right to cancel this Policy, without the obligation to pay any benefits or refund any premiums I have paid.
- I have read, understood, and agreed to the terms and conditions of the Policy. In this regard, I understand, declare, and warrant that my heirs, family members, or anyone acting on my behalf forever release and discharge PT. AXA Insurance Indonesia, its directors, commissioners, employees, and/or affiliates from any form of legal action or claim I may have or may have in the future, directly and/or indirectly related to the use of my data, and if in the future there is data and written correspondence related to this Online Claim Submission and/or Policy that is not correct, I am willing to be held accountable according to applicable laws and regulations.
- PT. AXA Insurance Indonesia is allowed to store, use, and disclose my data to any third parties (as necessary) in connection with the claims process.
Statement of Authorization and Consent
- I hereby consent to authorize PT. AXA Insurance Indonesia to use, utilize, and disclose my personal data/personal information to third parties collaborating with AXA in connection with the provision of commercial programs aimed at enhancing features, facilities, and/or services for my benefit.
- I hereby permit PT. AXA Insurance Indonesia to inform me about products, programs, and other activities related to the improvement of AXA's features, facilities, and/or services to data owners through written means (electronic and non-electronic media).
CLAIM REIMBURSEMENT PROCEDURE FOR HEALTH INSURANCE WITH
A NOMINAL AMOUNT ABOVE Rp 5,000,000 (FIVE MILLION RUPIAH)
A NOMINAL AMOUNT ABOVE Rp 5,000,000 (FIVE MILLION RUPIAH)
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The policyholder should submit the following original documents:
- Completed and signed claim form by the Insured and the treating Doctor
- Photocopy of Medical Treatment Resume
- Photocopy of valid Insured's identification (ID card, Driver's License, Passport, KITAS/KITAP for foreigners)
- Original receipts and detailed treatment expenses
- Photocopy of prescription
- Photocopy of laboratory test results or other diagnostic examinations.
- Original benefit coordination letter and claim payment details, if the claim has been guaranteed by another insurance company.
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The policyholder should send all original hard copy documents to the designated TPAs (Third Party Administrators) as specified in the Policy:
- Admedika PT Administrasi Medika Telkom STO Gambir, Gedung C Jl. Medan Merdeka Selatan No. 12, Jakarta Pusat 10110 Phone: 02134831100 Fax: 02134830101
- Fullerton Indonesia Fullerton Health Group Indonesia CIBIS Nine 5th Floor Jl. TB Simatupang No. 2 South Jakarta Indonesia 12560
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Third-party administrator (TPA) will conduct a Claim Analysis according to policy terms.
- Third-party administrator (TPA) will provide a claim decision based on the analysis: Claim Approved / Claim Rejected / Pending Claim.
- If necessary, the policyholder must complete the claim documents as per the information received within the specified time limit in the Policy.
Pengajuan Klaim Berhasil
Disclaimer
Disclaimer
- For claims with a maximum amount of Rp 5,000,000, original documents must be kept for 90 days from the date of claim submission by the Claimant and/or Policyholder and/or Insured, to be provided to PT. AXA Insurance Indonesia if required.
- PT. AXA Insurance Indonesia reserves the right at any time to request original documents for all claim documents submitted by the Claimant and/or Policyholder and/or Insured. Original documents must be submitted to PT. AXA Insurance within 30 (thirty) days from the request for the submission of original documents to the Claimant and/or Policyholder and/or Insured.
- The accuracy and/or content of the claim submission documents are entirely the responsibility of the Claimant and/or Policyholder and/or Insured, and they hereby grant PT. AXA Insurance Indonesia an irrevocable authority to conduct an investigation and/or inquiry into the accuracy of the information in the documents submitted by the Claimant and/or Policyholder and/or Insured.
- The acceptance of this online Claim Submission shall not be construed as an acknowledgment of responsibility by PT. AXA Insurance Indonesia. All costs arising from the procurement of supporting documents and reports requested by PT. AXA Insurance Indonesia shall be the responsibility of the Claimant and/or Policyholder and/or Insured.
