TM Executive Medicare

TM Executive Medicare is the medical-plus-life bundle for the customer who wants one policy schedule covering private-hospital treatment and a death/disability backstop together. It is an annually renewable, reimbursement-based health plan with four tiers (Plans A/B/C/D) that cap the overall annual claim — the RIPLAY calls it the Total Annual Cost (Biaya Tahunan Keseluruhan) — at Rp 100M, 200M, 300M and 500M respectively. Around the medical core sit three embedded riders: an Additional Expense Rider covering a companion’s travel and repatriation costs if the insured dies or stays hospitalized five or more consecutive days; an Accidental Death and Disability Benefit (Sum Assured / Uang Pertanggungan) of Rp 100M to Rp 2B depending on plan; and a Natural Death Benefit of Rp 500M available on Plans C and D only.

The structural point is that this is not a pure health card — it folds life-protection mechanics into a single health policy. Entry age is 18 to 65 for the adult insured (15 days to 22 years for a child), and the coverage period (Masa Pertanggungan) runs to the insured’s age 70.

Critical caveat: the brochure is not publicly published. Everything below is reconstructed from the RIPLAY only. The customer cannot self-verify from public collateral, so the agent must walk the policy schedule through explicitly at every pitch.

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The RIPLAY (TMLI-LC/PD/iv/POLDOC/4/2024) defines four standardized plans by overall annual claim ceiling (Biaya Tahunan Keseluruhan). The figures below are taken directly from the benefit table in the source — no figure is invented; where a value is absent from the RIPLAY it is marked “not in source.”

Critical insight for the agent narrative: the published numbers describe ceilings and sums assured, not price. The lone sample case understates real exposure because it pairs a large ceiling with a tiny claim. Lead with the ceiling logic and run a live quote — never anchor the customer on the Rp 13.5M sample.

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Sweet Spot — Lead with TM Executive Medicare

• Age 28–50, married, 1–2+ dependents
• Household income Rp 20M+/month (mass affluent to affluent)
• Already holds BPJS but wants a private-hospital speed layer for self and spouse
• Prefers certainty on what is covered (fixed annual ceiling) over complex health architectures
• Accepts an annual ceiling in exchange for a bundled life backstop
• Wants hospitalization plus a basic accidental-death payout in one policy
• Domestic focus, minimal regional travel
• Comfortable with reimbursement (pays first, claims after) rather than expecting a cashless card

Borderline Fit — Discuss but qualify carefully

• Age 51–60 — premium escalates steeply with age, full underwriting applies, and the Plan-A downgrade at 61 looms. Probe medical history upfront.
• Customers with chronic conditions (diabetes, hypertension) — the 12-month pre-existing exclusion AND the 12-month Special Disease (Penyakit Khusus) window both apply. Expect a delayed effective-cover date.
• High earners (Rp 30M+/month) wanting comprehensive cover — Plans C/D may feel capped at Rp 500M. Probe whether they need a higher-ceiling or multi-region product instead.
• Families with 3+ dependents — the policy is individual; stacking is required. Discuss total household cost upfront.

Do Not Pitch

• Mass-middle market with a health budget under roughly Rp 2M/month — entry tiers are priced for the affluent segment and will not convert.
• Customers with no BPJS or public-insurance base — sell the foundation first.
• Prospects wanting outpatient breadth (routine check-ups, dental, optical) — this is hospitalization-and-surgery focused and will disappoint. The RIPLAY explicitly excludes preventive check-ups, dental, refraction/lasik, and vaccination.
• Late-life prospects (65+) — entry caps at 65 and cover ends at 70; limited relevance for new business.
• Anyone seeking investment returns or cash value — this is protection only. There is a proportional premium refund on surrender, not a savings account.

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Rule of thumb: if the customer’s first sentence pairs “saya mau kalau masuk rumah sakit dicover” (I want hospitalization covered) WITH “kalau terjadi apa-apa, keluarga dapat santunan” (if something happens to me, my family gets a payout), TM Executive Medicare is in the conversation. If they say “saya hanya mau kartu rumah sakit cashless” (I only want a cashless hospital card) or “saya sudah punya asuransi jiwa lengkap” (I already have full life insurance), it is probably not the best fit.

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This section is QUALITATIVE. Health-category quantitative benchmarking is below the 60% PDF-coverage threshold, so the comparisons below are analyst judgment against peer reimbursement hospital-and-surgery (H&S) products, not population-scale metrics. Treat structural reads as RIPLAY-backed and economic reads as directional.

Confidence note: structural dimensions are high-confidence (RIPLAY-backed). Economic and competitive reads are analyst judgment, weakened by the missing by-age rate table and the unpublished brochure. Refresh trigger: when the project’s health PDF coverage clears 60%, OR when TMLI publishes the brochure with rate tables, re-run Section 5 against real quantitative benchmarks.

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Opening — establish the bundled-value frame

“Most people treat health insurance and life insurance as two separate purchases — a hospital card from one company, life protection from another. I want to show you a product that puts both in one policy: it covers your hospital and surgery costs, and if something happens to you, your family receives a payout. That combination is uncommon, and it’s worth ten minutes.”

“Kebanyakan orang anggap asuransi kesehatan dan asuransi jiwa itu dua hal terpisah — kartu rumah sakit dari satu perusahaan, proteksi jiwa dari yang lain. Saya mau tunjukkan satu produk yang gabungkan keduanya dalam satu polis: biaya rumah sakit dan operasi tercover, dan kalau terjadi sesuatu pada Anda, keluarga dapat santunan. Kombinasi seperti ini jarang, dan layak kita bahas sepuluh menit.”

The bundled-life value prop

“With this policy you get three things most health products don’t put together. First, up to Rp 300 million a year for hospitalization and surgery on Plan C. Second, if you have an accident, your family receives Rp 1 billion in accidental death and disability protection. Third, if you’re hospitalized for more than five days, the policy covers a family member’s flight and accommodation to be with you. That third piece is genuinely unusual.”

“Dengan polis ini Anda dapat tiga hal yang biasanya tidak digabung produk kesehatan lain. Pertama, sampai Rp 300 juta per tahun untuk rawat inap dan operasi di Plan C. Kedua, kalau Anda mengalami kecelakaan, keluarga dapat Rp 1 miliar santunan meninggal dan cacat akibat kecelakaan. Ketiga, kalau Anda dirawat lebih dari lima hari, polis menanggung tiket dan akomodasi keluarga untuk mendampingi Anda. Bagian ketiga ini benar-benar jarang ada.”

The reimbursement reality (set this honestly)

“One thing I always make clear up front: this works by reimbursement, not a cashless card. You settle the hospital bill, then submit the claim, and Tokio Marine pays you back up to the plan limit. You file within 30 days of discharge. I’ll help you prepare the documents so it’s smooth. If a swipe-and-go cashless card is essential for you, tell me now and we’ll look at the right option — I’d rather you know exactly how this works than be surprised at the cashier.”

“Satu hal yang selalu saya jelaskan di awal: ini sistemnya reimbursement, bukan kartu cashless. Anda bayar dulu tagihan rumah sakit, lalu ajukan klaim, dan Tokio Marine ganti sampai batas plan Anda. Klaim diajukan dalam 30 hari setelah keluar rumah sakit. Saya bantu siapkan dokumennya supaya lancar. Kalau kartu cashless memang wajib buat Anda, bilang sekarang dan kita lihat opsi yang tepat — saya lebih suka Anda tahu persis cara kerjanya daripada kaget di kasir.”

The fixed-ceiling clarity

“Let me be precise about the medical limit. Plan C covers up to Rp 300 million per policy year. For a serious event — say a long ICU stay or cancer treatment in a top private hospital — you could reach that ceiling. So this isn’t unlimited; what it is, is predictable. You know your maximum exposure. And the life side — Rp 1 billion for accident, Rp 500 million for natural death on Plan C — covers your family’s immediate need no matter what the hospital bill was.”

“Saya jelaskan tepat soal batas medis. Plan C menanggung sampai Rp 300 juta per tahun polis. Untuk kejadian berat — misalnya rawat ICU lama atau pengobatan kanker di rumah sakit swasta papan atas — Anda bisa sampai ke batas itu. Jadi ini bukan tanpa batas; tapi ini pasti. Anda tahu maksimum risiko Anda. Dan sisi jiwanya — Rp 1 miliar untuk kecelakaan, Rp 500 juta untuk meninggal alami di Plan C — menjaga kebutuhan keluarga Anda berapa pun tagihan rumah sakitnya.”

The plans-comparison pitch

“There are four plans. Plan A is Rp 100 million medical, entry level. Plan B doubles that to Rp 200 million and lifts accidental death to Rp 500 million — a sensible middle. Plan C is Rp 300 million medical, Rp 1 billion accidental, plus Rp 500 million if you die of natural causes. Plan D is the ceiling: Rp 500 million medical, Rp 2 billion accidental, same natural-death amount. Most of the clients I work with land on Plan B or C.”

“Ada empat plan. Plan A Rp 100 juta medis, level dasar. Plan B menggandakannya jadi Rp 200 juta dan menaikkan santunan kecelakaan ke Rp 500 juta — titik tengah yang masuk akal. Plan C Rp 300 juta medis, Rp 1 miliar kecelakaan, plus Rp 500 juta kalau Anda meninggal alami. Plan D yang tertinggi: Rp 500 juta medis, Rp 2 miliar kecelakaan, santunan meninggal alami sama. Kebanyakan nasabah saya memilih Plan B atau C.”

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1. BPJS adequacy

“I already have BPJS. Why do I need private insurance on top?”

“Saya sudah punya BPJS. Kenapa perlu asuransi swasta lagi?”

Don't say “BPJS isn’t enough.” — confrontational and dismisses a state programme the customer values.

Don't say “BPJS tidak cukup.”

Do say “BPJS is a solid foundation — keep it. This adds speed and choice. On BPJS you queue at a public hospital and the specialist roster is limited. With this, you go to the private hospital you choose, see your own doctor, and skip the queue. For a serious event — appendix, accident, cancer — that speed matters. Most of my clients keep BPJS and layer a private plan on top; the two work together.”

Do say “BPJS itu fondasi yang bagus — pertahankan. Ini menambah kecepatan dan pilihan. Di BPJS Anda antre di rumah sakit umum dan pilihan spesialisnya terbatas. Dengan ini, Anda ke rumah sakit swasta pilihan Anda, ditangani dokter sendiri, tanpa antre. Untuk kejadian serius — usus buntu, kecelakaan, kanker — kecepatan itu penting. Kebanyakan nasabah saya tetap pakai BPJS dan menambah plan swasta di atasnya; keduanya saling melengkapi.”

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2. Premium escalation at renewal / older age

“How much does the premium rise each year as I get older?”

“Preminya naik berapa setiap tahun seiring usia saya bertambah?”

Don't say “Just standard increases.” — too vague; invites distrust.

Don't say “Naik standar saja kok.”

Do say “I’ll be straight with you. This renews yearly, so the premium moves with two things: your age — it rises naturally as you get older — and medical inflation in Indonesia, which has been running roughly 20% or more a year. There’s one more thing you should know: on Plans B, C and D, when you reach age 61 the policy converts to Plan A and the premium is re-set. So entering now, at your current age, is the cheapest point you’ll ever have. I’ll run a projection at your exact age before you decide anything.”

Do say “Saya jujur ke Anda. Ini diperpanjang tiap tahun, jadi premi bergerak ikut dua hal: usia Anda — naik alami seiring bertambah tua — dan inflasi medis di Indonesia, yang belakangan sekitar 20% atau lebih per tahun. Ada satu hal lagi yang perlu Anda tahu: di Plan B, C, dan D, saat Anda mencapai usia 61 polis berubah jadi Plan A dan premi disesuaikan. Jadi masuk sekarang, di usia Anda saat ini, adalah titik termurah yang akan pernah Anda dapat. Saya buatkan proyeksi di usia persis Anda sebelum Anda memutuskan apa pun.”

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3. Low utilization (“I’m healthy, this is wasted money”)

“I’m rarely sick. I’d be paying for something I never use.”

“Saya jarang sakit. Rasanya bayar untuk sesuatu yang tidak pernah dipakai.”

Don't say “Everyone gets sick eventually.” — fear-selling, and it sounds MLM.

Don't say “Semua orang pasti sakit nanti.”

Do say “Being healthy is exactly the right time to buy — it’s why you qualify at the best terms and without exclusions piling on. You’re not buying this for the small bills you can pay yourself; you’re buying it for the one event that could cost Rp 200–300 million and arrive without warning. And remember this plan isn’t only medical: the accidental-death and disability cover protects your family even in a year you never see a hospital. If you stop the policy, you surrender the protection on the day you might need it most.”

Do say “Justru saat sehat adalah waktu paling tepat untuk membeli — karena Anda memenuhi syarat dengan ketentuan terbaik dan tanpa banyak pengecualian. Anda tidak membeli ini untuk tagihan kecil yang bisa Anda bayar sendiri; Anda membelinya untuk satu kejadian yang bisa menghabiskan Rp 200–300 juta dan datang tanpa aba-aba. Dan ingat, plan ini bukan cuma medis: santunan kecelakaan dan cacat tetap melindungi keluarga Anda bahkan di tahun Anda tidak pernah ke rumah sakit. Kalau Anda hentikan polisnya, Anda melepas proteksi tepat di hari Anda mungkin paling membutuhkannya.”

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4. Annual-limit anxiety

“Rp 300 million isn’t enough if I get a serious illness.”

“Rp 300 juta tidak cukup kalau saya kena penyakit serius.”

Don't say “It’s plenty.” — the customer has heard private-hospital prices and won’t believe it.

Don't say “Rp 300 juta cukup banget kok.”

Do say “You’re thinking about this correctly. A long ICU stay or a cardiac event in a top Jakarta private hospital can run Rp 200–400 million, so on Plan C a very severe case could brush the ceiling. Here’s the honest mechanic: if the bill is Rp 350 million, the plan pays Rp 300 million and you cover Rp 50 million — very different from being uninsured. If the ceiling worries you, Plan D gives you Rp 500 million, which covers nearly any single domestic event. We size the plan to the risk you actually want to manage, not to a brochure number.”

Do say “Cara Anda berpikir ini benar. Rawat ICU yang lama atau serangan jantung di rumah sakit swasta papan atas Jakarta bisa habis Rp 200–400 juta, jadi di Plan C kasus yang sangat berat bisa mendekati batas. Ini mekanisme jujurnya: kalau tagihan Rp 350 juta, plan bayar Rp 300 juta dan Anda menanggung Rp 50 juta — sangat berbeda dengan tanpa asuransi sama sekali. Kalau batasnya membuat Anda khawatir, Plan D memberi Rp 500 juta, yang menanggung hampir semua kejadian tunggal di dalam negeri. Kita sesuaikan plan dengan risiko yang benar-benar ingin Anda kelola, bukan dengan angka brosur.”

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5. Exclusion list / pre-existing conditions

“There’s a long list of exclusions, and I have a pre-existing condition. Will I actually be covered?”

“Pengecualiannya panjang, dan saya punya kondisi bawaan. Apa saya benar-benar tercover?”

Don't say “Don’t worry about the fine print.” — exactly what triggers a mis-selling complaint later.

Don't say “Tenang, jangan pikirkan tulisan kecilnya.”

Do say “Let’s go through it honestly, because this is where trust is built. Two rules apply for the first 12 months: any condition you already have today, and any of the named Special Diseases — diabetes, hypertension, certain tumours, hernia, kidney conditions and so on — are not covered. From month 13 onward, those are covered. There are also permanent exclusions: cosmetic and refraction surgery, dental, pregnancy and childbirth, congenital conditions, and high-risk activities. Tell me your full medical history now; I’d rather set the right expectation today than have a claim declined later.”

Do say “Mari kita bahas jujur, karena di sinilah kepercayaan dibangun. Dua aturan berlaku untuk 12 bulan pertama: kondisi apa pun yang sudah Anda miliki sekarang, dan Penyakit Khusus yang disebutkan — diabetes, darah tinggi, tumor tertentu, hernia, gangguan ginjal, dan sebagainya — tidak dicover. Mulai bulan ke-13, semua itu dicover. Ada juga pengecualian permanen: operasi kosmetik dan refraksi mata, gigi, kehamilan dan persalinan, kelainan bawaan, serta aktivitas berisiko tinggi. Ceritakan riwayat kesehatan lengkap Anda sekarang; saya lebih suka memberi harapan yang tepat hari ini daripada klaim Anda ditolak nanti.”

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These are the issues most likely to trigger OJK complaints or customer churn under the tightened 2026 conduct regime. Build agent training around avoiding all of them.

1. POJK 36/2025 co-payment regime — mandatory disclosure. Effective January 2026, POJK 36/2025 imposes a co-payment (risiko sendiri) requirement on ALL health insurance products. The RIPLAY in hand does not spell out a co-pay percentage or cap, so the agent must NOT tell a customer “you pay nothing beyond the premium.” Before pitching, confirm with TMLI how the co-payment regime applies to TM Executive Medicare (percentage, floor, ceiling) and disclose it explicitly. Treating this product as exempt is a conduct violation.

2. Reimbursement, not cashless — expectation mis-set. The RIPLAY frames benefits as reimbursement (penggantian) of treatment cost. An affluent customer who assumes a swipe-and-go cashless card will feel mis-sold at the hospital cashier. Disclose the reimbursement mechanic and the 30-day claim-filing window verbally and in writing at SPAJ stage.

3. Overall annual limit (Biaya Tahunan Keseluruhan) exhaustion. Quoting “up to Rp 300 million medical” without clarifying it is an overall ceiling per policy year that a serious illness can exhaust is high complaint risk. Example: a Plan C holder with a Rp 350M bill owes Rp 50M out of pocket. The customer must confirm understanding of the ceiling, documented separately on the SPAJ.

4. Coverage ends at age 70 — renewability / continuation gap; plus the forced Plan-A downgrade at 61. Cover runs only to the insured’s age 70, and on Plans B/C/D the policy is forcibly converted to Plan A at age 61 with the premium re-set. A 55-year-old buyer expecting lifelong, level cover is being mis-set. State both the age-70 endpoint and the age-61 downgrade in writing; have the customer initial them.

5. Natural Death Benefit absent on Plans A/B. Customers may assume every plan includes a death payout. Plans A and B carry zero natural-death benefit. This is discovered at claims time unless disclosed. The absence must be stated in writing on the application, separate from the main benefit table, with the customer’s sign-off.

6. Pre-existing condition AND Special Disease 12-month exclusions stack. The product hard-excludes both pre-existing conditions and 18 named Special Diseases (Penyakit Khusus) for the first 12 months. A customer diagnosed with diabetes today has diabetes claims excluded for 12 months. The RIPLAY language is dense and bilingual — translate plainly: “Anything you have today, and the listed conditions, are not covered for the first 12 months; from month 13 they are.” Get verbal and written confirmation. Note also the proportional, no-interest preming handling on cancellation for misstatement — material non-disclosure can void cover.

7. Publishing-gap B data-quality flag — brochure unavailable. The brochure is not publicly published; it sits on the TMLI internal portal only. Customers cannot independently verify product details from public collateral, so the agent must walk the policy schedule, ceiling table, and rider conditions through explicitly at every pitch and document that the customer reviewed the RIPLAY (or an agent-produced summary) before signing the SPAJ. This brief is itself reconstructed from the RIPLAY alone — treat any figure not present in the RIPLAY as unconfirmed until the brochure or policy is obtained.

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1. Confirm the POJK 36/2025 co-payment treatment with TMLI in writing. Ask the TMLI relationship manager exactly how the January-2026 co-payment regime applies to TM Executive Medicare — percentage, floor, ceiling, and any exempt benefit lines. Until this is documented, agents must disclose co-pay as “applicable, terms to be confirmed” and never as zero. This is the single highest compliance priority.

2. Build a “Plans at a Glance” comparison card (EN + ID) showing all four plans side by side — medical ceiling, accidental-death amount, natural-death amount — with two bold footnotes: “Plans A/B have no natural-death benefit” and “Plans B/C/D convert to Plan A at age 61.” Print it and use it in every pitch to kill plan-confusion mis-sells.

3. Create a “Ceiling and Reimbursement Explained” handout (EN + ID) with a worked scenario (“Rp 350M bill, Plan C pays Rp 300M, you cover Rp 50M”) and a plain statement that the product reimburses rather than runs cashless. Get the customer’s sign-off on this sheet before SPAJ submission to establish mutual understanding of both the ceiling and the claim mechanic.

4. Develop a pre-existing and Special Disease declaration checklist (EN + ID) listing all 18 named Penyakit Khusus (diabetes, hypertension, hernia, asthma, kidney/liver failure, tumours, etc.). Walk each prospect through it, record findings on the SPAJ, and use it to set the correct 12-month effective-cover expectation up front.

5. Refresh trigger — obtain and extract the brochure. Flag TM Executive Medicare for re-brief the moment TMLI publishes a public brochure OR releases a by-age rate table / sample-premium grid. At that point, re-run Section 2 (real pricing), Section 5 (quantitative benchmarking against the health category once PDF coverage clears 60%), and lift Analyst confidence above Medium-Low. Set a 30-day calendar check with the TMLI RM to chase brochure availability.

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