Corresponding Author: Herry
Polontoh
Email: [email protected]
INTRODUCTION
Insurance has
a central role in the economy as a financial institution that protects against
the risks faced by society. By utilizing insurance mechanisms, people can
protect themselves from the risk of accidents, the risk of illness, and death,
which can threaten their financial stability (Rani, 2016). More than just a business entity, insurance
acts as a risk insurer that helps individuals and families manage the
uncertainties of everyday life (Humaemah & Ulpatiyani,
2021). An insurance policy allows a person to
transfer financial risks to an insurance company so that the individual will
not be financially burdened when the risk occurs. Insurance contributes to
people's peace of mind and financial security by providing guaranteed
protection, making it an inseparable component of a country's financial system (Toyyibah & Hariyanto,
2015).
Insurance
companies are responsible for paying claims to insurance participants who
experience losses per the policy's provisions. However, the reality on the
ground often shows that insurance companies reject claims. The claim process is
an official submission from the insured to the Insurance company to request
reimbursement. However, various reasons can cause the Insurance company to
reject the participant's claim (Nurkholidah, 2018). There are at least five common reasons why
a life or health insurance claim may be denied. First, rejection can occur if
the insurance policy is inactive (lapses) because the premium is not paid after
maturity. Second, dishonesty in disclosing disease history when purchasing a
policy can be a reason for rejection, especially if the participant had certain
health conditions before the protection benefits took effect (pre-existing
conditions). The third reason is the importance of completing all documents requested
by the insurance company when submitting a claim because incomplete documents
can cause delays in claim payment. Fourth, claims can be rejected if they fall
within an exception. Namely risks not covered by the policy agreement.
Meanwhile, the fifth reason is submitting a claim past the expiration date
because every insurance claim has a specific deadline that the customer must
follow to submit a claim request.
Previous research by (Afrita and
Arifalina, 2021) examined the legal
responsibility of life insurance companies towards the insured in paying
insurance claims. The research results showed that the legal responsibility of life insurance
companies towards the insured in paying insurance claims where the life
insurance agreement called the policy is valid if has been closed (there has
been an agreement with the wishes) based on these provisions, the payment of
compensation money to the policyholder or nominee must be carried out by the
insurer if an event or risk occurs. The legal settlement carried out by the
life insurance company against the insured in payment of insurance claims in
the event of the Insurance Company's bankruptcy, the guarantee of protection
for the insurance policyholder has been strictly regulated by the policyholder
getting repayment before other creditors.
Another
research by (Mahfud, 2021) examined the
review of Islamic law on the mechanism for submitting Sharia insurance claims;
the results of the research show that the process of submitting health
insurance claims provided by the insurance company starts from submitting the
participant to the insurance to the claim analysis process to see whether the
claim submitted has occurred�delay, rejection, and acceptance. Then, the next step is the claim payment process if the claim is
accepted in accordance with Sharia principles. Claims in insurance are a process where participants
obtain their rights according to the policy agreement. The procedures and conditions stated in the policy do not contain
any elements that make things difficult for participants. Health insurance
claims are submitted by the contracts and agreements that have been agreed upon
from the start.
The novelty of this research comes from the research object,
namely the legal responsibility of insurance companies for unpaid participant
claims, which has never been studied before. The results of this research can
contribute to increasing consumer awareness regarding their rights in insurance
claims. Consumers can better understand their rights and how to involve the
authorities if their claim is denied for no apparent reason. The purpose of
this research is to analyze the legal responsibility of insurance companies for
unpaid participant claims.
METHOD
This research
uses normative legal research methods. Normative research methods are research
approaches that focus on the analysis of existing laws and regulations or legal
norms. This descriptive research prioritizes formal legal aspects rather than
involving empirical data. Research data was obtained through a literature
study. The library study data collection technique collects information through
literature in books, journals, articles, papers, and other sources related to
the research topic. Research data was analyzed qualitatively using descriptive
analysis methods. Descriptive analysis describes the legal provisions governing
the legal responsibilities of insurance companies, factors that can cause claim
rejection by insurance companies, and the legal responsibilities of insurance
companies for unpaid participant claims.
RESULTS AND DISCUSSION
Insurance is defined based on
article 246 of the Commercial Code (KUHD) of the Republic of Indonesia, namely,
"Insurance or coverage is an agreement, whereby an insurer binds himself
to the insured, by receiving a premium, to provide compensation to him due to a
loss, damage or loss of expected profits, which he may suffer due to an
unspecified event.� Based on this law, insurance is a tool to overcome future
risks by paying premiums to the insurer (insurance company (Anam & Astuti, 2020). In Indonesia, Law Number 40 of 2014 concerning Insurance
applies, which regulates the industry of healthy, reliable, trustworthy, and
competitive insurance to increase protection for policyholders, insureds, or
participants and play a role in encouraging national development (Ratnaningsih, 2022). Then, the provisions of Article 1 number 28 of Law No. 40 of
2014, it is regulated Insurance Agents, namely people who work alone or work
for a business entity, who act for and on behalf of an Insurance Company or
Sharia Insurance Company and fulfill the requirements to represent an Insurance
Company or Sharia Insurance Company marketing insurance products or sharia
insurance products (Sumiyati, 2017) Insurance benefits
according to (Kusnadi
& Lisnawati, 2020) are categorized into two parties,
namely for customers and insurance companies :
1. For Customers
a. It provides a sense of security
and protection
b. Fairer distribution of costs and
benefits
c. Functions as savings
d. Risk spreading tool
e. Helps increase business
activities
2.
For Insurance Companies
a. Profits from premiums given to
customers
b. Profits from capital
participation from other companies
c. Profit from interest yields from
investments in securities
The characteristics of insurance
agreements are based on the limitations of Article 246 of the Criminal Code in
Erlina et al. (2022) are as follows:
1.
An insurance
agreement is basically a compensation agreement (shcadevezekering or
indemnities contract). The insurer is bound to compensate for losses because
the insured party suffers losses, and what is compensated is proportional to
the losses suffered (principle of indemnity).
2.
An insurance
agreement is a conditional agreement. The obligation to indemnify the insurer
is only carried out if an event that is not specified for which the insurance
is provided occurs.
3.
The insurance
agreement is reciprocal. The insurer's obligation to compensate for losses is
expected from the insured's obligation to pay premiums. The loss suffered
resulted from an unspecified event in the name of which insurance was provided.
The basis for submitting an
insurance claim is an insurance policy based on an agreement between the
parties and the principle of good faith. It can be interpreted that submitting
an insurance claim is an official request to the insurer to request a payment
amount based on the insurance policy's provisions. Submission of insurance
liability is proposed by carrying out a review by the insurance company for
validation, and then ultimately, a sum of money will be paid to the insured.
Good faith and agreements made by both parties in the form of an insurance
agreement must be based on compliance by the parties with the contents of the
agreement made (Saputra et al., 2021). In a life insurance contract, the policyholder, insurance
company, and intermediary (insurance enthusiast) benefit from each other, and
the insurance company's rights and obligations are also the policyholder's
rights and obligations. According to (Sari et al., 2023), these rights and obligations include:
1.
Policy Holder
Rights
a.
The right to
compensation if an incident occurs.
b.
The right to
payment of insurance money if no accident occurs during the insurance period.
2.
Policyholder
Obligations
a.
Obligation to
provide premiums to insurance companies.
b.
Obligation to
insurance companies to provide information in good faith.
The legal responsibility of the
life insurance company towards the insured in paying insurance claims where the
life insurance agreement called the policy is valid if it has been closed
(there has been an agreement of will) in the life insurance agreement, the
parties, namely the policyholder, the insurer and the appointed person
(insurer) have the rights and The respective obligations are reciprocal where
the rights and obligations of the policyholder are also the rights and
obligations of the insurance company as the insurer. Based on these provisions,
the insurer must pay compensation money to the policyholder or nominee if an
event or risk occurs (Afrita & Arifalina, 2021).
An insurance claim is an official
request to the insurance company to request payment based on the insurance
policy's provisions. The company will review the submitted insurance claims for
validity and then pay the insured party after approval. According to article
246 of the Commercial Law (KUHD), an insurance claim is a claim from the
insured party in connection with the existence of a contractual agreement
between the insurance company and the insured party, where each party binds
itself to guarantee payment of compensation by the insurer if the insured party
has made the insurance premium payment. The insured party when a disaster
occurs that is suffered by the insured party (Handayani, 2017). An insurance claim aims to provide benefits by the insurance
policy's provisions to the policyholder (insured) (Handayani, 2017).
If the participant's claim is not
paid, the participant can file for bankruptcy through the court. Because
insurance participants have legal protection. The regulations that form the
legal umbrella for protecting customers/insurance participants consist of Law
Number 8 of 1999 concerning Consumer Protection, Law Number 40 of 2014
concerning Insurance, Decree of the Minister of Finance No.422/KMK.06/2003
concerning Implementation of Insurance Business and Reinsurance Companies, and
Financial Services Authority Regulation Number 23/POJK.05/2015 concerning
Insurance Products and Marketing of Insurance Products (Bonita & Nurdin, 2021). Legal protection for insurance policyholders as consumers is not
only regulated in the Insurance Law. However, it is also regulated by the
Consumer Protection Law, which provides certainty regarding the security and
safety of consumers when consuming goods and services (Pangaribuan & Girsang, 2022). These two laws regulate the responsibilities that must be faced
by business actors, in this case, insurance companies providing information
that is not understood by consumers, which has a detrimental impact on
consumers or insurance policyholders (Laksono, 2018).
In principle, customers will be guaranteed legal protection by
statutory provisions stipulating various prohibited provisions. At the same
time, insurance companies make regulations or policies prohibited by statutory
regulations to give customers legal protection. When a dispute or conflict
arises between an insurance policy holder and an insurance company, by its
function, duties, and authority, the Financial Services Authority carries out a
mechanism for resolving consumer disputes either through justice or litigation
or extrajudicial or non-litigation dispute resolution (Majid & Sumriyah, 2023).
CONCLUSION
Insurance companies that reject participant claims may be subject to legal
responsibility in both civil and criminal realms. Based on this, insurance participants can file for bankruptcy
through a judicial process. The legal basis that protects insurance
participants consists of several regulations, including Law Number 8 of 1999
concerning Consumer Protection, Law Number 40 of 2014 concerning Insurance,
Decree of the Minister of Finance No.422/KMK.06/2003 concerning the
Implementation of Insurance Business and Reinsurance Companies, as well as
Financial Services Authority Regulation Number 23/POJK.05/2015 concerning
Insurance Products and Marketing of Insurance Products. Legal protection for
insurance policyholders who act as consumers are regulated in the Insurance Law
and consumer provisions in the Consumer Protection Law.
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