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This study aims to describe the excess claim at PT Insurance X provider for policy issued in 2012 at January 2012 ? October 2013 Service Period. This study is cross sectional study with descriptive design through a quantitative approach. The result showed taken from Insurance Company secondary data describe that the excess claim cost influence by some factors, for classification of provider factor; gold provider reach 50.20% and 49.80% for silver provider from totally excess claim cost. Type of membership factor; employee 43.98%, couple 36.68% and children membership 19.35% from totally excess claim cost. The next factor of package benefit/health services that consist of inpatient 51.43%, outpatient 29.05%, maternity 13.19%, dental service 6.24% and package benefit of glasses 0.09% from totally excess claim cost. From the factor of compatibility policy content related to limitation of benefit inpatient 52.96%, outpatient 23.75%, maternity 15.05%, dental service 8.16% and package benefit of glasses 0.11% from totally excess claim cost. From the exclusion policy that caused by diagnose exclusion 41.38%, medicine exclusion 31. 27%, not indication treatment 18.48%, services out of effective date policy 7.13%, non medical 1.07% and member that have not benefit package 0.66% from totally excess claim cost.
Claims management becomes very important in the business of insurance and re-established role in the company's image. As an administrator Insurance, PT TPA Xrequired to guarantee proper claim to all members. This research is quantitative andqualitative design, using the techniques of data collection includes in-depthinterviews, and a review of documents. The results showed that the resources thataffect the precision of the analysis process claims TPA X at PT Asuransi Y is achange of policy provisions, lack of some facilities and infrastructure informationsistems also support the accuracy of the analysis process claims.Keywords:claims managements, claims analysis accuracy.
The duration of claim settlement is an important indicator in assessing the efficiency of insurance services, particularly for hospital daily cash benefit products. Delays in the claim process may reduce customer satisfaction and trust in insurance companies. This study aims to analyze the factors associated with the duration of claim settlement for hospital daily cash benefits at PT. X based on 2023–2024 data. A cross-sectional design with a quantitative approach was used, utilizing secondary data from 320 claims. The analysis was conducted using univariate and bivariate methods with ordinal logistic regression. The results showed that most claims were settled within 6–14 days (39.1%) and 0–5 days (37.5%). Two variables showed statistically significant relationships with claim duration: region of origin and completeness of documents. Participants from outside Java Island tended to experience longer claim durations, while claims submitted with complete documents had a significantly higher likelihood of being processed more quickly. The other four variables—reason for hospitalization, hospital type, claim amount, and claim history—were not statistically significant but showed relevant practical trends.
Industri asuransi kesehatan memegang peranan penting dalam memberikan perlindungan finansial terhadap risiko biaya perawatan medis yang terus meningkat. Dalam praktiknya, perusahaan asuransi seringkali bekerja sama dengan reasuradur guna mengelola dan memitigasi beban risiko secara lebih efektif, terutama dalam menghadapi tren peningkatan klaim yang signifikan. Penelitian ini bertujuan untuk menganalisis pola klaim yang diajukan oleh PT Asuransi X kepada PT Reasuransi Y dengan focus pada biaya perawatan tertinggi (high-cost claims) dan penyakit terbanyak (high-frequency diseases). Penelitian ini menggunakan pendekatan kuantitatif deskriptif dengan analisis data sekunder yang diambil dari laporan klaim riil perusahaan periode Desember 2021–November 2024, serta dianalisis menggunakan uji Chi-square. Hasil penelitian menunjukkan bahwa penyakit muskuloskeletal, genitourinari, dan kardiovaskular menjadi penyumbang terbesar biaya klaim, meskipun tidak termasuk dalam kategori penyakit dengan frekuensi klaim terbanyak. Selain itu, ditemukan bahwa jenis perawatan yang paling berkontribusi terhadap tingginya biaya klaim adalah tindakan operasi dan aneka perawatan rumah sakit, yang diikuti oleh rawat inap dan layanan pasca perawatan. Hal ini menunjukkan bahwa kompleksitas tindakan medis, terutama yang bersifat invasif, memberikan dampak signifikan terhadap nilai klaim secara keseluruhan. Dengan demikian, penelitian ini menyoroti bahwa besarnya biaya klaim tidak hanya ditentukan oleh jenis penyakit atau frekuensinya, tetapi juga oleh jenis layanan kesehatan yang digunakan. Kesimpulan dari penelitian ini menekankan pentingnya pemahaman menyeluruh terhadap pola klaim serta diharapkan dapat memberikan wawasan dan rekomendasi strategis yang mendalam bagi kedua belah pihak dalam mengembangkan kebijakan underwriting, pengelolaan risiko, perencanaan premi yang lebih tepat, serta pengembangan produk berbasis tren klaim.
The health insurance industry plays a crucial role in providing financial protection against the rising costs of medical treatment. In practice, insurance companies often collaborate with reinsurers to manage and mitigate risk more effectively, particularly in response to the growing trend of significant claim increases. This study aims to analyze the claim patterns submitted by PT Insurance X to PT Reinsurance Y focused on two categories: high-cost claims and high-frequency diseases. A descriptive quantitative approach was employed, utilizing secondary data drawn from actual company claim reports spanning the period of December 2021 to November 2024, and analyzed using the Chi-square test. The results show that musculoskeletal, genitourinary, and cardiovascular diseases were the largest contributors to total claim costs, despite not being among the most frequently claimed conditions. Additionally, the types of treatments that contributed most to the high cost of claims were surgical procedures and various hospital treatments, followed by inpatient services and post-treatment care. This indicates that the complexity of medical procedures—especially invasive ones—has a substantial impact on overall claim value. Thus, the study highlights that the magnitude of claim costs is influenced not only by the type or frequency of diseases but also by the type of medical services utilized. The conclusion of this research underscores the importance of a comprehensive understanding of claim patterns and is expected to provide in-depth insights and strategic recommendations for both parties in developing underwriting policies, improving risk management, setting more accurate premiums, and designing insurance products based on claim trends.