Benefit Limits Eliminated in Health Insurance

KOMPAS/RIZA FATHONI

Cataract Surgery – A doctor examines the condition of a patient\'s eyes before undergoing cataract surgery at Gatot Subroto Army Hospital, Jakarta, Tuesday (6/3/2018).

JAKARTA, KOMPAS – The Supreme Court (MA) has revoked three regulations on insurance benefits for cataracts, postnatal care for natural births and medical rehabilitation issued by the Healthcare and Social Security Agency’s (BPJS Kesehatan) director of healthcare service insurance. With the revocation, there will be no more benefit limits for beneficiaries of the National Health Insurance-Indonesian Health Card (JKN-KIS) program.

The judicial review on the three regulations was filed by the United Indonesian Doctors Association (PDIB) in August this year. The ruling was delivered by judges Irfan Fachruddin, Is Sudaryono and Yulius in a court session on Thursday (18/10/2018).

The three revoked regulations were BPJS Kesehatan director of healthcare service insurance’s regulations No. 2 on insurance benefits for cataract, No. 3 on insurance benefits for postnatal care on natural delivery and No. 5 on insurance benefits for medical rehabilitation. The PDIB deemed the three regulations to be potentially harmful toward patients, doctors and healthcare facilities.

PDIB secretary Patrianef, who was listed as a petitioner in the judicial review, said on Monday (22/10) that the PDIB did not see any other way than to pursue legal action against the three regulations. Despite protests from the National Social Security Council (DJSN), the House of Representatives, the Indonesian Doctors Association (IDI) and several medical professional organizations, BPJS Kesehatan insisted on implementing the regulations.

Patrianef said the three BPJS Kesehatan regulations harmed JKN beneficiaries’ rights to obtain the best and high quality medical services. “The MA ruling has revoked the three regulations. There is no more benefit limits for JKN beneficiaries,” he said.

Conflicting

PDIB attorney Muhammad Reza Amulana said the three regulations were in conflict with Law No. 40/2004 on National Social Security System, Law No. 24/2011 on BPJS, Law No. 12/2011 on Lawmaking and Presidential Regulation No. 12/2013 on Health Insurance. “The three regulations violate certain rights of patients,” he said.

Among the widely lambasted points in the regulation on cataract insurance benefits is that BPJS Kesehatan insures benefits for cataract operations with preoperative visus of less than 6/18. It is feared that the limit will only lead to a growing number of people with cataracts.

In terms of newborns, despite having been born healthy, babies require optimal care due to risks of illnesses, deformities and even death. Limitations on medical rehabilitation may lead to ineffective therapy.

BPJS Kesehatan spokesperson Iqbal Anas Ma’ruf said the three regulations had been issued as part of the agency’s cost control to ensure its sustainability and quality control. Benefit claims for cataract operations reached Rp 2.65 trillion (US$174.23 million) in 376,527 cases. Claims for postnatal care for natural births reached Rp 1.17 trillion in the same period. Postnatal care for natural delivery costs amount to Rp 3.8 million, while costs for C-section postnatal care is Rp 5.4 million.

Claims for medical rehabilitation and physiotherapy reached Rp 965 billion. It was a huge burden for BPJS Kesehatan, which was why claims for medical rehabilitation were limited.

Despite the MA having revoked the three regulations, BPJS Kesehatan may launch other cost-saving efforts, including the implementation of an online referral system to facilitate patients and increase service effectiveness.

Iqbal said BPJS Kesehatan would respect and abide by the ruling, of which the agency had yet to receive a copy.

To resolve budget deficits in the JKN program, PDIB chair James Allan Rarung proposed the establishment of a small independent team comprising experts that can formulate efforts to improve BPJS Kesehatan’s funding management.

“Efficiency and effectiveness are highly necessary in implementing JKN. However, cost issues should not reduce the quality of medical services. Instead, we must strive to always give the best [medical care],” he said. (ADH/SON)