The Implementation of Coordination of Benefit (COB) within

Indonesian National Health Insurance System (BPJS Kesehatan)

Hilda Yunita Sabrie, Zahry Vandawati, Prawitra Thalib

Faculty of Law, Universitas Airlangga, Indonesia

Keywords: Coordination of Benefit, Government, Health, Insurance.

Abstract: The Indonesian national health insurance program is organized by BPJS Kesehatan with a compulsory

membership covering the entire population of Indonesia; whom its implementation will be carried out by the

government gradually. Participants of the health insurance program by BPJS Kesehatan are required to pay

contributions as a premi in order to obtain health insurance benefits. The benefit in this case is social

security to the right of participants and their families. Benefits of health insurance that can be obtained by

these participants are individual health services, including promotive, preventive, curative and rehabilitation

services, that includes health services and consumed medicine in accordance with the necessary medical

needs. Benefits provided by BPJS Kesehatan in such a way, by some scholars, are considered to be unable

to meet the health needs of the people. Therefore, the government provides this facilities in the form of

Coordination of Benefit (COB) or benefit coordination between BPJS Kesehatan and Commercial Insurance

in order to provide additional benefits of health services that have been obtained by BPJS Kesehatan

participants’ by purchasing additional health insurance products for participants in need of health services

improvement. However, the existence of this COB system can indicate the violation of Indemnity principle

so that there is a need for a deeper analysis and more careful arrangement in implementing COB system.

1 INTRODUCTION

Coordination of Benefit (COB) or benefit co-

ordination is a method whereby two or more insurers

underwrite same person for the same health

insurance benefit with the limit of total benefit not

exceeding the amount of health services that are

financed (Peraturan Badan Penyelenggara Jaminan

Sosial Kesehatan Nomor 4 Tahun 2016 tentang

Petunjuk Teknis Penyelenggaraan Koordinasi,

2016). The first party to pay claims is called the

primary payer while the party who pays the

remainder of the claim is called the secondary payer

(Unit Pemasaran BPJS Kantor Cabang Batam,

2015). COB is a system used to determine the

liability of payments for health claims when there is

more than one guarantor. COB helps ensure that

participants who have more than one health

insurance will receive an appropriate benefit while

also avoiding overpayment by one of the guarantor

(Admin AdMedika, 2016).

This COB program is governed by the Badan

Penyelenggaran Jaminan Sosial Kesehatan

Regulation (Hereinafter, BPJS Regulation) No. 4 of

2016 on the Technical Guidelines for the

Implementation of Benefit Coordination in the

National Health Insurance Program. This COB

Program is the implementation of the Law of the

Republic of Indonesia Number 40 Year 2004

regarding National Social Security System, Law of

the Republic of Indonesia Number 24 Year 2011 on

Social Security Administering Body, and

Presidential Regulation of the Republic of Indonesia

Number 12 Year 2013 regarding Health Insurance as

amended several times the latest by Presidential

Regulation No. 12 of 2013.

This new COB system will be enforced if BPJS

Kesehatan participants purchase additional health

insurance from the provider of additional health

insurance programs that have cooperated with BPJS

Kesehatan. Presently, there are 33 additional Health

Insurance companies listed as the partners of BPJS

Kesehatan per 2017(Humas BPJS Kesehatan, 2017).

COB Principles in BPJS Kesehatan is

implemented when BPJS Kesehatan participants

purchase additional health insurance from the

provider of the Additional Health Insurance Program

or other Guarantee Agency in collaboration with

Sabrie, H., Vandawati, Z. and Thalib, P.

The Implementation of Coordination of Beneﬁt (COB) within Indonesian National Health Insurance System (BPJS Kesehatan).

DOI: 10.5220/0010051000180023

In Proceedings of the International Law Conference (iN-LAC 2018) - Law, Technology and the Imperative of Change in the 21st Century, pages 18-23

ISBN: 978-989-758-482-4

BPJS Kesehatan (Humas BPJS Kesehatan, 2017).

BPJS Kesehatan will then guarantee the applicable

tariff charges under the JKN program, while the

remaining tariff will be the responsibility of

commercial insurance as long as it complies with the

prevailing rules and procedures.

This regulation of coordinated benefits or COB

is not a new thing. It has been known since the

issuance of the Law of the Republic of Indonesia

Number 40 Year 2004 regarding National Social

Security System (SJSN), whereas the government

has arranged the coordination of benefits as

mentioned in Article 23,:

"In case the participant requires hospitalization,

then the hospital service class is given based on the

standard class". The explanation of Article 23

further states that, "Participants who want a higher

grade than their rights (standard class), the

difference between the cost guaranteed by the Social

Security Administering Body at the cost of

improving the treatment class."(Undang-Undang

Nomor 40 Tahun 2004 tentang Sistem Jaminan

Sosial Nasional, 2004)

The COB system is an implementation of JKN,

every citizen will be guaranteed by the JKN program

and for those who already have health insurance, the

guarantee will be considered as a "top-up payer".

Top-up payers are conditions where if the health

insurance participant wants a higher class than the

participant's rights that is guaranteed by BPJS

Kesehatan, they can get upgraded by paying the

remaining fees to the Additional Health Insurance.

In accordance with Presidential Regulation No. 12

of 2013 on Health Insurance, Article 27 paragraph

(2) states that BPJS Kesehatan and the providers of

additional health insurance or insurance programs

must be able to coordinate in providing benefits for

health insurance participants.

COB system for COB participants conducted by

BPJS Kesehatan with an Additional Health

Insurance Provider by selling indemnity, cash plan

and managed care products, providing additional

condition as follows: (Berita Negara Republik

Indonesia, 2016)

a. BPJS Kesehatan as the first guarantor; or

b. Provider of Additional Health Insurance as the

first payer.

Regarding indemnity products, hospital cash

plan, and managed care, it can be described as

follows:

a. Indemnity

Indemnity is a health insurance product where cost

reimbursement is based on the limit / benefit owned

by health insurance participants referring to the

agreement at the time of policy closing.

Replacement fees are made based on when each

participant is being treated (Humas BPJS Kesehatan,

2015).

b. Hospital Cash Plan

Hospital Cash Plan is a health insurance product that

provides reimbursement of daily maintenance and

compensation expenses if the health insurance

participant is hospitalized due to a sickness or

accident in accordance with policy guarantees. The

amount of reimbursement of the cost is adjusted to

the type of premium agreed by the participant of the

health insurance (Adira Care, 2016).

c. Managed Care

Managed care is a health insurance product when

there is a healthcare financing system compiled

based on the number of registered members with

controls ranging from service planning and includes

contracts with health service provider (Henni

Djuhaeni, 2009). This product provides costs

reimbursement to health insurance participants in

accordance with the costs billed. The cost of bills

paid by the insurer is the result of an agreement

between the insurer and the hospital (Rachmad

Suhanda, 2015). Participants of health insurance

are limited to the hospitals that are cooperating with

the insurer and on the basis of the agreed agreement

at the time of policy closing. Things that can be

reimbursed are in accordance with the agreement,

such as reimbursement of medicine costs, patient

rooms, and so forth.

If a Participant or Business Entity has more than

1 (one) Additional Health Insurance for himself /

hers, workers and members of his / her family, then:

a. Coordination of benefits is only made by one

of the Additional Health Insurance Providers

in collaboration with BPJS Kesehatan;

b. Participants or Business Entities may directly

without going through an Additional Health

Insurance Provider.

2 THE PURPOSE OF

COORDINATION OF BENEFIT

(COB)

Related to COB's objectives, there are actually quite

a lot of COB's goals, it depends on the viewpoint of

what the person is looking at. The government has

its own target on health, since improving health

services is also included in the criteria of advancing

public welfare as stipulated in the preamble of the

The Implementation of Coordination of Beneﬁt (COB) within Indonesian National Health Insurance System (BPJS Kesehatan)

1945 Constitution of the Republic of Indonesia. The

purpose of COB system is to increase the number of

BPJS Kesehatan participants, so then the

implementation of the JKN program is being

increasingly massive and be more comprehensive

(Humas BPJS Kesehatan, 2016). The

implementation of COB cooperation will have an

impact on the reduction of the contribution fee of the

participants with high commercial health insurance,

because part of the health insurance cost will be

borne by BPJS Kesehatan. It is expected to increase

the interest of COB participants because of the

relatively cheaper premium; yet, it offers more

benefits to be gained.

The next objective is that the COB participants

will obtain additional health protection coverage in

accordance with the needs required by the

participants. This is due to the fact that through

COB, participants are not limited to the facility

provided by BPJS Kesehatan, but participants can

also raise the level of health services and facility in

accordance with the standard needed by the

participants. With the COB, it is expected that

participants will benefit from the presence of

coordination between BPJS Kesehatan and

Additional Health Insurance (AKT).

Additionally, with the COB system, it is hoped

that it will decrease the stigma that there is business

competition between BPJS Kesehatan and

Commercial Insurance. BPJS Kesehatan is not a

private insurance, but the existence of BPJS

Kesehatan is intended for raising public awareness

about the importance of having health insurance.

With COB, participants who are financially capable

and want to get a better health care facility can apply

for the scheme. Through the coordination between

the two, BPJS Kesehatan and Commercial Insurance

can complement each other advantages and

disadvantages.

3 MECHANISM OF

COORDINATION OF BENEFIT

(COB)

BPJS Kesehatan in organizing COB program may

cooperate with Additional Health Insurance or other

guarantor that is in accordance with regulation

provisions in the form of: (Peraturan Direksi Badan

Penyelenggara Jaminan Sosial Kesehatan Nomor 47

Tahun 2016).

a. Coordination of Benefit

Coordination of benefits is when two or more

insurers underwrite same person for the same health

insurance benefit with the limit of total benefit not

exceeding the amount of health services that are

financed. In this case, BPJS Kesehatan with

Additional Health Insurance (Commercial

Insurance) jointly collaborated to underwrite the

same person that applied for COB.

b. Participation Coordination

Coordination of participation includes the

registration of business entities that will cooperate

with BPJS Kesehatan and Additional Health

Insurance, data entry of workers and family

members, data change mechanism, including the

participant's identity sharing.

c. Coordination of Socialisation

Coordination of socialization between BPJS

Kesehatan and additional health insurance or other

guarantor body means that they can conduct joint

socialization to COB participants for the health

facilities, and other related parties programmed. The

coordination mechanism of socialization is

important because to succeed the COB system

program launched by the government it needs to be

socialized to the people.

d. Coordination of premium

Coordination of premium can be conducted through

the participants premium payment through BPJS

Kesehatan or through the Additional Health

Insurance.

e. Coordination of Information System

The coordination of the information system of BPJS

Kesehatan and additional health insurance or other

guarantor bodies taken form into the merging of

participants’ information.

3.1 Indemnity Principle on the

Coordination of Benefit System

(COB) within BPJS Kesehatan

BPJS Kesehatan is included in social / compulsory

health insurance. Social / compulsory health

insurance is conducted to provide social security to a

community or group of people. Implementation of

social / compulsory insurance is based on mandatory

legislation and in it; there are certain objectives of

the government to provide protection for the

community or some members of the community so

that the system is referred to as social insurance.

Health insurance is actually one of the development

variants of insurance money and loss insurance.

There are several principles underlying an

insurance agreement, one of which is the principle of

iN-LAC 2018 - International Law Conference 2018

indemnity. The indemnity principle applies in all

insurance agreements, except life insurance. This is

because human life is unable to be measured by

value.

Indemnity principle is very essential in insurance

agreement. Based on Article 253 of Indonesian

Commercial Code (Kitab Undang-Undang Hukum

Dagang, KUHD), Indemnity principle is the amount

of compensation should be equal to the amount of

losses suffered. Within the indemnity principle, the

insurer is only required to compensate

proportionally to the loss suffered (Kornelius

Simanjuntak, et al, 2011).

In loss insurance, the Insured has the possibility

to suffer losses and the insurer is willing to bear it,

the event insured in general has been regulated in the

policy of events that provide financial losses and the

insurer is willing to bear it. An event will not be

guaranteed by the policy if the cause includes

exceptions in the policy. Thus, this principle

guarantees a reasonable and balanced compensation

wherein the insured is only allowed to receive

reimbursement of fees paid in accordance with the

amount of costs that actually being suffered by the

insured.

This can be explained in the insurance law

through a coverage contract based on the principle

of Indemnity that is in essence, is that the Insured

receives reimbursement of the cost of recovery

(financially) after a loss but the benefit can only be

amounted to the situation of the insured before the

loss occurs, so then there will be no additional profit

of the insured by making a claim.

The Indemnity principle of the COB system is in

principle the same as the Indemnity principle applied

in the insurance agreement as discussed earlier.

Indemnity principle in COB system can be

exemplified if we spend money Rp 25.000, - for the

cost of purchasing medicine, hence replacement cost

obtained by health insurance participant must also

match with suffered that is equal to Rp 25.000, - or

should not exceed from that amount.

In every insurance agreement there is always the

potential for violation of Indemnity principle.

Similarly in the COB system, there is potential for

violation of Indemnity principle. This is because the

concept of coordination of benefits that is applied

and become the basic reference in BPJS Kesehatan.

Coordination of benefits which in essence there is

more than one insurer who bear the cost of health

insurance from the insured may lead to potential

violations of Indemnity principle through the

payment of claim that is exceeding the value of the

total cost of health services.

Some potential violations of Indemnity principle

that is common in COB system in BPJS Kesehatan

are as follows:

1. Additional Benefit in Additional Health

Insurance

When the insured filed a claim to the Additional

Health Insurance (Commercial Insurance), there is a

potential violation of Indemnity principle. This is

because sometimes the existing insurance agreement

in health insurance products owned by Commercial

Insurance is not only limited to the contracted-on

COB system, but sometimes there are additional

clauses that are included if the insured willing to pay

a premium with a greater value to Additional Health

Insurance (Commercial Insurance). Insured not only

get the cost of replacing the maximum amount of

health services that will be reimbursed by BPJS

Kesehatan alone, but the insured can also receive

reimbursement of the Additional Health Insurance in

order to cover the cost difference that has been borne

/ paid by BPJS Kesehatan. Additionally, when the

insured applied for a higher premium value as

mentioned above, it will then provide higher

compensation received causing the violation of

indemnity principle. When calculated, the amount

received by the insured already exceeds the amount

of costs that should be paid by the insured.

2. Product of Hospital Cash Plan

Health insurance products under the Hospital

Cash Plan scheme are health insurance products that

provide insurance coverage when the insured is

hospitalized on the basis of a medical indication and

on the recommendation of a doctor caused by illness

or accident. In this scheme, the insurer will provide

daily benefits of hospitalization in the form of daily

cash compensation (Admin, 2015). Such products

may potentially lead to violations of Indemnity

principle. This is because the product provides the

insured of cash when the insured suffers from an

illness. This could potentially violate the principle of

Indemnity because if the insured has already covered

BPJS Kesehatan and Additional Health

Insurance, but they still receive cash for their

hospitalization. Insured will then receive benefit that

is higher than the total value of health care costs

suffered by the insured.

3. Submission of Photocopied Invoice of the

Claim

Submission of Photocopied Invoice of the Claim

may potentially lead to a violation of Indemnity

principle. Submission of Photocopied Invoice of the

Claim referred here is the condition in which the

insured filed a claim for health care costs in the form

of a copied. The receipt is filed as a claim on the

The Implementation of Coordination of Beneﬁt (COB) within Indonesian National Health Insurance System (BPJS Kesehatan)

cost of health services to Commercial Insurance.

This could potentially be a violation of the

Indemnity principle because the copy is a copy of

the original receipt that has been claimed to BPJS

Kesehatan. This cannot be denied or avoided since

there is no regulation that prohibits a person from

insuring an object of insurance on more than one

insurer and a person is also allowed to insure an

object of insurance on more than one insurer for the

same risk (Irene Nindia Laksmi, et al., 2016).

However, if we refers to the provisions of the

rules governing the COB system or the regulation of

claims filing procedures, there should be no

indication of violation of Indemnity principle in

COB system in health BPJS. COB scheme in BPJS

Kesehatan have been created to comply with the

indemnity principle through limiting the total benefit

in a certain amount that does not exceed the amount

of health care that is guaranteed.

In the regulation of health insurance, there are no

rules that concretely prohibit a person from insuring

an insurance object on more than one insurer for the

same risk. This happens because there are rules

where if the Insured has filed a claim for the whole

loss (claim for the full loss) to one Insurer, then the

Insured must not file another claim to the Insurer.

This is done to prevent the Insured benefit from the

payment of insurance claims (Irene Nindia Laksmi,

2015). In the health insurance mechanism,

indemnity principle can be understood that the form

of reimbursement given shall meet the cost of

treatment.

4 CONCLUSION

This study concludes that there is some indication of

indemnity principle violation in the implementation

of COB system at BPJS Kesehatan. This violation

might exist in the form of reimbursement claim that

exceeding the cost of health treatment suffered.

Providing a clear regulation through the rules

governing the COB system or the regulation of

claims filing procedures can avoid violation of

Indemnity principle in COB system in BPJS

Kesehatan. COB scheme in BPJS Kesehatan have

been created to comply with the indemnity principle

through limiting the total benefit in a certain amount

that does not exceed the amount of health care that is

guaranteed.

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iN-LAC 2018 - International Law Conference 2018

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The Implementation of Coordination of Beneﬁt (COB) within Indonesian National Health Insurance System (BPJS Kesehatan)