Financial Services Authority Circular Letter

Number 7/SEOJK.05/2025 on the Implementation of Health Insurance Products

Abstract: As a follow-up to the issuance of Financial Services Authority Regulation (POJK) Number 36 of 2024 concerning Amendments to POJK Number 69/POJK.05/2016 concerning the Conduct of Business by Insurance Companies, Islamic Insurance Companies, Reinsurance Companies, and Islamic Reinsurance Companies, regulations are required regarding the criteria for Insurance Companies, Islamic Insurance Companies, and Islamic Units within Insurance Companies that can conduct the Health Insurance business line. Furthermore, this Circular Letter establishes the application of adequate prudential principles and risk management for Insurance Companies, Islamic Insurance Companies, and Islamic Units within Insurance Companies in conducting the Health Insurance business line.

Legal Basis for this Financial Services Authority Circular Letter: POJK No. 36 of 2024.

This Circular Letter regulates provisions regarding Insurance Companies and Islamic Insurance Companies conducting health insurance products, which must meet 3 (three) requirements consisting of: 1. digital capability; 2. medical capability; and 3. the establishment of a Medical Advisory Council (DPM).

This Circular Letter regulates provisions regarding Insurance Companies, Islamic Insurance Companies, and Islamic Units within Insurance Companies, which must have information systems developed independently or in collaboration with other Insurance Companies, Islamic Insurance Companies, and Islamic Units within Insurance Companies, Third-Party Administrators (TPA), the National Health Insurance Implementing Body (BPJS Kesehatan), other benefit providers offering health services, or companies that can provide digital services.

This Circular Letter regulates provisions regarding Insurance Companies, Islamic Insurance Companies, and Islamic Units within Insurance Companies, which may have a Medical Advisory Council (DPM) independently, in collaboration with other Insurance Companies, Islamic Insurance Companies, and Islamic Units within Insurance Companies, or with a TPA.

This Circular Letter regulates provisions regarding insurance products, which must apply risk-sharing (co-payment) borne by the Policyholder, Insured, or Participant of at least 10% (ten percent) of the total claim submission, with a maximum out-of-pocket cost limit of: 1. for outpatient care, Rp300,000.00 (three hundred thousand rupiah) per claim submission; and 2. for inpatient care, Rp3,000,000.00 (three million rupiah) per claim submission.

This Circular Letter regulates provisions regarding Insurance Companies, Islamic Insurance Companies, and Islamic Units within Insurance Companies marketing Health Insurance Products for individuals, which must consider the implementation of medical check-ups (MCU) for prospective Policyholders, Insured, or Participants, adjusted to the underwriting policy of the Insurance Company, Islamic Insurance Company, and Islamic Unit within the Insurance Company at the time of insurance policy closure.

This Circular Letter regulates provisions regarding Insurance Companies, Islamic Insurance Companies, and Islamic Units within Insurance Companies, which must obtain claim performance reports for Policyholders at the time of insurance policy closure for Group Health Insurance Products.

This Circular Letter regulates provisions regarding health insurance products, which must contain features enabling the coordination of benefits between Insurance Companies, Islamic Insurance Companies, and Islamic Units within Insurance Companies with other benefit providers.

This Circular Letter regulates provisions regarding Insurance Companies, Islamic Insurance Companies, and Islamic Units within Insurance Companies, which must actively conduct health campaigns to increase public awareness to maintain health.

Abstract: This Financial Services Authority Circular Letter takes effect on January 1, 2026. This Financial Services Authority Circular Letter was established on May 19, 2025. Coverage or participation in health insurance products that are already in effect at the time this Financial Services Authority Circular Letter was established is declared to remain valid until the coverage or participation period ends. For health insurance products that: 1. can be automatically renewed; and 2. have received approval from the Financial Services Authority or have been reported to the Financial Services Authority before this Financial Services Authority Circular Letter takes effect, must be adjusted to this Financial Services Authority Circular Letter no later than December 31, 2026.