MEDICAL SERVICE PROPOSAL

COMP “A” Rp. 80.000/ person

COMP “B” Rp. 70.000/ person
COMP “C” Rp. 50.000/ person
COMP “D” Rp. 40.000/ person H. Novotel
Total
No Type of Services COMP COMP “B” COMP “C” COMP “D” Remark
“A”
1 Out – Patient Treatment  Charis Klinik Nagoya, Charis Klinik Panbil, Charis Klinik
Tj. Piayu, RSCM Batu Aji, Kasih Ibu Clinic Btm. Centre,
No Limit
No Limit No Limit No Limit Utama Medika Clinic Sei Panas, Alam Sehat Clinic Btm.
Centre.
2 Specialist Treatment  Referral from Charis Klinik (if necessary)
 For any normal pregnancy cases, member can visit to
8x 6x 5x 4x Specialist Obgyn with the maximum of 8,6,5,4 times visit
in the pregnancy period
3 Pedeatric Direct Direct Referal Referal  Direct
 Referral from General Doctor
4 Hospitalisation RSOB RSOB RSOB RSOB  Referral from Charis Klinik (if necessary)
I Class II Class III Class III Class  Not available for emergency case
Plafond Plafond Plafond Plafond  Hospitalization in RSOB with maximum covered/ year
Rp. 5.000.000/thn Rp.4.000.000/thn Rp.3.000.000/thn Rp.2.000.000/thn
RSBK RSBK RSBK RSBK  Referral from Charis Klinik (if necessary)
IC II Class III Class III Class  Not available for emergency case
Plafond Plafond Plafond Plafond  Hospitalization in RSBK with maximum covered/ year
Rp. 5.000.000/thn Rp.4.000.000/thn Rp.3.000.000/thn Rp.2.000.000/thn 
RS Charis Medika RS Charis Medika RS Charis RS Charis  Can go direct to General Doctor & Dentist every time
I Class I Class Medika Medika  Hospitalization in Rumah Sakit Charis Medika is not
100% covered 100% covered II Class II Class limited (365 days/ year)
100% covered 100% covered
5 Normal or Pathology  For Normal or Complicated delivery at Rumah Sakit
Delivery at RS Charis 100% covered 100% covered 100% covered 100% covered Charis Medika 100% covered by Charis Medika
Medika
Normal Delivery Rp. 800.000,- Rp. 700.000,- Rp. 600.000,- Rp. 500.000,-  For Normal or Pathology delivery which is done out side
outside RSCM Charis Medika Hospital, Charis Clinik will be paid
Pathology Delivery Rp. 3.000.000,- Rp.2.500.000,- Rp. 2.000.000,- Rp. 1.500.000,- accordingly with maximum coverage.
outside RSCM
6 Special Services :
 Spectacles/ Glases Rp. 350.000,- Rp. 300.000,- Rp. 250.000,- Rp.200.000,-  Can only be claim after 6 (six) months being member / 2
(Frame&Lenses) years
 Lenses only Rp. 175.000,- Rp. 150.000,- Rp. 125.000,- Rp. 100.000,-  Anytime (with medically indication)
 Dental Protease Rp. 350.000,- Rp. 300.000,- Rp. 250.000,- Rp. 200.000,-  Can only be claim after 6 (six) months being member / 2
 Hearing aid Rp. 350.000,- Rp. 300.000,- Rp. 250.000,- Rp. 200.000,- years
accessory  Can only be claim after 6 (six) months being member / 2
 Legs & Hands Rp. 350.000,- Rp. 300.000,- Rp. 250.000,- Rp. 200.000,- years
Prothese  Can only be claim after 6 (six) months being member / 2
 Pasang & Rp. 500.000,- Rp. 500.000,- Rp. 500.000,- Rp. 500.000,- years
Pelepasan Pein  Can only be claim after 6 (six) months being member / 2
years
7 Special Disease
Compensation :
 Cancer Rp. 1.000.000,- Rp. 700.000,- Rp. 500.000,- Rp. 500.000,-  Special diseases which are not 100% covered bt Charis
 Haemodialysis Rp. 1.000.000,- Rp. 700.000,- Rp. 500.000,- Rp. 500.000,- Clinic
 Heart Attach Rp 1.000.000,- Rp. 700.000- Rp. 500.000,- Rp. 500.000,-  For all disease Charis Clinic only give compensation
 Pelepasan dan Rp 500.000,- Rp 500.000,- Rp 500.000,- Rp 500.000,-
pemasangan
pain