TM Optima Hospital & Surgery Plus

TM Optima Hospital & Surgery Plus is the premium-tier comprehensive answer to the customer who says “I want real hospital cover, not a table of sub-limits telling me what I can’t claim.” It is an annually renewable health indemnity policy that reimburses on a Reasonable & Customary basis (Biaya Wajar dan Lazim) rather than itemised daily sub-limits, structured as a plan ladder across three coverage regions — Indonesia & Malaysia (IDMY), Asia (excluding Singapore, Japan, Hong Kong), and Worldwide — each available in standard and PLUS (higher-limit) form, plus an EXECUTIVE range (Silver / Platinum) for the high-net-worth segment.

Annual overall caps scale from Rp 100M on the entry IDMY tier all the way to Rp 60B on EXECUTIVE Platinum. Room and ICU are covered up to 365 days per policy year, renewal runs to age 100, and in-region claims are reimbursed at 95% (customer bears 5%).

In one line: Comprehensive cover, no sub-limit surprises, pick your region and your annual cap, renew to age 100 — Tokio Marine pays the reasonable and customary charges.

For Legacy Income this is a home-carrier product. Agents can quote, illustrate, and place it directly — the positioning work below is meant to be deployed, not just filed as intel.

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The official RIPLAY illustration uses Putri, female, age 34, EXECUTIVE Silver (Indonesia & Malaysia), pro-rata, zero deductible, Rp 9,278,000 annual premium. Decoded against the sourced plan ladder:

Critical insight for the agent narrative: the power feature is the R&C charge model layered on a wide plan ladder. A customer who has hit a “Rp 300K/day room” cap on a competitor product immediately understands “if a reasonable room in your area is Rp 1.5M/day, we pay 95% of it.” The honest trade-off is the Year 1 special-disease cap of Rp 5M and the 24-month pre-existing window — both must be disclosed, never buried.

Brochure vs RIPLAY note: the customer brochure headlines a separate, simpler “TM Optima Hospital & Surgery 300” plan (150-day room, 45-day ICU, single Indonesia region, Rp 70M overall limit). The RIPLAY for “Plus” does NOT contain a “300” tier — its tiers are 500 / 1.000 / 1.500 plus EXECUTIVE, all at 365-day room/ICU. Treat “300” as a lower sibling product; do not quote 300-plan numbers when illustrating “Plus”.

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Sweet Spot

• Age 32–55, married, 1–3 dependents.
• Household income Rp 15M+/month, with Rp 8–15M/year comfortably available for health premium.
• Already holds or is actively buying life cover; health-conscious professional, business owner, or executive.
• Has experienced sub-limit caps on a competitor product and dislikes them — the R&C model is an easy “aha”.
• Moves between Indonesia and Malaysia for business, family, or healthcare access — the IDMY plan fits exactly, at the full 95% in-region rate.
• Comfortable accepting the Year 1 special-disease Rp 5M cap as the price of an affordable entry premium.
• For the affluent / HNW prospect who wants near-uncapped protection, the EXECUTIVE Platinum (Rp 60B overall limit) or a PLUS tier (Rp 1B–3B) is the natural lead.

Borderline Fit

• Age 56–65 — entry is allowed but premium loads meaningfully and underwriting tightens; probe for stable health vs a chronic condition that will simply hit the 24-month pre-existing wall.
• Age 25–32, strong income trajectory — entry-level premium (~Rp 8–10M) is a stretch; frame as future-proofing, not immediate need.
• Customers wanting full ambulatory cover (routine outpatient, wellness, dental) — Optima is inpatient/surgery-led with selected outpatient (accident, dialysis, cancer, physiotherapy). Position it as the hospital backbone; add or accept a separate outpatient solution.
• Customers cross-shopping Allianz / Prudential premium medical — close peer set. Optima’s edge is regional-tier flexibility + renewal to 100 + R&C transparency; competitors may counter on currency optionality or specific network depth. Let the customer’s real travel and budget pattern decide.

Do Not Pitch

• Budget under Rp 5M/year for health — entry premium is above that; refer to the lower “300” sibling, a rider, or BPJS-plus.
• Customers with diagnosed chronic conditions on the special-disease list (diabetes, hypertension, hernia, asthma, kidney/liver disease, tumours, etc.) who are unwilling to accept the 24-month wait — the pre-existing exclusion will void most early claims. Be transparent up front.
• Sharia-only customers — Optima is conventional; refer to a Sharia-compliant alternative.
• Customers who recently had a claim declined elsewhere and now deeply distrust insurers — the R&C model plus underwriting will not rebuild trust quickly; resolve the prior grievance first.
• Self-employed / gig workers with unstable income — the Rp 9M+ annual commitment creates lapse risk; verify sustainable income before writing.

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Coverage / confidence note: the Indonesia health category sits below 60% numeric (PDF-extracted) coverage in the Market Intelligence inventory. The comparison below is therefore QUALITATIVE and structural — a read against peer cashless/reimbursement hospital & surgery products — NOT population statistics. Treat directional reads (e.g. “top of category on renewal age”) as analyst judgment pending deeper extraction, not as a measured percentile. Confidence: Medium for structural claims, Low for any implied cost ranking.

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Opening — set the right frame

“Most people think health insurance is about getting a discount at the hospital. I see it differently. It is about making sure that when you genuinely need care, you get the care you need — not the care a sub-limit table happens to allow.”

“Kebanyakan orang mengira asuransi kesehatan itu soal dapat diskon di rumah sakit. Saya melihatnya beda. Ini soal memastikan, pas Anda benar-benar butuh perawatan, Anda dapat perawatan yang memang dibutuhkan — bukan yang kebetulan diizinkan oleh tabel limit.”

The structural value prop — R&C beats sub-limits

“In this policy you will not find a line that says ‘Room: Rp 300K maximum per day.’ Instead it says: if a reasonable room in your area costs, say, Rp 1.5M a day, that is what we work from. We pay our share, you pay yours, no nasty surprise when the bill arrives.”

“Di polis ini Anda nggak akan nemu baris ‘Kamar: maksimal Rp 300 ribu per hari.’ Yang ada justru: kalau kamar yang wajar di daerah Anda harganya, misalnya, Rp 1,5 juta sehari, itu yang jadi dasar perhitungan kami. Kami bayar bagian kami, Anda bagian Anda, dan nggak ada kejutan pas tagihan keluar.”

The regional pitch — Indonesia & Malaysia families

“You work in Jakarta but your parents are in KL and you are back and forth for business. The IDMY plan covers both countries at the same 95% in-region rate. Admitted in Jakarta or in Kuala Lumpur — same cover, same cost-sharing.”

“Anda kerja di Jakarta tapi orang tua di KL, dan Anda bolak-balik buat bisnis. Plan IDMY mengcover dua negara itu dengan rate yang sama, 95% di dalam wilayah. Mau dirawat di Jakarta atau di Kuala Lumpur — covernya sama, bagi biayanya juga sama.”

The age-100 renewal pitch

“Many health policies stop renewing at 80 or 85. This one renews to 100. That is unusual here. It means when you are 70, 75, 80 — when you actually use hospitals more — your cover is still there, on the same terms.”

“Banyak polis kesehatan berhenti diperpanjang di usia 80 atau 85. Yang ini bisa terus sampai 100. Itu jarang di Indonesia. Artinya pas Anda 70, 75, 80 — justru saat lebih sering ke rumah sakit — proteksi Anda masih ada, dengan syarat yang sama.”

The Year 1 special-disease talk — disclose the trade-off

“There is one trade-off I want to be straight with you about. In your first year, if you are diagnosed with something on the special-disease list — cancer or kidney failure needing dialysis, for example — the benefit for that condition is capped at Rp 5 million. In year two it becomes 50% of the approved claim, and from year three it is full benefit. This is part of how the premium stays affordable, and it is something you should know going in.”

“Ada satu hal yang mau saya sampaikan terus terang. Di tahun pertama, kalau Anda terdiagnosa penyakit yang masuk daftar penyakit khusus — misalnya kanker atau gagal ginjal yang perlu cuci darah — manfaat untuk kondisi itu dibatasi Rp 5 juta. Tahun kedua jadi 50% dari klaim yang disetujui, dan mulai tahun ketiga manfaatnya penuh. Ini bagian dari cara menjaga premi tetap terjangkau, dan ini hal yang sebaiknya Anda tahu dari awal.”

The premium-feels-high reframe

“Compare it to a capped rider. With a Rp 500K room cap, a Rp 1.5M room means you cover Rp 1M a day from your own pocket — over a five-day stay that is Rp 5M you carry alone. This policy works from reasonable charges instead. The premium is higher up front, but the out-of-pocket risk when you actually claim is much lower.”

“Bandingkan dengan rider yang ada capnya. Dengan cap kamar Rp 500 ribu, kamar Rp 1,5 juta berarti Anda nanggung Rp 1 juta sehari dari kantong sendiri — lima hari berarti Rp 5 juta Anda tanggung sendirian. Polis ini pakai dasar biaya yang wajar. Preminya memang lebih tinggi di depan, tapi risiko keluar uang pas benar-benar klaim jauh lebih kecil.”

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1. “BPJS already covers me. Why pay extra?”

Objection “I already have BPJS — why do I need this on top?”

Objection “Saya sudah punya BPJS — kenapa harus bayar ini lagi?”

Don't say “BPJS is useless.” — dismissive and untrue; many use BPJS well.

Don't say “BPJS itu nggak ada gunanya.”

Do say “BPJS is a good foundation, and keep it. But it works on a referral and class system, with queues for certain procedures and a limited room class. This policy is what you reach for when you want a private room, a specialist of your choice, or faster access — reimbursed on reasonable charges, not a fixed class. Many of my clients run both: BPJS as the base, Optima for choice and speed.”

Do say “BPJS itu fondasi yang bagus, dan sebaiknya tetap dipertahankan. Tapi BPJS jalan pakai sistem rujukan dan kelas, ada antrean untuk tindakan tertentu, dan kelas kamarnya terbatas. Polis ini yang Anda andalkan pas mau kamar pribadi, dokter spesialis pilihan sendiri, atau akses lebih cepat — diganti berdasarkan biaya yang wajar, bukan kelas tetap. Banyak klien saya pakai keduanya: BPJS sebagai dasar, Optima untuk pilihan dan kecepatan.”

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2. “The premium will keep climbing as I get older.”

Objection “This renews every year — won’t the premium just keep rising as I age?”

Objection “Ini diperpanjang tiap tahun — preminya naik terus kan seiring umur?”

Don't say “No, the premium is fixed.” — false; this is an annually renewable, age-banded product.

Don't say “Nggak kok, preminya tetap.”

Do say “Be clear-eyed about this: it is annually renewable, so premium does step up with age band over time — that is true of every honest medical policy. Two things work in your favour. One, you lock in entry now while you are younger and healthier, before any condition is on record. Two, there is a 10% no-claim discount on the next year’s premium when you have a clean year. The value is that the cover follows you all the way to age 100 — something most policies cannot offer.”

Do say “Saya jujur soal ini: ini diperpanjang per tahun, jadi seiring naiknya kelompok usia, preminya memang naik — itu berlaku untuk semua polis medis yang jujur. Dua hal menguntungkan Anda. Pertama, Anda kunci masuk sekarang selagi lebih muda dan sehat, sebelum ada kondisi yang tercatat. Kedua, ada diskon no-claim 10% untuk premi tahun berikutnya kalau setahun Anda bersih tanpa klaim. Nilainya, proteksi ini ikut Anda sampai usia 100 — sesuatu yang nggak bisa ditawarkan kebanyakan polis.”

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3. “I’m healthy and barely go to the hospital — it feels like wasted money.”

Objection “I’m rarely sick. This feels like money I’ll never use.”

Objection “Saya jarang sakit. Ini kayak buang-buang uang yang nggak kepakai.”

Don't say “You never know when you’ll get sick.” — fear-selling, and vague.

Don't say “Anda nggak pernah tahu kapan sakit.”

Do say “Good — staying healthy is exactly the point, and the no-claim discount rewards you for it: 10% off next year when you don’t claim. This is not for the small coughs and colds you handle yourself. It is for the one event you cannot budget for — an accident, an emergency surgery, a sudden serious diagnosis — where a few days in a private hospital can run tens of millions. You are not buying frequent use; you are buying a ceiling on a catastrophic bill.”

Do say “Bagus — justru tetap sehat itu intinya, dan diskon no-claim malah menghargai itu: 10% lebih murah tahun depan kalau Anda nggak klaim. Ini bukan buat batuk-pilek kecil yang bisa Anda urus sendiri. Ini buat satu kejadian yang nggak bisa Anda anggarkan — kecelakaan, operasi darurat, diagnosis serius yang tiba-tiba — di mana beberapa hari di rumah sakit swasta bisa puluhan juta. Anda bukan beli pemakaian sering; Anda beli batas atas untuk tagihan yang katastrofik.”

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4. “What’s the point of an annual limit? What if I blow through it?”

Objection “There’s still an annual cap. What happens if a big illness exceeds it?”

Objection “Tetap ada limit tahunan. Gimana kalau penyakit besar melebihi itu?”

Don't say “That will never happen to you.” — a promise you cannot keep.

Don't say “Itu nggak akan kejadian ke Anda.”

Do say “Fair concern, and this is where choosing the right tier matters. The entry IDMY tier caps at Rp 100M a year; the PLUS tiers go to Rp 1B, 2B, 3B; and EXECUTIVE Platinum reaches Rp 60B. We size the annual limit to your real exposure and budget. For someone worried about a catastrophic event — a complex cancer course or a long ICU stay — we pick a PLUS or EXECUTIVE tier so the ceiling is well above any realistic bill, not a tight Rp 100M.”

Do say “Kekhawatiran yang wajar, dan di sinilah pemilihan tier yang tepat jadi penting. Tier IDMY dasar limitnya Rp 100 juta setahun; tier PLUS sampai Rp 1, 2, 3 miliar; dan EXECUTIVE Platinum mencapai Rp 60 miliar. Kita sesuaikan limit tahunan dengan eksposur nyata dan anggaran Anda. Untuk yang khawatir kejadian katastrofik — rangkaian terapi kanker yang kompleks atau ICU lama — kita ambil tier PLUS atau EXECUTIVE supaya batasnya jauh di atas tagihan realistis, bukan Rp 100 juta yang mepet.”

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5. “I have a pre-existing condition — will this even cover me?”

Objection “I already have diabetes / hypertension — is that covered, or am I wasting my time?”

Objection “Saya sudah punya diabetes / darah tinggi — itu dicover nggak, atau saya buang waktu saja?”

Don't say “Don’t worry, everything is covered.” — flatly false and a mis-selling risk.

Don't say “Tenang, semua dicover kok.”

Do say “I’ll be honest because it matters. If you already have a condition, anything related to it — treatment, tests, medication, complications — is excluded for the first 24 months, and it must be declared on your application. So the real question is what you are buying this for. If you need cover for the diabetes itself right now, this is not the right fit and I’ll say so. If you are protecting against the new things — an accident, a fresh cancer diagnosis, an emergency unrelated to the diabetes — then it works well, and the exclusion is a known boundary we accept together, in writing.”

Do say “Saya jujur karena ini penting. Kalau Anda sudah punya kondisi tertentu, segala yang terkait — perawatan, tes, obat, komplikasi — dikecualikan selama 24 bulan pertama, dan harus dideklarasikan di aplikasi. Jadi pertanyaan sebenarnya: ini Anda beli untuk apa. Kalau Anda butuh cover untuk diabetesnya itu sendiri sekarang, ini bukan produk yang pas dan saya akan bilang begitu. Tapi kalau Anda melindungi diri dari hal-hal baru — kecelakaan, diagnosis kanker baru, kondisi darurat yang nggak terkait diabetes — ini cocok, dan pengecualian tadi adalah batas yang kita sepakati bersama, secara tertulis.”

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1. POJK 36/2025 co-payment regime applies to ALL health products from Jan 2026 — explain risiko sendiri. The 2026-06-04 RIPLAY itself does not cite POJK 36/2025 by name, but the regulation governs every health product sold from January 2026. The agent MUST explain the customer’s cost-sharing (risiko sendiri / ko-asuransi): in Optima this appears as the 5% in-region customer share plus any chosen deductible. Show it in the illustration and obtain a co-payment acknowledgment. Never present the product as “100% covered”.

2. Reimbursement vs cashless expectation. Confirm the customer’s expectation up front. Reimbursement means the customer may pay first and claim back; cashless depends on the hospital being a participating provider. Do not let a customer assume every hospital is cashless. State which pathway applies and that out-of-network use shifts the “reasonable” benchmark to Tokio Marine’s regional table, not the hospital invoice.

3. Annual Overall Limit (Limit Tahunan Keseluruhan) exhaustion. Each plan tier has a hard annual ceiling (Rp 100M entry IDMY up to Rp 60B EXECUTIVE Platinum). Once exhausted in a policy year, further claims that year are not paid. The agent must size the tier to the customer’s exposure and state the ceiling explicitly — selling an entry tier to someone who needs catastrophic cover is a mis-sell.

4. Pre-existing condition & waiting-period disclosure. The 24-month pre-existing exclusion is broad and covers both declared and undeclared prior conditions; non-disclosure on the SPAJ can void a claim. Walk the customer through the special-disease list. If any listed condition is present, state plainly that it is excluded for 24 months. Get this in writing.

5. Special-disease Year 1 / Year 2 staging. The Rp 5M Year 1 cap and 50% Year 2 benefit on Perawatan Penyakit Khusus (which includes cancer and dialysis-related care) is material. A customer who believes cancer is fully covered from day one and is diagnosed in month four is a complaint waiting to happen. Disclose the staging in writing and have it acknowledged separately at SPAJ.

6. Reasonable & Customary (Biaya Wajar dan Lazim) basis. Benefits are paid on an R&C basis subject to per-treatment and annual limits — not on whatever the hospital invoices. Explain that an overcharge or a non-standard treatment may be reduced at claim. Never imply the policy pays any amount a hospital bills.

7. Regional reimbursement step-downs. In-region pays 95%, but Worldwide-tier treatment outside Asia/IDMY pays 80%, and out-of-region inpatient on an IDMY plan drops to 50% (Asia) or 10% (Worldwide). Match the plan region to where the customer actually expects treatment, and disclose the step-down bands. Selling an IDMY plan to someone who travels widely, without explaining the penalty bands, is a mis-sell.

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1. Build the Optima plan-ladder quoting cheat sheet (EN+ID, mobile/printable). One page mapping the three regions x standard/PLUS/EXECUTIVE to their Annual Overall Limits (Rp 100M → Rp 60B), 365-day room/ICU, and in-region 95% / step-down bands. This is the single most useful field tool for matching a tier to a customer in one conversation. Owner: product/training lead. Deadline: 2 weeks.

2. Create the Year 1 special-disease handout (EN+ID), signed at SPAJ. Vertical, mobile-friendly: the special-disease list, the Rp 5M Year 1 cap, the 50% Year 2 phase-in, full benefit Year 3+, with one worked example. Make customer acknowledgment a mandatory, separately signed item — this is the top churn-back and OJK-complaint risk.

3. Issue a POJK 36/2025 co-payment talking-points card to every agent. Show the 5% in-region share plus deductible options, explain why it is compliant, and use Putri’s case for the rupiah impact. Make co-payment disclosure a standard step in every Optima illustration, not optional.

4. Run a field audit of recent Optima SPAJs. Five-item checklist per file: (a) Year 1 Rp 5M cap disclosed and signed; (b) pre-existing / special-disease list reviewed; © plan region matched to expected treatment location and step-downs explained; (d) Annual Overall Limit ceiling stated; (e) co-payment acknowledged. Flag any file missing two or more as high-risk.

5. Add an Optima + life pairing micro-training (15 min). Optima buyers are affluent and health-aware — the natural next gap is income protection. Script the bridge: “Beyond hospital bills, how is your family’s income protected if something happens to you?” Pair Optima (hospital layer) with a term or whole-life policy (income layer). This directly advances Legacy Income’s agency growth and revenue target.

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