Below are several links to help you find answers to frequently asked questions from our corporate customers. If you have any questions not answered here, please email us at wecaregroup-id@greateasternlife.com so our Customer Service Officer can provide a more comprehensive answer.
Do I have to bring my Medical Card for every inpatient procedure at a partner hospital?
The Medical Card must be shown for the cashless system , but is not required for the reimbursement system . In the event of an emergency hospitalisation, participants can contact AdMedika at the following telephone number:(021) 1500-811 within 2 x 24 hours by providing the Participant card number, Employee/Participant name & NIK, company name, hospital name, hospital admission date, and date of birth for manual guarantee handling first before the Medical Card can be shown to hospital staff.
What should I do if my Medical Card is lost or damaged and I need to be hospitalised?
By contacting AdMedika, I will assist you in getting cashless inpatient care at a partner hospital , even if my card is lost. During the verification process, the hospital will ask me to show another form of identification (KTP) that matches my data on file with AdMedika.
Is there a limit to the amount of treatment that can be covered?
Yes. The limit for each treatment is as stated in the benefit plan, while recovery benefits can be enjoyed within 30 days of hospital discharge from the previous treatment.
Should surgical procedures that do not require hospitalisation ( day surgery ) still be performed in hospital?
All surgical procedures must be performed in a hospital and cannot be performed in a clinic, including operations that do not require hospitalisation.
How do I submit a claim for coordination of benefits , which part of the costs have been covered by another insurance company but the remainder is to be submitted to Great Eastern Life Indonesia?
Participants can submit a medical service claim form by attaching copies of all receipts/claim documents that have been legalised by the other insurance company along with a notification letter from the other insurance company regarding the amount of the claim that has been submitted and has been paid by the other insurance company along with the details.
Can a paper receipt/payment note be considered a receipt?
The payment receipt or note is not an original receipt, so submitting a claim with a payment receipt/note cannot get a replacement.
Is it possible that there will be excess costs (excess claims) for inpatient care, childbirth, outpatient care, dental care that will be billed later by Great Eastern Life Indonesia?
This may happen, where the causes are as follows:
Can I immediately undergo a laboratory examination if I am not feeling well, and what laboratory examinations are covered by the Great Eastern Life Indonesia policy?
Laboratory tests will only be reimbursed if they are performed on the written recommendation of the Participant's treating physician and are relevant to and support the diagnosis. Laboratory tests requested by the Participant will not be reimbursed.
If the receipt issued by the doctor is a combination of doctor's services and medication, do I need to ask the doctor to separate the doctor's service fees and medication fees?
For all receipts that combine doctor's fees and medication, ask the doctor/clinic to separately detail the doctor's fees and medication costs. Great Eastern Life Indonesia requires this information to ensure the costs incurred are reasonable and customary.
Is acupuncture treatment replaceable?
Acupuncture is reimbursed if the procedure is performed by an acupuncture doctor officially licensed by the health department.
Does Great Eastern Life Indonesia provide reimbursement for medical treatment to Chinese healers or midwives?
Chinese medicine and mantra therapy, including the administration of herbal remedies, are categorised as traditional medicine and therefore are not reimbursed. Treatment by midwives is only reimbursed for prenatal checkups and normal delivery.
Can the Medical Card be used abroad for outpatient and inpatient care?
The cashless treatment facility from the Medical Card is generally only valid in Indonesia, so treatment abroad can only be reimbursed using the reimbursement system. However, treatment at AdMedika Partner hospitals in Singapore and Malaysia can be served cashless . For inpatient care abroad, all treatment costs will be converted into rupiah using Bank Indonesia's middle rate per the transaction date or the date the Participant is discharged from the hospital and compared to the Participant's entitlement according to the benefits contained in the policy. For the Medical Card program (excluding treatment), Participants are entitled to certain discounts that can be obtained from various Medical Card program partners abroad.
In the pre-authorisation process, what is meant by the criteria "medically necessary"?
Medically necessary is a health service or treatment referred by a doctor and must meet all of the following conditions:
What is meant by "reasonable and customary" treatment/care?
Is the treatment/care fulfilling the following conditions:
What might cause Great Eastern Life Indonesia to disapprove a treatment in the pre-authorisation process?
There are several circumstances under which Great Eastern Life Indonesia may not approve a treatment and/or cover its costs. These include cases where the diagnosis falls within a policy exclusion, the medical data provided by the participant for pre-authorisation is incomplete, the service is not medically necessary, or the service does not meet the requirements for "reasonable and customary" treatment/care.
What if Great Eastern Life Indonesia believes that the services or hospitalisation recommended by the doctor do not comply with medical service guidelines?
An AdMedika or Great Eastern Life Indonesia doctor will contact the Participant's treating physician and discuss the situation. If a medical indication is not yet available, the Participant can still be hospitalised but must first complete a letter of commitment to cover treatment costs if the final diagnosis issued by the Participant's treating physician states that the treatment is not covered by the Great Eastern Life Indonesia policy.
How to reduce Excess Claims?
Excess claims occur due to the use of care that is not in accordance with the participant's plan or exceeds the participant's benefits. For example, if the plan states that inpatient care is covered in a Class I room, but the participant requests a VIP room. The participant must cover the difference in costs between a VIP room and a Class I room at the hospital. Therefore, participants must wisely choose a hospital and treatment room that aligns with their benefits or plan.
What should be done if the card is lost, while the Participant has to be hospitalised?
What to do is:
The reimbursement payment procedure states that participants are required to submit a medical service form completed by a doctor, including a diagnosis, etc. What if the participant forgets to request a doctor's diagnosis while the claim documents have already been submitted to HR?
The doctor's diagnosis is important for verification by Great Eastern Life Indonesia. Therefore, claim processing will be delayed if the participant does not provide this information. In such circumstances, the participant needs to:
How do I submit a claim to another insurance company?
Participants can submit a request letter to HRD to submit the remaining claim not covered by Great Eastern Life Indonesia to another insurance company.
If an employee has more than 3 children and the first child is over 21 years old but is not married and not working, is he still entitled to become an insurance participant?
No, because he is over 21 years old. Registration of children as insurance participants is limited to a maximum of 3 (three) children who are under 21 years old, not married or not working. If the first child is no longer registered according to the applicable criteria, then the 4th (fourth) child can be registered to replace the first child.
Are all employees entitled to maternity benefits?
No. Maternity benefits are only provided to married permanent employees, or wives of permanent employees aged between 16 - 45 years (who are not yet 45 years old on the policy anniversary). Coverage applies to births up to the third child (3).
How can I find out my claims/benefit usage history?
Participants can contact Great Eastern Life Indonesia Customer Care at the following phone number : (021) 2554-3800 on weekdays from 09.00 am – 16.30 pm or email to wecaregroup-id@greateasternlife.com by stating the Participant number and Medical Card number.
What if a participant is hospitalised repeatedly due to an illness? Is there a specific time period for the participant to receive coverage again after being hospitalised?
If the participant is hospitalised again for the same diagnosis, the costs will still be covered as long as there is a 30-day gap between the previous hospital discharge date and the next inpatient admission date. There is no waiting period for treatment with a different diagnosis.
If a participant does not bring a medical service form when visiting a doctor, is the doctor's diagnosis still required?
Yes, the doctor's diagnosis must be included. If the participant does not bring a medical service claim form , the participant can ask the doctor to write the diagnosis on the back of the receipt, in a doctor's memo, on a blank prescription form, or on a special form provided by the hospital for writing diagnoses. The doctor will need to sign and stamp the diagnosis information.
Will Great Eastern Life Indonesia reimburse over-the-counter medications purchased without a doctor's prescription?
Great Eastern Life Indonesia policies do not reimburse over-the-counter medications purchased without a doctor's prescription.
Can I make my own diagnosis?
No, the diagnosis must be given and written by the treating physician.
Can employees who have resigned remain participants in this insurance program?
No, their membership automatically ends upon leaving the company. If they are interested in exploring the possibility of being covered by other insurance products from Great Eastern Life Indonesia, they can contact Customer Care .
Do hospital staff know the exact limit of the participant's inpatient benefits?
No. Hospital staff only know the inpatient room rate to which the participant is entitled. To meet the benefit limit, participants can contact Great Eastern Life Indonesia Customer Care .
Are receipts printed from a hospital computer (not handwritten) valid?
If the printout says "receipt," then it is valid proof of payment (stamped properly). Receipts and notes are not considered valid receipts.
Will the hospital still ask for a deposit when a participant is admitted for inpatient care, even if they have used the cashless facility ?
As long as the participant uses the facility in accordance with the guarantee and a guarantee letter has been issued to them, the hospital will not ask for a deposit. If the hospital still asks for a deposit, please contact AdMedika at the following telephone number:(021) 1500-811 so that it can be followed up immediately.
If a partner hospital refuses to accept the Medical Card, what should participants do?
Contact AdMedika or Great Eastern Life Indonesia Customer Care to help clarify with the hospital by providing the card number, participant name, and NIK.
Women over 30 are often prone to cysts, fibroids, and similar conditions. Are medical expenses for analysing and treating medical complaints (such as excessive pain or bleeding) covered?
Yes, but participants are required to provide detailed information about their condition to support the analysis for Great Eastern Life Indonesia's verifier.
For outpatient care at non-partner clinics, can medication purchases be made cashless at partner clinics? If a participant receives outpatient treatment at a non-partner clinic, we do not guarantee
cashless
medication purchases, but reimbursement is possible .
Does Great Eastern Life Indonesia cover reconstructive surgery?
Great Eastern Life Indonesia covers reconstructive surgery for accidents and burns that aims to restore bodily function within a maximum of 30 days after the accident. Reconstructive surgery for accidents and burns that is not intended to restore bodily function but is purely cosmetic is not covered.
Are pregnancy and post-natal check-ups covered?
Prenatal and postnatal care for 40 days (postpartum period) is reimbursed for maternity benefits. If the participant's Medical Card still has cashless benefits, using this postnatal care benefit will reduce the maternity benefit, not the outpatient benefit.
If I experience pregnancy complications (e.g., hyperemesis gravidarum , preeclampsia, eclampsia , placenta praevia , etc.) and the doctor recommends hospitalisation, will I be reimbursed?
Complications that occur during pregnancy and require hospitalisation, as well as postpartum complications up to 40 days after delivery that require hospitalisation, will be covered under the maternity benefit.
Can I give birth at a partner hospital using the cashless facility ?
Giving birth at a partner hospital is cashless. Any excess claims incurred will be billed before the participant leaves. Other excess claims, if any, will be billed later through HR after the claim is received from the partner hospital and processed by Great Eastern Life.
If I give birth to my fourth (4th) child, is it still covered under the maternity benefits?
Great Eastern Life covers maternity benefits for up to three (3) children.
If I already have 1 child and then I give birth to twins so that I will have 3 children after the second delivery, will the third delivery be covered if I get pregnant again?
No, because the maternity benefit is provided for up to three (3) children.
If I give birth to twins, how will the maternity benefits be reimbursed? Will I receive two (2) benefits or just one (1) benefit?
Insurance reimbursement for maternity benefits is just one benefit, because twins are basically born in one birth process.
Is giving birth with a midwife reimbursed by insurance?
Yes. Giving birth with a midwife will be reimbursed by Great Eastern Life, provided the delivery is normal and the midwife holds a legal license from the health department.
If the doctor prescribes a medication that can be redeemed more than once (iter), can I redeem the medication at a partner clinic using a cashless system or a reimbursement system without a diagnosis?
Participants can redeem the above medicines using a cashless system with the following conditions:
How do I file a claim if there are two different diagnoses?
Please ask the examining physician to write down both diagnoses. If only one diagnosis is listed, the medication purchased for the unlisted diagnosis will be considered unrelated and will not be reimbursed.
Are prescription-based vitamin purchases covered?
Yes, as long as there is a written recommendation from the Participant's treating physician, and the vitamins are consumed in reasonable amounts and relevant to the diagnosis or medical indication.
Are food supplements covered?
Yes, as long as there is a written recommendation from the Participant's treating physician, and the supplements are consumed in reasonable amounts and relevant to the diagnosis or medical indication.
Is an acupuncture examination guaranteed?
It is guaranteed if the procedure is performed by a doctor officially licensed by the health department to perform acupuncture treatments, and the therapy is not performed for cosmetic or aesthetic reasons.
Does Great Eastern cover treatment with traditional healers, traditional healers, midwives, and midwives?
Treatment with traditional healers, traditional healers, and midwives, including the administration of herbal remedies, is categorised as traditional medicine and therefore not covered. Treatment with midwives is covered only for prenatal checkups and normal delivery.
Are Meridian Zone ( Cronosonic Ultrasound ) and Chiropractic treatments guaranteed?
No, as Meridian Zone and Chiropractic treatments are considered alternative medicine.
I had an X-ray at the doctor's referral. Do I need to attach the original X-rays? What is the procedure?
Please send the medical service form, original receipt, and a copy of the doctor's reading of the X-rays. Photos of the X-rays are not necessary. X-rays at the doctor's referral will be reimbursed through outpatient benefits.
Can I have a laboratory test immediately if I'm feeling unwell?
Laboratory tests will only be replaced if they are based on a written recommendation from the attending physician and are relevant to the diagnosis.
Why aren't insurance policies covering typhoid, flu, PCV, or varicella immunisations covered?
Because the policy doesn't cover the cost of preventative care, such as immunisations.
If the doctor's invoice combines medical services and medication, should I ask the doctor to separate the costs for the services and medication?
Great Eastern Life needs this information to ensure the reasonableness of the charges.
Do I always have to bring a medical service form with me every time I visit a non-partner clinic?
A medical service form is a document required for reimbursement claims. It provides clarity on the diagnosis and treatment provided by the doctor treating the participant. If the participant does not bring the form, ask the doctor to write the diagnosis on a blank sheet of prescription paper or on the back of the doctor's receipt, which must be certified with the doctor's signature, name, and stamp.
Will wisdom teeth surgery be covered under any benefit?
Wisdom teeth surgery will be covered under the complex dental benefit.
Is tartar cleaning guaranteed?
Yes. Please see the explanation of the benefits of dental care.
Why, when I swipe my Medical Card at the hospital ( cashless ) during outpatient treatment, is it still showing benefits, but becomes an Excess Claim later after treatment is completed?
This can happen because the reimbursement claim submission and the cashless transaction occurred within a short timeframe. When the swiping occurs, the reimbursement claim that was just received before the swiping may not have been processed yet, so the benefits listed on the EDC Terminal at the time of the swiping haven't been reduced.
Does Great Eastern cover medication purchases that are not made immediately (e.g., within one week of a doctor's prescription)?
Medication purchases must be made immediately after the doctor issues the prescription. Medication purchases made more than two days after the doctor's consultation will not be covered.
If my wife and child buy glasses frames and lenses, can they be replaced?
No, because the replacement of glasses only applies to permanent employees and does not include their dependents.
Can I claim both glasses and contact lenses at the same time?
No, participants must choose only one.
Is eye surgery covered?
LASIK surgery is not covered, but Great Eastern covers eye surgeries related to the following eye conditions: cataracts, retinal detachment, glaucoma, and retinal detachment.
Can an employee's spouse, child, or family member who experiences eye pain and goes to the doctor and is given medication for an eye infection, oral medication, or vitamins be covered? Which benefit should they use?
The costs of eye examinations for family members can be covered under the outpatient benefit.
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