Faktor-Faktor yang Berhubungan dengan Keputusan Klaim Asuransi Kesehatan Kumpulan PT. SGMW Motor Indonesia pada Pialang Asuransi PT. Cipta Integra Duta

(Factors Relating to Decisions on Claims for Group Health Insurance PT. SGMW Motor Indonesia at Insurance Broker PT. Create Integra Duta)


  • Wawa Wardil Hasan STIKes Indonesia Maju




Health Insurance, Claim Decision, Insurance Broker, Claim Verification


Introduction: Commercial health insurance companies can cater to the diverse desires of individuals. However, as a consequence, the company will design various products according to public demand with certain terms and conditions in the policy. This study aims to determine the factors associated with the insurance claim decision of the group of PT. SGMW Motor Indonesia at Insurance Broker PT. Cipta Integra Duta 2020.

Methods: This analysis uses independent submission variables that are claimed from completely rejected claims, accepted and claimed claims in their entirety and the dependent variable is insurance membership status, completeness of files, over-limit claims, health insurance benefits, non-original claim documents and resources. analysis of claims and insurance guarantee letters. This research data was obtained from secondary data in the form of claim data from PT SGMW Motor Indonesia for the period of coverage from January 1, 2020 to December 31, 2020 as an accumulation of the results of the analysis of claims from the insurer PT. International Services Pacific Cross with a total sample of 7,123. Statistical method using non-parametric comparative test analysis was performed on two variables using the Chi Square method.

Results: The factors that were most related to the decision that were claimed in whole and claimed to be partially accepted were the health insurance benefits factor with a p value of 0.001 and human resource analysis claims with a p value of 0.000.

Discussion: Therefore, it is necessary to improve the quality of human resources for claims analysts who work in the health insurance sector either by training, certification, seminars and periodic socialization, as well as socializing insurance benefits and advocating for insurance companies suspected of fraud in their claims analysis, so that public trust in insurance is needed, can grow.