Legal Review Of Health Insurance Claim Denial

Abstract

Health insurance provides financial protection against health risks, yet disputes over claim denial remain frequent in Indonesia. This study analyzes the legal basis of health insurance claim rejection, identifies the principal causes of disputes, and examines legal protection available to policyholders. A normative juridical method was applied through statutory and conceptual approaches using legislation, legal doctrine, scientific literature, and relevant regulatory materials. The analysis shows that claim denials commonly arise from incomplete medical documentation, pre-existing-condition clauses, waiting periods, policy exclusions, and differences in the interpretation of medical necessity between hospitals and insurers. The contractual imbalance between insurers and policyholders, combined with limited transparency of policy terms, can intensify disputes. Existing protection is grounded in contract law, consumer protection law, insurance regulation, and Financial Services Authority rules, but implementation requires greater consistency. Stronger disclosure standards, standardized medical-necessity criteria, digitalized claim verification, and effective complaint and dispute-resolution mechanisms are required to improve fairness, transparency, and legal certainty in Indonesian health insurance services.