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Simple and Easy
 | No medical examination |
| Single or Group Plans |
| No remote location or out of major city loadings |
| No hazardous occupation loading |
| Hospitals paid direct - No claim forms needed in most cases |
Summary of Hospital Benefits
| All in hospital accomodation, treatment and services, including MATERNITY
services and surgical services. |
| Post hospital follow up treatment following discharge. |
| Prescription drugs, medical supplies. |
| Home nursing following hospital discharge. |
| Local road ambulance service. |
| Emergency room services. |
Other Benefits
| Outpatients Services including Primary Care Physicians, Specialists,
Pathology, Imaging etc.
 | Prescription Drugs and Dressings etc. |
| Emergency Outpatient Services. |
|
| Dental Services including Diagnostic and Preventative Services,
|
Schedule of Benefits | Premium per Year | General
Policy Conditions
Discount | Hospital Accomodation
Plan Area |
Gold US$ |
Platinum US$ |
| Hospital & Ancillary |
500,000 |
2,500,000 |
| Maternity Normal
Abnormal |
2,000
4,000 |
5,000
10,000 |
| Outpatient |
2,500 |
10,000 |
| Dental Diagnostic Services
Preventative Services
Oral Surgery
Restorative Services
Endodentics
Emergency Services
Annual Dental Limit |
150
200
200
350
700
150
1,750 |
250
350
200
500
900
300
2,500 |
| Additional Benefits Evacuation
Repatriation
Accidental Death Benefits
Organ Transplant |
Unlimited
Unlimited
30,000
50,000 |
Unlimited
Unlimited
30,000
100,000 |
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| Age |
Gold US$ |
Platinum US$ |
| Hospital & Ancillary 0 - 17
18 - 30
31 - 40
41 - 45
46 - 50
51 - 55
56 - 60
61 - 65 |
164
330
330
424
424
544
642
802 |
246
492
492
603
603
766
766
958 |
| Maternity |
450 |
Included |
| Outpatient 0 - 17
18 - 30
31 - 40
41 - 45
46 - 50
51 - 55
56 - 60
61 - 65 |
116
161
169
184
195
266
356
416 |
189
249
263
270
308
399
564
690 |
| Dental |
160 |
205 |
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| Age Limit |
31 Days - 65 Years |
| Pre-Existing Condition |
1 Year |
| Pre-Hospital Diagnostic Service |
30 Days |
| Post Hospital Follow-up Treatment |
30 Days |
| Home Nursing Following Hospitalisation |
Reasonable & Customary Charges |
| Maternity |
1 Year |
| Notification of Claim |
60 Days |
| Legal Proceedings |
Law of Indonesia |
| Co-Insurance for Outpatient & Dental |
20.00% |
| Co-Insurance for Treatment in USA/Canada |
20.00% |
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Optional deductibles for Hospital Benefits:
If you agree to pay the first US$100, US$200 or US$500 of each claim for Hospital
Benefits you can reduce the Hospital premium cost as follows:
| Total |
Discount |
| US$ 100 |
12.5% |
| US$ 200 |
17.5% |
| US$ 500 |
22.5% |
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| Gold |
Indonesia
Overseas |
VIP
Sharing Accomodation |
| Platinum |
Indonesia
Overseas |
VVIP
Private Accomodation |
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