DAFTAR RINCIAN SANTUNAN MEDIPRO Asuransi ABC

Mata
Mata Uang/Currency
Uang/Currency Rupiah Rupiah

MANFAAT MAKSIMUM PER KETIDAKMAMPUAN /MAX IMUM BENEFIT PER DISABILITY PLAN 1 PLAN 2 PLAN 3 PLAN 4 PLAN 5 PLAN 6 PLAN 7

RAWAT INAP/IN-PATIENT
1. Biaya Kamar (santunan harian untuk kamar, makan & perawatan umum) 1,000,000 750,000 500,000 400,000 300,000 200,000 100,000
per hari maks. 70 hari per ketidakmampuan
Daily Room & Board & general nursing Benefit per day max. 70 days per disability.
2. Unit Perawatan Intensif (ICU) per hari maks. 20 hari per ketidakmampuan 2,000,000 1,500,000 1,000,000 800,000 600,000 400,000 200,000
Emergency Unit (ICU) per day max. 20 days including 70 days for each disability
3. Macam-macam Biaya Rumah Sakit per ketidakmampuan 40,000,000 30,000,000 20,000,000 16,000,000 12,000,000 8,000,000 4,000,000
(penggunaan ruang operasi, anastesi, pemeriksaan lab., obat bius, obat-obatan, infus, dll)
Special Hospital Service Benefit per disability(use of operating room,lab,test,drugs,medicine,etc)
4. Maximum biaya dokter bedah per ketidakmampuan
Maximum Surgeon fees per disability
- Complex 50,000,000 37,500,000 25,000,000 20,000,000 15,000,000 10,000,000 5,000,000
- Major 32,000,000 24,000,000 16,000,000 12,000,000 10,000,000 6,000,000 3,200,000
Intermedia 16,000,000 12,000,000 8,000,000 6,000,000 5,000,000 3,000,000 1,600,000
-teMinor 8,000,000 6,000,000 4,000,000 3,000,000 2,000,000 1,500,000 800,000
5. Kunjungan dokter di Rumah Sakit per hari, maks 1 kunjungan per hari 1,000,000 750,000 500,000 400,000 300,000 200,000 100,000
maks.70 hari per ketidakmampuan, termasuk dokter spesialist
In-Hospital Doctor's Visit per day, 1 visit/day max. 70 days per disability
6. Pengobatan Darurat Rawat Jalan 5,000,000 3,750,000 2,500,000 2,000,000 1,500,000 1,000,000 500,000
EmergencyOut-Patient Treatment Expenses due to accident incurred within 48 hours
7. Biaya konsultasi dokter ahli/ahli bedah 31 hari sebelum 3,000,000 2,250,000 1,500,000 1,200,000 900,000 600,000 300,000
dan 90 hari sesudah perawatan Rumah Sakit.
Specialist/Surgeon's fees 31 days before and 90 days after hospitalization.
8. Biaya diagnostic X-Ray & pemeriksaan laboratorium 31 hari 3,000,000 2,250,000 1,500,000 1,200,000 900,000 600,000 300,000
sebelum dan 90 hari sesudah perawatan Rumah Sakit
Diagnostic, X-ray & Lab. Test Expenses 31 days before and 90 days after hospitalization
9. Santunan kematian baik karena kecelakaan atau sakit (hanya untuk Karyawan) 50,000,000 50,000,000 50,000,000 50,000,000 30,000,000 30,000,000 30,000,000
Life Insurance Benefit (for employee only)
10 Santunan kematian karena kecelakaan (hanya untuk karyawan) 50,000,000 50,000,000 50,000,000 50,000,000 30,000,000 30,000,000 30,000,000
Personal Accident Benefit (for employee only)

BATAS PER TAHUN / ANNUAL LIMIT UNLIMITED UNLIMITED UNLIMITED UNLIMITED UNLIMITED UNLIMITED UNLIMITED

MANFAAT MAKSIMUM / MAXIMUM BENEFIT PLAN 1 PLAN 2 PLAN 3 PLAN 4 PLAN 5 PLAN 6 PLAN 7

RAWAT JALAN / OUT-PATIENT (100% Reimbursement)

1. Maksimum Biaya Konsultasi Dokter Umum per kunjungan, termasuk obat yang diresepkan, 500,000 400,000 300,000 200,000 150,000 100,000 80,000
maksimum 30 kunjungan per tahun
Max.GP Fee per visit including Prescribed Medicines, max.30 visits per year
2. Maksimum Biaya Konsultasi Dokter Spesialis per kunjungan, termasuk obat yang diresepkan, 1,000,000 800,000 600,000 400,000 300,000 200,000 160,000
maksimum 15 kunjungan per tahun
Max. Specialist Fee per visit including Prescribed Medicines, max.15 visits per year
3. Pengobatan Gigi Dasar per kunjungan maksimum 4 kali kunjungan per tahun 1,000,000 800,000 600,000 400,000 300,000 200,000 160,000
Basic Dental per visit, max 4 visits per year
4 Pemeriksaan Diagnostik dan Laboratorium sesuai dengan rujukan dokter, maks. per tahun 1,500,000 1,200,000 900,000 600,000 450,000 300,000 240,000
Diagnostic and Laboratory Test, maximum per policy year
5 Fisioterapi, batas maksimum per tahun 1,500,000 1,200,000 900,000 600,000 450,000 300,000 240,000
Physiotherapy, maximum limit per policy year

LIMIT TAHUNAN / ANNUAL LIMIT 33,000,000 26,400,000 19,800,000 13,200,000 9,900,000 6,600,000 5,280,000
 Rincian Peserta

MANFAAT/BENEFITS PLAN I PLAN II PLAN III PLAN IV PLAN V PLAN VI PLAN VII
1. IN-PATIENT (REIMBURSEMENT)
Karyawan/Employee
Karyawan dan Pasangan
Karyawan dan max 3 anak
Karyawan dan Keluarga (max 3 anak)

1. IN-PATIENT (CASHLESS)
Karyawan/Employee
Karyawan dan Pasangan
Karyawan dan max 3 anak
Karyawan dan Keluarga (max 3 anak)

2. OUT-PATIENT (REIMBURSEMENT)
Karyawan/Employee
Karyawan dan Pasangan
Karyawan dan max 3 anak
Karyawan dan Keluarga (max 3 anak)

Note :
1. The cost estimation is calculated based on data that we received by e-mail on
2. The maximum entry age for employee is 59 year old.
3. Minimum entry age for children is 15 days and maximum coverage age is 23 y.o (unmarried and or full
 PREMIUM TAHUNAN MEDIPRO

MANFAAT/BENEFITS PLAN I PLAN II PLAN III PLAN IV PLAN V PLAN VI PLAN VII
1. IN-PATIENT (REIMBURSEMENT)
Karyawan/Employee 5,202,068 3,959,752 2,717,436 2,220,510 1,630,462 1,133,535 636,609
Karyawan dan Pasangan 10,668,258 8,059,395 5,450,531 4,406,986 3,270,319 2,226,773 1,183,228
Karyawan dan max 3 anak 12,655,964 9,550,174 6,444,384 5,202,068 3,866,630 2,624,314 1,381,998
Karyawan dan Keluarga (max 3 anak) 18,122,154 13,649,817 9,177,479 7,388,544 5,506,487 3,717,552 1,928,617

1. IN-PATIENT (CASHLESS)
Karyawan/Employee 5,947,458 4,518,794 3,090,131 2,518,665 1,854,078 1,282,613 711,148
Karyawan dan Pasangan 12,233,576 9,233,383 6,233,190 5,033,113 3,739,914 2,539,837 1,339,760
Karyawan dan max 3 anak 14,519,438 10,947,779 7,376,121 5,947,458 4,425,673 2,997,009 1,568,346
Karyawan dan Keluarga (max 3 anak) 20,805,557 15,662,369 10,519,180 8,461,905 6,311,508 4,254,233 2,196,958

2. OUT-PATIENT (REIMBURSEMENT)
Karyawan/Employee 3,818,076 3,054,461 2,290,845 1,527,230 1,145,423 763,615 610,892
Karyawan dan Pasangan 8,017,959 6,414,367 4,810,775 3,207,184 2,405,388 1,603,592 1,282,873
Karyawan dan max 3 anak 11,072,420 8,857,936 6,643,452 4,428,968 3,321,726 2,214,484 1,771,587
Karyawan dan Keluarga (max 3 anak) 15,272,303 12,217,842 9,163,382 6,108,921 4,581,691 3,054,461 2,443,568
 PLAN I PLAN II

P
M r T M
e e o e
MANFAAT/BENEFITS m m
b m t b
e i a e
r u l r
m

1. IN-PATIENT (REIMBURSEMENT)
Karyawan/Employee - 5,202,068 - -
Karyawan dan Pasangan - 10,668,258 - -
Karyawan dan max 3 anak - 12,655,964 - -
Karyawan dan Keluarga (max 3 anak) - 18,122,154 - -

SUB TOTAL (Rp'000) -

TOTAL ANNUAL PREMIUM - IN PATIENT (Rp) - Reimbur

1. IN-PATIENT (CASHLESS)
Karyawan/Employee - 5,947,458 - -
Karyawan dan Pasangan - 12,233,576 - -
Karyawan dan max 3 anak - 14,519,438 - -
Karyawan dan Keluarga (max 3 anak) - 20,805,557 - -

SUB TOTAL (Rp'000) -

TOTAL ANNUAL PREMIUM - IN PATIENT (Rp) - Cashless

2. OUT-PATIENT (REIMBURSEMENT)
Karyawan/Employee - 3,818,076 - -
Karyawan dan Pasangan - 8,017,959 - -
Karyawan dan max 3 anak - 11,072,420 - -
Karyawan dan Keluarga (max 3 anak) - 15,272,303 - -

SUB TOTAL (Rp'000) -

TOTAL ANNUAL PREMIUM - OUT PATIENT (Rp)

GRAND TOTAL ANNUAL PREMIUM (Rp) Alt 1
GRAND TOTAL ANNUAL PREMIUM (Rp) Alt 2
 PREMIUM TAHUNAN MEDIPRO

PLAN II PLAN III PLAN IV

P P P
r T M r T M r T
e o e e o e e o
m m
m t b m t b m t
i a e i a e i a
u l r u l r u l
m m m

3,959,752 - - 2,717,436 - - 2,220,510 -

8,059,395 - - 5,450,531 - - 4,406,986 -
9,550,174 - - 6,444,384 - - 5,202,068 -
13,649,817 - - 9,177,479 - - 7,388,544 -

- - -

4,518,794 - - 3,090,131 - - 2,518,665 -

9,233,383 - - 6,233,190 - - 5,033,113 -
10,947,779 - - 7,376,121 - - 5,947,458 -
15,662,369 - - 10,519,180 - - 8,461,905 -

- - -

3,054,461 - - 2,290,845 - - 1,527,230 -

6,414,367 - - 4,810,775 - - 3,207,184 -
8,857,936 - - 6,643,452 - - 4,428,968 -
12,217,842 - - 9,163,382 - - 6,108,921 -

- - -

-
- Inpatient & Outpatient Re
- Inpatient CASHLESS & Ou
 PLAN V PLAN VI PLAN VII

P P P
M r T M r T M r T
e e o e e o e e o
m m m
b m t b m t b m t
e i a e i a e i a
r u l r u l r u l
m m m

- 1,630,462 - - 1,133,535 - - 636,609 -

- 3,270,319 - - 2,226,773 - - 1,183,228 -
- 3,866,630 - - 2,624,314 - - 1,381,998 -
- 5,506,487 - - 3,717,552 - - 1,928,617 -

- - -

- 1,854,078 - - 1,282,613 - - 711,148 -

- 3,739,914 - - 2,539,837 - - 1,339,760 -
- 4,425,673 - - 2,997,009 - - 1,568,346 -
- 6,311,508 - - 4,254,233 - - 2,196,958 -

- - -

- 1,145,423 - - 763,615 - - 610,892 -

- 2,405,388 - - 1,603,592 - - 1,282,873 -
- 3,321,726 - - 2,214,484 - - 1,771,587 -
- 4,581,691 - - 3,054,461 - - 2,443,568 -

- - -
Outpatient Reimburse
ASHLESS & Outpatient Reimburse