Health Care Financing Program for

International Students

Valid Until august, 31, 2018

INPATIENT BENEFITS
 The maximum limit of the reimbursement is Rp.
7.000.000,- (Six Million Rupiah) per case as stated in
the insurance card.

 The maximum covered every 4 months follow this rule

Periode Sept until Jan until May until

Dec 2017 Apr 2018 Aug 2018

Max. Claim Rp 10.000.000,- Rp 10.000.000,- Rp 10.000.000,-

OUT PATIENT BENEFITS

 The maximum limit of the

reimbursement is Rp. 200.000,-
(Two hundred Rupiah) per case as
stated in the insurance card (Max. 3
cases per 6 months)
PERMANENT TOTAL DISABILITY BENEFITS

Loss of: two legs, two arms, two eyes, one arm
and one leg, one arm and one eye, one leg and
eye

The coverage is Rp 10.000.000,- (Ten

million rupiah)
DEATH BENEFITS - COMPENSATION

 If the insurance participant in the

insurance coverage died, his/her
beneficiary is entitled to receive
compensation of a sum of Rp.
10.000.000,- (Ten Million Rupiah)
 Claim Doctor
Documents Reviews
Executive Coordinator

Execu - The use of medicine is

INTERNATIONAL appropriate with the diagnostic
OFFICE tive - Lab tests is appropriate with
Coordi the diagnostic
- The price of medicine is
nator reasonable

Head of
Disbursement of
Program
funds to the
Executive Coordinator Approval
finance
(treasurer)

CLAIM PROCESS
CLAIM DOCUMENTS – IN/OUT PATIENT
 Copy of insurance card
 Copy of Student card
 Original document of medical resume from a
doctor
 Original or copy of official invoice from hospital
 Copy of a letter from a doctor for check lab. along
with the details and copies of check lab. results
 Original or copy of official invoice from the
laboratorium.
CLAIM DOCUMENTS – DEATH CASE
 Original Insurance Card
 Medical Resume for the death due to illness
 Official police report for accidental death
 Proof of Beneficiary
 The beneficiary completes the provided submission
form of payment claims for death benefit.
EXCEPTIONAL CASE
 Alternative medicine (not medically)
 Care or treatment related to mental health, drugs or
alcohol addiction.
 Treatment-related to infertility.
 Care or treatment for obesity (obesity), weight reductions
or attempt to gain weight.
 Care or treatment related to cosmetics

## exceptional is the case doesn’t covered in this program

EXCEPTIONAL
 Eye refractive disorders, including the treatment and /
or medication related to the additional glasses.
 Circumcision

## exceptional is the case doesn’t covered in this

program
EXCEPTIONAL
 Care and / or treatment related to HIV / AIDS, including
disease or condition associated with HIV / AIDS and
sexually transmitted diseases.
 Non-medical costs (such as tissue, telephone charges,
toiletries, etc.)
 Food Supplement
 Vitamin without medical indication.
 Family planning, contraception and sterilization measures
 Free medicines (medicines purchased without a
prescription)

## exceptional is the case doesn’t covered in

this program
EXCEPTIONAL
 Care and / or treatment as a result of war, riots, fights,
crimes or violations of statutory provisions and rules
 Intentional injury and attempted suicide.
 Treatment and / or medication that caused by the
participant doing flight using chartered aircraft ,
military / police, or helicopter.

## exceptional is the case doesn’t covered in this

program
EXCEPTIONAL
 Treatment and / or dental treatment which is not
caused by an accident as well as cosmetic dentistry
(including orthodonti treatments, teeth whitening and
the whole treatment of cosmetic dentistry).
 The complications of pregnancy, childbirth and
miscarriage / abortion on medical indication.

## exceptional is the case doesn’t covered

in this program
EXCEPTIONAL
 All care and / or treatment that has been paid by
insurance companies.
 Natural disasters
 Acts of crimes committed by the participant

## exceptional is the case doesn’t covered

in this program
Universitas Brawijaya Hospital is
the only referral hospital for
Health Care Financing Program
for International Students, except
for an emergency case.