Policy - Riders English (04062012)

ENGLISH TRANSLATION
RIDERS
PT. ASURANSI ALLIANZ LIFE INDONESIA
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ADDENDUM
ADDITIONAL INSURANCE
CRITICAL ILLNESS PLUS (CI PLUS)
We shall give insurance coverage to person(s) whose named is (are) written as the Insured on
the Policy Data page of Basic Policy where this Additional Insurance enclosed, by following any
stipulations existing in this Additional Insurance Coverage herein. We shall give this additional
insurance due to your request related to Basic Policy You own, and shall be valid only if this
Additional Insurance has been written on the Policy Data of the Basic Policy or on the
Endorsement/Addendum and its paid Premium.
Article 1
DEFINITION
1.
Daily Activity shall mean 5 (five) things as follows:

a.
Taking a bath shall refer to self-ability to clean own body when taking a bath or using
shower or cleaning own body using other good manners.
b.
Dressing shall refer to self-ability to wear, put off, tighten, loosen all kinds of dresses.
c.
Feeding shall refer to self-ability to put the food into own mouth in which the food has
been prepared and served.
d.
Relieving shall refer to self-ability to defecate and urinate in toilet or water closet, or at
least able to defecate or urinate to keep good self-health condition.
e.
Moving shall refer to self-ability to move own body from bed to chair with upright
support or to move from one place to another on flat floor without using a wheelchair.
Article 2
BENEFIT
1.
During the Policy effectiveness, We will pay Additional Insurance Benefit after receiving
and approving any claim evidences proposed in case the Insured suffers/firstly diagnosed
from a kind of illness based on the definition stated in Article 3 of this Additional Insurance
hereof.
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2.
Benefit payment aforementioned above will be conducted after being calculated with total
loans and other obligations, if present, and shall not reduce total Basic Policy Insurance
Coverage.
3.
After above benefit being 100% paid, Additional Insurance on Critical Illness shall be
automatically terminated.
Article 3
DEFINITION OF CRITICAL ILLNESS
This benefit shall bear one of 38 (thirty eight) critical illnesses as follows:
1.
The First Heart Attack

Infarct as a heart muscle caused by lack of blood supply to heart. Diagnostic criteria to meet
at the time of heart attack shall be to meet 3 criteria out of 5 criteria as follows whichever
conforms with the first heart attack:
a.
Specific painful on chess at the time of attack;
b.
Change of electrocardiogram description specifically showing Infarct Myocardial of

early stadium and;
c.
Increasing heart enzyme content CK-MB;
d.
Increasing Troponin (T or I);
e.
Left Ventricular Ejection fraction less than 50% (fifty percent) that occurs for 3 (three)
or more months after the onset.
2.
Stroke
Whatever cerebrovasculary attack, in which it causes permanently neurological symptoms,
in which it occurs more than 24 (twenty four hours including brain tissue infarct, brain
bleeding, thrombosis and embolism. This diagnosis should be supported by some
conditions as follows:
a.
Evidence on permanently neurological deficit shall be erected by a neurologist doctor

and the symptoms occurred at least during 6 months after the onset.
b.
The discovery is derived from Magnetic Resonance Imaging, Computerized

Tomography, or other examinations using Imaging technique according to the
diagnose of new stroke.
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Excepted illnesses:
3.
a.
Transient Ischaemic Attacks;
b.
Brain damage due to accident or injury, infection, vasculity, and inflamed illness;
c.
Blood vessel illness influencing eyes and optical nerves.
d.
Ischaemic attacks from vestibulary system.
Coronary Cardiac Surgery

Surgery operation by opening the cardiac wall, to conduct surgery on one or more artery
vessels due to constriction or obstruction on the artery vessel. Diagnose shall be erected
based on Angiography showing meaningful coronary arterial obstruction and the procedure
shall be based on a consideration made by cardiologist.
Excluding any techniques requiring surgery as Angiplasty or laser.
4.
Surgery Operation on to Change Cardiac Valves

Surgery operation by opening the cardiac to change or repair any valves due to defective
cardiac valves. Abnormal cardiac valves diagnose shall be erected on the basis of cardiac
catheterization or echocardiogram and the examining procedure shall be based on any
consideration made by cardiologist.
5.
Cancer
It is a kind of illness signed with malignant tumor due to uncontrolled cell growth and
spreading malignant tumor cell and invasion to tissue. Diagnose shall be erected on the
basis of tissue examination and diagnosed by Oncologist or Pathologist. Excluding illnesses
are as follow:
-
Carcinoma Insitu and any tumors histologically describing pre-cancer or not invasive,
including Breast Carcinoma In Situ, Cervical Dysplasia CIN 1, CIN 2 and CIN 3.
Hyperkeratoses, basal cell and squamous skin cancer, and melanorma with thickness
less than 1.5 mm Breslow, or less than Clark Level 3 except there is other evidence
showing any spreads;
Prostate Gland Cancer based on tissue examination and also TNM classification T1a or
T1b or prostate gland cancer based on same classification or Lesser Classification,
TIN0M0 Papillary microcarcinoma of thyroid gland with diamter less than 1 cm,
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Paopillary microcarcinoma of urinary bladder, and Chronic Lymphocytic Leukemia less

than RAI stage 3; and
-
All kinds of tumor caused by HIV infection.
Including all kinds of leukemia (except for lymphatic leukemia), malignant tumor on all body
organs but all kinds of skin tumor (except for melanoma malignum) and benign tumor and
cancer stadium insitu shall not be insured under this Additional Insurance coverage.
6.
Kidney Failure
Final stage of kidney failure described as functioning failure of both chronic kidneys and can
not be recovered, that it requires ordered kidney dialysis or kidney transplantation.
7.
Paralysis
Loss of joint functions at least those of arms and both legs, or one arm and one leg, totally
and constantly, and continuously occurs at leas for 6 (six) weeks. Such a condition shall be
erected by neurologist. Any injuries caused by intentional actions by oneself shall be
excluded from this illness.
8.
Multiple Sclerosis
It is a kind of illness causing defects on central neurological system progressively that
causing brain and brain stem defects. Fixed diagnose without hesitancies shall be made by
neurologist confirming combination of the following: any symptoms leading to fibers (white
substance) including optical nerves, brain stem, spinal cord, that causing neurological deficit;
and has developed minimal for 6 (six) months in which it causes disturbance on
coordination and functions of motor censor. Data supporting reoccurrence and symptoms
appearance or neurological deficit.
Neurological system defect due to other illnesses as SLE and HIV shall be excluded from
this kind of illness.
9.
Transplantation of Body Vital Organ

Experiencing surgery operation as a transplantation recipient of:
-
Haematopoitic stem cells preceded by total ablasion of haematopoitic stem cells; or
One of human organs as follows: kidney, heart, hepar, and lungs, pancreas due to final
failure of such organs functions.
Other Stem Cell transplantation shall be excluded from this illness.
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10. Alzheimer/Degenerative Organic Brain Illness that cannot be recovered.

Decline or loss of intellectual ability or abnormal behavior proved through clinical condition
and questionnaire or acceptable standard test regarding Alzheimer Illness or any problems
on degenerative organic brain that cannot be recovered, in case it causes real decrease in
mental and social functions that that requires continuous monitoring towards the Insured.
Progressive degeneration occurrence of kornu anterior medulla spinalis (lesion lower motor
neuron), traktus kortiko spinalis (lesion upper motor neuron) and nucleic motor brain stem.
Diagnose shall clinically be confirmed by specialist doctor accordingly appointed by the
Insurer. Excluded illnesses shall be as follows:
-
Non-Organic Illnesses as neurosis and psychosis, mental illness.
Brain damage due to alcohol consumption.
11. Coma
Unconsciousness condition without any reactions or responses to external stimuli or internal
needs that continuously occur with the result that requires life-supporting tools including a
need to use respirator at leas during 96 (ninety six) hours. Permanently neurological deficit
must occur and continuously be suffered for 42 days. Coma due to direct alcohol abuse or
drugs shall be excluded.
12. Parkinson Illness
Undoubtedly-definite diagnosis regarding Parkinson Idiopathic illness given by neurologist
and recommended by any doctors appointed by the Insurer where the Insureds condition
cannot be controlled using drugs; showing progressive defects. This Insurance shall be for
Parkinson Idiopathic only. All other kinds of Parkinson shall be excluded from this Insurance.
Inability to conduct Daily Activities with or without supporting device minimal 3 out of 5 Daily
Activities and such inability has occurred continuously for minimal 6 months.
Daily Activities (in accordance with Article 1):
-
Taking a bath
Dressing
Feeding
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Relieving
Moving
Parkinson due to drugs use shall be excluded from this illness.

13. Terminal Illness
In condition the illness or final stadium suffered by the Insured based on diagnosis made by
examining doctor while it has been approved by the Insureds doctor predicting that life
expectancy of the Insured shall be less than 12 months.
Terminal Illness due to HIV infection shall be excluded from this illness.
14. Chronic Lungs Diseases/Final Stage
Final stage illness shall included intersisial lungs due to chronic respiration failure.
Diagnosis shall be erected by lungs specialist doctor and shall meet symptoms and
evidences as follows:
-
Requiring extensive and permanent oxygen therapy.
FEV1 test result shall be less than 1 liter.
Analysis on arterial blood gas using partial oxygen pressures 55 mmHg or less
(PaO2<55 mmHg)
Short of breath when taking a rest
15. Chronic Hepatitis

Final stage illness signed by all things as follows:
a.
Permanent yellow
b.
Ascites
c.
Hepatic enchelopathy
Chronic hepatitis due to alcohol and drugs consumption shall be excluded from this
additional insurance.
16. Neuron Motor Illness
Undoubtedly-definite diagnosis regarding Neuron Motor Illness due to progressive
degeneration on brain stem and Anterior horn cells neuron bulbar efferent including athropy
spinal muscle, progressive bulbar palsy, amyotophic lateral sclerosis and primary lateral
sclerosis. And it is supported by definite evidences from the signs and deficit neurological
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symptoms and approved by Insurers doctor. And the diagnosis shall be erected by
neurologist.
17. Muscular Dystrophy
It is combination of hereditary muscle degeneration illnesses causing weaknesses or
muscle athropy. Diagnosis shall be erected definitely by neurologist, and the evidence shall
be based on daily activities examination that confirms the Insureds inability for conducting
daily activities with or without helps, minimal 3 out of 5 Daily Activities taking place minimal
6 months.
-
Taking a bath
Dressing
Feeding
Relieving
Moving
18. Aplastis Anemia

The chronic and persistent failure of spinal cord functions causing anemia, neutropenia and
thrombositopenia requiring minimal one of the following treatments:
a.
Blood transfusion
b.
Stimulating medicine for spinal cord
c.
Immunosuppressive medicine
d.
Spinal cord transplantation
Diagnosis shall be erected by Haematologist.

19. Aorta Vessel Surgery
It is a kind of surgery conducted to treat any aorta vessel disorders in the form of aneurisma,
constriction, obstruction requiring excision and surgery to change disordered aorta by
opening stomach and chest cavities. Aorta intended in this definition shall be thorax and
abdominal aorta excluding those Aorta branches.
Surgery in nature of invasive minimal or intra-arterial technique shall be excluded from this
stipulation.
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20. Hepatitis Fulminant

Liver failure due to submassive or massive liver parenchyma death caused by Hepatitis
virus. Hepatitis fulminant due to suicide trial, poisoned, drugs overdoses and over-alcohol
shall be excluded from this Insurance.
Diagnostic criteria shall be as follows:
-
Rapid size reducing of the liver.
Liver parenchyma death including almost all liver lobus. And causes reticular damages
and its functions.
Liver function testing showing massive liver parenchyma damages.
Obvious icterus.
Hepatic encephalopathy.
21. Pulmonary Arterial Hypertension Primer

Pulmonary Arterial Hypertension Primer illness showing enlargement of right ventricle
erected based on clinical examination, cardiac catheterization, causing permanent physical
disorders and based on Classification Cardiac Impairment The New York Heart Association
(NYHA) included minimal class IV (Unable to conduct any physical activities while the
symptoms may emerge at the time of taking a rest).
22. Bacterial Meningitis
Bacterial meningitis causing inflamed brain membrane or spinal cord that causes
permanently neurological inability and occurs minimal for 6 months. While the diagnosis
shall be confirmed by neurologist, and there should be found bacterial infection in the brain
fluid obtained from punksi lumbal.
23. Benign Brain Tumor

Life threatening due to brain tumor not cancer causing brain defects and special symptoms
of increasing pressure in the skull as papilloedema, mental disorder, insane, and sense
disorders confirmed by neurologist. The existence of tumor as the basic shall be confirmed
by CT Scan or MRI.
Cyst, granuloma, form deviation on or of brain artery or vena (AVM), hematoma, and
pituitary gland tumor or that of spinal cord shall be excluded from this illness.
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24. Inflamed Brain

Inflammation diagnosis of brain (cerebral hemisphere, brain stem or cerebellum) due to
virus infection, causing meaningful complication occurring minimal for 6 (six) weeks,
including permanent nerve deficit and been confirmed by neurologist. Hearing disorder
deficit, speaking disorder, weaknesses or paralysis.
Inflamed brain due to HIV infection shall be excluded from this illness.
25. Burn
Burn level three (All Skin Layers) minimal 20% (twenty percent) of total wide surface area of
the Insureds body.
26. Poliomyelitis
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Polio virus shall be the cause, and
Muscle paralysis on moving muscle components or breathing muscles causing the

Insured unable to make 3 (three) out of 5 (five) Daily Activities continuously minimal for
3 (three) months.
27. Serious Head Trauma

Any accidents causing head injury that causing permanently neurological deficit not less
than 6 (six) weeks since the accident occurred that the Insured cannot carry out his/her 3
(three) out of 5 (five) Daily Activities for minimal 6 (six) months. This diagnosis shall be
erected by neurologist and supported by Magnetic Resonance Imaging technique,
Computerized Tomography, or other acknowledged techniques. The accident shall occur
directly from outside body parts, visible, and shall not depend on other cause(s).
The following conditions shall be excluded:
-
Spinal cord Injury/Trauma, and
Head injury due to other causes
28. Apallic Syndrome

Total brain cortex damages while the brain stem is still normal. This diagnosis shall be
erected by neurologist and condition of this syndrome shall constantly occur minimal for 1
(one) month.
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29. Other Serious Coronary Cardiac Disorders

Constriction occurred on one of coronary arteries with minimal 75% (Seventy five percent)
and 2 (two) other coronary arteries minimal 60% (sixty percent) proved by coronary
arteriography, without viewing whether the surgery has been conducted or not.
The intended coronary artery shall be Left Main Coronary Artery (LC), Left Anterior
Descending Artery (LAD), Circumflex Artery and Right Coronary Artery (RC).
30. Angioplasty and other invasive procedure for Coronary Cardiac Disorder
Limit for this benefit payment shall be 10% of Total Critical Illness Insurance or maximal not
more than Rp. 200,000,000 or US$ 50,000 after the Insured follows ballooning angioplasty
or intra arterial catheter procedure for treating the constriction minimal for coronary vessel
60% of one or more coronary arterial blood vessel in which majority is proved by
angiographic. Revascularization shall be in accordance with indication and consultant
cardiologist or cardiac specialist.
The aforementioned benefit payment for this illness shall only be paid once and remained
benefit for additional Insurance of this critical illness shall be continued by the remaining of
90% (ninety percent) of Total Insurance Coverage for Critical Illness.
Diagnostic Action by angioplasty shall be excluded from this illness.
31. Systemic Lupus Erythematosus
It is a kind of multi-systemically and multifactor autoimmune disorders signed with
increasing auto-antibody attacking various body antigen. Type of System Lupus
Erythematosus to insure by this Additional Insurance shall be limited to types of Systemic
Lupus Erythematosus involving kidney (Class III to Class IV of Lupus Nephritis, defined by
kidney biopsy, and in accordance with WHO classification). Those excluded from critical
illness claim on Systemic Lupus Erythematosus shall be other kinds of lupus, namely
discoid lupus and other types involving joints and hematology system.
Erection of Systemic Lupus Erythematosus diagnosis shall be carried out by Specialist on
Rheumatology and Immunology.
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WHO Classification on Lupus Nephritis:

Class I
: Minimal Change Lupus Glomerulonephritis
Class II
: Messangial Lupus Glomerulonephritis
Class III
: Focal Segmental Proliverative Lupus Glomerulonephritis
Class IV
: Diffuse Proliferative Lupus Glomerulonephritis
Class V
: Membranous Lupus Glomerulonephritis
32. HIV obtained through Blood Transfusion and Work

A.
The Insured is infected by Human Immunodeficiency Virus (HIV) through blood

transfusion of the following conditions:
1.
Blood transfusion that medically required and given as a part of treatment

process.
2.
Blood transfusion shall be conducted in Indonesia after the Policy Date effective,
Date of Policy Change or date of policy recovery, whenever occurs earlier.
3.
Infection source shall be from any institutions holding blood transfusion and the
institutions can track the source of HIV-infected blood, and
4.
B.
The Insured shall not either Thalassaemia major or Hemophilia sufferer.
Human Immunodeficiency Virus (HIV) infection shall be obtained from an accident in

workplace after effective date of the Policy or the date of Policy change or date of
Policy recovery, whichever occurs earlier, as long as the Insured perform his or her
normally professional obligations of his or her jobs in Indonesia, by following any
evidences and stipulations existing of the company as follows:
1.
HIV infection obtained due to accident in workplace shall be within 30 (thirty)

days commenced on the accidence, and
2.
Any evidences that the accident due to his or her work shall be the cause of HIV
infection, and
3.
Any evidences that cero-conversion of negative HIV to positive HIV shall occur
within 180 (one hundred and eighty) days after the accident happens. This
evidence shall be completed by testing negative HIV antibody within 5 (five)
days commenced on the date of accident due to his or her works.
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4.
HIV infection due to other causes including sexual activities and drugs uses in
intra-vena shall be excluded from this illness.
This benefit shall be valid if the Insured works as Medical Worker, Medical worker
student, certified nurse, laboratory technician, dentist, paramedic, works in health
center and clinic (in Indonesia).
This benefit shall not be valid in if point A and B has received medical treatment for
treating AIDS and for treating any impacts due to HIV virus infection, or managing for
preventing AIDS. The treatment intended shall be any treatments to make HIV inactive
and non-infectious.
33. Deaf (Loss of Audio Senses Function)
Unable to heal and total loss on audio senses functions in both ears due to illness or
accident. The diagnosis shall be supported with audiometry and audio testing provided and
certified by Ear, Nose and Throat Specialist physician.
34. Mute (Loss of Vocal Ability)
Unable to heal and total loss on vocal function due to accident or disorders on vocal cord.
Vocal inability shall continuously occur for 12 months. Diagnosis of this disorder shall be
supported by evidences made by Ear, Nose and Throat specialist physician.
Psychological and mental disorders shall be excluded.
35. Blindness
Loss of total visual ability and unable to heal due to illness or accident. The blindness shall
be diagnosed by ophthalmologist.
36. Progressive Schleroderma
It is a kind of collagen blood vessel disorder that systematically causes total fibrosis
progressively within the skin, blood vessel and other body organs. Diagnosis of this disorder
shall be supported by biopsy and other supporting evidences as results of serology and this
illness shall be in accordance with systemic proportion related to heart, lungs and kidney.
The following shall be excluded from this illness:
-
Local schleroderma (linier or morphea schleroderma)
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Eosinophilic Fascitis; and
CREST syndrome
37. Medullary Cyst Illness

It is a kidney disorder that progressively hereditary characterized with cyst and medulla,
tubular atrophy and intestifial fibrosis with clinical anemia manifestation, polyuria and loss of
sodium through kidney, developing to chronic kidney failure. This diagnosis shall be
supported by kidney biopsy.
38. Cardiomyopathy
Diagnosis erected by cardiologist that cardiomyopathy shall be caused by functional
disorder of cardiac ventricle chamber, showed by abnormal ECG results and confirmed by
echocardiography and causing physical inability permanently with minimal degree on Class
III in accordance with New York Association Classification of Cardiac Impairment.
Class III Meaningful inability signed with Patient in comfortable position of resting
position but ability in conducting very limited daily activities of normal condition and shows
any symptoms of congestive cardiac failure.
Class IV Inability to perform any activities. Congestive cardiac failure symptoms emerges
though in resting condition. Anytime physical activities increase, uncomfortable condition
occurs.
Cardiomyopathy directly relates with alcohol abuse shall be excluded.
39. Celebral Anaeurysm Requiring Brain Surgery

The actual undergoing of brain surgery to correct an abnormal widening of the cerebral
artery involving all three layers of the cerebral arterial wall. The diagnosis must be made by a
licensed neurosurgeon, using standard cerebral angiography which indicates the need for
open surgery.
Exclusions:
infection and mycotic aneurysm; and
limited craniectomy and burr hole procedures.
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40. Multiple Root Avulsions of Brachial Plexus

The complete and permanent loss of use and sensory functions of an upper extremity
caused by avulsion of 2 or more nerve roots of the brachial plexus through accident or injury.
Complete injury of 2 or more nerve roots should be confirmed by electrodiagnostic study
done by a physiatrist or neurologist.
41. Stroke Requiring Carotic Endarterectomy Surgery

Stroke Requiring Carotid Endarterectomy Surgery means the undergoing of carotid
Endarterectomy by expert and licensed surgeon, based on current standard medical
indications, to prevent recurrent ischemic cerebrovascular events.
42. Surgery for Idiopathic Scoliosis

Surgery for idiopathic scoliosis means the undergoing of spinal surgery to correct an
abnormal curvature of the spine from it's normal straight line viewed from the back. The
condition must be present without an identifiable underlying cause and the curve of the spine
must be more than cobb angle 40 degree. Spinal deformity associated with congenital
defects and neuromuscular diseases are excluded
43. Chronic Relapsing Pancreatitis

Chronic Relapsing Pancreatitis as a result of progressive severe destruction of pancreas,
this condition must be a result of recurrent acute pancreatitis and characterized by:
recurrent acute pancreatitis for a period of at least 2 years;
generalize calcium deposits in pancreas from imaging study; and
chronic continuous pancreatic function impairment resulting in mal-absorption of intestine

(high fat in stool) or diabetes.
Chronic Relapsing Pancreatitis directly cause by alcohol consumption is excluded.
44. Elephantiasis
Chronic filariasis characterized by:
severe and permanent edema of arm and leg or other part of body from lymphatic
obstruction; and
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the presence of microfilariae infection from laboratory study.

Lymphatic obstruction caused by sexual transmitted disease, cancer, wound, surgery scar,
radiation, heart failure or congenital anomaly is excluded.
45. Loss of Independent Living

Confirmation by a Consultant Physician of the loss of independent existence lasting for a
minimum period of 6 months and resulting in a permanent inability to perform at least three
(3) of the following Activities of Daily Living either with or without the use of mechanical
equipment, special devices or other aids and adaptations in use for disabled persons. For
the purpose of this benefit, the word "permanent", shall mean beyond the hope of recovery
with current medical knowledge and technology.
The Activities of Daily Living are based on article 1

Necrotising fasc Daily Activities (in accordance with Article 1):
-
Taking a bath
Dressing
Feeding
Relieving
Moving
46. Necrotising Fasciitis or Gangrene

Necrotising Fasciitis characterized by:
clinical symptoms complied with diagnostic criteria of Necrotising Fasciitis;
specific type of bacterial infection; and
extensive muscular destruction resulting in total permanent loss of involved body part.
47. Severe Rheumatoid Arthritis

Chronic rheumatoid arthritis is a result of an autoimmune disorder confirmed by a physician
who specialized in rheumatology and immunology. It is characterized by all of the following:
diagnosis according to American College of Rheumatology, and
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destruction and deformity of at least 3 of the following joints: interphalangeal hand joint,
wrist, elbow, knee, hip, ankle, cervical spine or interphalangeal foot joint. Clinical findings
and imaging study must evidence these changes, and
physical impairment resulting in inability to perform at least 3 of the 6 Activities of Daily

Living without the continual physical assistant of another person for a continuous period
of at least 180 days.

-
Taking a bath
Dressing
Feeding
Relieving
Moving
48. Severe Ulcerative Colitis or Cronhs disease

Severe Ulcerative Colitis or Cronhs Disease characterized by at least 2 of the following:
total removal of large intestine;
partial removal or many parts removal of intestine at separate surgery;
ascending sclerosing cholangitis as a co-impairment;
autoimmune chronic active hepatitis and cirrhosis confirmed by pathological study;
carcinoma in situ of large intestine.
49. Kawasaki Disease with Heart Complications

The diagnosis of Kawasaki disease by a consultant paediatrician or other appropriate
medical specialist. There must be echocardiographic evidence of cardiac involvement
manifesred by dilatation or neurysm formation in the coronary arteries which must persist for
at least 6 consecutive months.
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Article 4
MAXIMUM INSURANCE COVERAGE
Maximum insurance coverage of total additional insurance for Critical Illness insured by Us for
the
same
Insured
shall
be
Insurance
Coverage
stated
on
the
Policy
data
or
Endorsement/Addendum by following stipulations:

a.
For Insured of 1 (one) year old through 17 (seventeen) years old shall not exceed Rp.
500,000,000 (five hundred million rupiahs) for Rupiah currency or US$ 100,000 (one
hundred thousand United States Dollars) for US Dollar currency.
b.
For Insured of 18 (eighteen) years old through 70 (seventy) years old shall not exceed Rp.
2,000,000,000 (two billion rupiahs) for Rupiah currency or US$ 250,000 (two hundred and
fifty thousand United States Dollars) for US Dollar currency.
c.
Insurance Coverage more than the above term a & b, effective if only agreed by the
Company.
Article 5
ELIMINATION PERIOD
Within 90 (ninety) days commenced on the effective date of this Additional Insurance or
commenced on the date of policy recovery, there shall not be benefit to pay from this Additional
Insurance.
Article 6
CLAIM NOTIFICATION AND EVIDENCE
1.
You shall be obliged to deliver to Us claim notification in written form and evidence of
related illness at the time of claim at the latest 30 (thirty) days commenced on the date of
diagnosis erected for related Critical Illness.
2.
Aforementioned notification shall be completed with original evidences at the time of claim
filing, among others:
a.
Original policy;
b.
Original confirmation issued by the physician firstly diagnosing;
c.
Effective Your and Insureds personal identity;
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d.
3.
Other required evidences.
In case above evidences could not be delivered to Us at the determined time, We shall
reserve the right not to pay related claim.
Article 7
HEALTH EXAMINATION
We shall reserve the right to ask for health examination on the Insured by Consultant Doctor We
assign, if required.
Article 8
EXCEPTION
No benefit shall be paid from Critical Illness Additional Insurance due to:
1.
All kinds of illness emerging from any injuries intentionally made both directly and
indirectly, suicide or suicide trial either in conscious or unconscious condition, or
2.
Any kinds of illness caused directly or indirectly by AIDS (Acquired Immune Deficiency
Syndrome) or AIDS Related Complex (ARC), or
3.
Any congenital illnesses, or
4.
The diagnosis shall be erected firstly before or within Elimination period.
Article 9
INSURANCE TERMINATION
This Critical Illness Additional Insurance shall be terminated at the time of, whichever occurs
earlier:
1.
Lapse or Surrender Basic Policy, or
2.
Insured reaches 70 (seventy) years old at the time of Basic Policy Anniversary, or
3.
After full payment of Additional Insurance Benefit in the form Critical Illness Compensation
of 100% has been paid.
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ADDENDUM POLICY FOR PERIODIC PREMIUM LINK UNIT

PT ASURANSI ALLIANZ LIFE INDONESIA
Critical Illness Accelerated (CI Accelerated)
the Policy Data page in which this Additional Insurance of CI Accelerated enclosed, by following
any stipulations existing in this Addendum Policy for Periodic Premium Link Unit of PT Asuransi
Allianz Life Indonesia for Critical Illness Accelerated (CI Accelerated) (hereinafter called as
Additional Insurance for CI Accelerated). We shall give this Additional Insurance for CI
Accelerated due to your request related to Policy You own, and shall be valid only if this
Additional Insurance for CI Accelerated has been written on the Policy Data page of the Policy.
Article 1
DEFINITION
a.
Taking a bath shall refer to self-ability to clean own body when taking a bath or using
shower or cleaning own body using other good manners.
b.
Dressing shall refer to self-ability to wear, put off, tighten, and loosen all kinds of dresses.
c.
Feeding shall refer to self-ability to put the food into own mouth in which the food has
been prepared and served.
d.
Relieving shall refer to self-ability to defecate and urinate in toilet or water closet, or at
least able to retain defecate or urinate to keep good self-health condition.
e.
Moving shall refer to self-ability to move own body from bed to chair with upright support
or to move from one place to another on flat floor without using a wheelchair.
Article 2
INSURANCE BENEFIT
1.
During the Policy effectiveness, We will pay Additional Insurance Benefit after receiving
and approving any claim evidences proposed in case the Insured suffers/firstly
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diagnosed from a kind of illness based on the definition stated in Article 3 of this
Additional Insurance for CI Accelerated hereof.
Special for the Insured of under 5 (five) years old, Insurance Coverage being paid shall
follow following stipulations:
2.
Insureds Age at the Time of Diagnosed with Critical
Insurance Coverage to
Illness
Receive
<=1
20%
40%
60%
80%
>=5
100%
Aforementioned benefit payment above will be conducted after being calculated with
total loans and other obligations, if present, and shall reduce total Basic Policy Insurance
Coverage equal to Insurance Coverage for CI Accelerated to pay.
3.
After above benefit being paid, Additional Insurance for CI Accelerated shall be
automatically terminated.
Article 3
DEFINITION OF CRITICAL ILLNESS
This benefit of Additional Insurance for CI Accelerated shall bear 38 (thirty eight) critical illnesses
as follows:
1.

Infarct of parts of heart muscles caused by lack of blood supply to heart. Diagnostic
criteria to meet at the time of heart attack shall be to meet 3 criteria out of 5 criteria as
follows whichever conforms the first heart attack:
a.
b.
Change of electrocardiogram description specifically showing Infarct Myocardial

of early stadium and;
c.
d.
- 21 -
e.
Left Ventricular Ejection fraction less than 50% (fifty percent) that occurs for 3
(three) or more months after the onset.
2.
Stroke
Whatever cerebrovasculary attack, in which it causes permanently neurological
symptoms, in which it occurs more than 24 (twenty four) hours including brain tissue
infarct, brain bleeding, thrombosis and embolism. This diagnosis should be supported by
some conditions as follows:
a.
Evidence on permanently neurological deficit shall be erected by a neurologist

doctor and the symptoms occurred at least during 6 months after the onset.
b.
The discovery is derived from Magnetic Resonance Imaging, Computerized

Tomography, or other examinations using Imaging technique according to the
diagnose of new stroke.
Excepted illnesses:
3.
a.
b.
Brain damage due to accident or injury, infection, vasculity, and inflamed illness;
c.
d.

It shall mean surgery operation by opening the cardiac wall, to conduct surgery on one or
more artery vessels due to constriction or obstruction on the artery vessel. Diagnose
shall be erected based on Angiography showing meaningful coronary arterial obstruction
and the procedure shall be based on a consideration made by cardiologist.
Any techniques requiring surgery as Angiplasty or laser shall be excluded.
4.
Surgery Operation to Change Cardiac Valves

It shall mean surgery operation by opening the cardiac to change or repair any valves
due to defective cardiac valves. Abnormal cardiac valves diagnose shall be erected on
the basis of cardiac catheterization or echocardiogram and the examining procedure
shall be based on any consideration made by cardiologist.
- 22 -
5.
Cancer
It is a kind of illness signed with malignant tumor due to uncontrolled cell growth and
spreading malignant tumor cell and invasion to tissue. Diagnose shall be erected on the
basis of tissue examination and diagnosed by Oncologist or Pathologist. Excepted
illnesses are as follow:
Carcinoma In situ and any tumors histologically describing pre-cancer or not

invasive, including Breast Carcinoma In Situ, Cervical Dysplasia CIN 1, CIN 2
and CIN 3.
Hyperkeratosis, basal cell and squamous skin cancer, and melanoma with
thickness less than 1.5 mm Breslow, or less than Clark Level 3 except there is
other evidence showing any spreads;
Prostate Gland Cancer based on tissue examination and also TNM classification
T1a or T1b or prostate gland cancer based on same classification or Lesser
Classification, T1N0M0 Papillary micro carcinoma of thyroid gland with diameter
less than 1 cm, Papillary micro carcinoma of urinary bladder, and Chronic
Lymphocytic Leukemia less than RAI stage 3; and
It shall be included all kinds of leukemia (except for lymphatic leukemia), malignant
tumor on all body organs but all kinds of skin tumor (except for melanoma malignum)
and benign tumor and cancer stadium in situ shall not be insured under this Insurance
coverage.
6.
Kidney Failure
Final stage of kidney failure described as functioning failure of both chronic kidneys and
can not be recovered, that it requires ordered kidney dialysis or kidney transplantation.
7.
Paralysis
Loss of joint functions at least those of arms and both legs, or one arm and one leg,
totally and constantly, and continuously occurs at leas for 6 (six) weeks. Such a condition
- 23 -
shall be erected by neurologist. Any injuries caused by intentional actions by oneself

shall be excluded from this illness.
8.
Multiple Sclerosis
It is a kind of illness causing defects on central neurological system progressively that
causing brain and brain stem defects. Fixed diagnose without hesitancies shall be made
by neurologist confirming combination of the following: any symptoms leading to fibers
(white substance) including optical nerves, brain stem, spinal cord, that causing
neurological deficit; and has developed minimal for 6 (six) months in which it causes
disturbance on coordination and functions of motor censor. Data supporting
reoccurrence and symptoms appearance or neurological deficit.
Neurological system defect due to other illnesses as SLE and HIV shall be excluded
from this kind of illness.
9.

It shall mean experiencing surgery operation as a transplantation recipient of:
Haematopoitic stem cells preceded by total ablasion of haematopoitic stem cells;

or
One of human organs as follows: kidney, heart, liver, and lungs, pancreas due to
final failure of such organs functions.

10.
Alzheimer/Degenerative Organic Brain Illness that cannot be recovered.

Decline or loss of intellectual ability or abnormal behavior proved through clinical
condition and questionnaire or acceptable standard test regarding Alzheimer Illness or
any problems on degenerative organic brain that cannot be recovered, in case it causes
real decrease in mental and social functions that that requires continuous monitoring
towards the Insured. Progressive degeneration occurrence of kornu anterior medulla
spinalis (lesion lower motor neuron), traktus kortiko spinalis (lesion upper motor neuron)
and nucleic motor brain stem. Diagnose shall clinically be confirmed by specialist doctor
accordingly appointed by the Insurer. Excluded illnesses shall be as follows:
- 24 -
11.
Coma
Unconsciousness condition without any reactions or responses to external stimuli or
internal needs that continuously occur with the result that requires life-supporting tools
including a need to use respirator at leas during 96 (ninety six) hours. Permanently
neurological deficit must occur and continuously be suffered for 42 days. Coma due to
direct alcohol abuse or drugs shall be excluded.
12.
Parkinson Illness
Undoubtedly-definite diagnosis regarding Parkinson Idiopathic illness given by
neurologist and recommended by any doctors appointed by the Insurer where the
Insureds condition cannot be controlled using drugs; showing progressive defects. This
Insurance shall be for Parkinson Idiopathic only. All other kinds of Parkinson shall be
excluded from this Insurance.
Inability to conduct Daily Activities with or without supporting device minimal 3 (three) out
of 5 (five) Daily Activities and such inability has occurred continuously for minimal 6
months.
Taking a bath
Dressing
Feeding
Relieving
Moving

13.
Terminal Illness
In condition the illness or final stadium suffered by the Insured based on diagnosis made
by examining doctor while it has been approved by the Insureds doctor predicting that
life expectancy of the Insured shall be less than 12 months.
- 25 -
14.
Chronic/Final Stage Lungs Diseases

Final stage illness shall included intersisial lungs due to chronic respiration failure.
Diagnosis shall be erected by lungs specialist doctor and shall meet symptoms and
evidences as follows:
Analysis on arterial blood gas using partial oxygen pressures 55 mmHg or less
(PaO2<55 mmHg)
15.
Chronic Hepatitis
a.
Permanent yellow
b.
Ascites
c.
Hepatic enchephalopathy
Chronic hepatitis due to alcohol and drugs consumption shall be excluded from this
insurance.
16.
Neuron Motor Illness

Undoubtedly-definite diagnosis regarding Neuron Motor Illness due to progressive
degeneration on brain stem and Anterior horn cells or neuron bulbar efferent including
atrophy spinal muscle, progressive bulbar palsy, amyotrophic lateral sclerosis and
primary lateral sclerosis. And it is supported by definite evidences from the signs and
deficit neurological symptoms and approved by Insurers doctor. And the diagnosis shall
be erected by neurologist.
17.
Muscular Dystrophy
It is combination of hereditary muscle degeneration illnesses causing weaknesses or
muscle atrophy. Diagnosis shall be erected definitely by neurologist, and the evidence
- 26 -
shall be based on daily activities examination that confirms the Insureds inability for
conducting daily activities with or without helps, minimal 3 (three) out of 5 (five) Daily
Activities taking place minimal 6 months.
18.
Taking a bath
Dressing
Feeding
Relieving
Moving
Aplastis Anemia
The chronic and persistent failure of spinal cord functions causing anemia, neutropenia
and thrombocytopenia requiring minimal one of the following treatments:
a.
Blood transfusion
b.
c.
d.

19.
Aorta Vessel Surgery

It is a kind of surgery conducted to treat any aorta vessel disorders in the form of
aneurism, constriction, obstruction requiring excision and surgery to change disordered
aorta by opening stomach and chest cavities. Aorta intended in this definition shall be
thorax and abdominal aorta excluding those Aorta branches.
Surgery in nature of invasive minimal or intra-arterial technique shall be excluded from
this stipulation.
20.
Hepatitis Fulminant
Liver failure due to sub massive or massive liver parenchyma death caused by Hepatitis
virus. Hepatitis fulminant due to suicide trial, poisoned, drugs overdoses and overalcohol shall be excluded from this Insurance.
- 27 -
Liver parenchyma death including almost all liver lobus. And causes reticular
damages and its functions.
21.
Obvious icterus.
Pulmonary Arterial Hypertension Primer

Pulmonary Arterial Hypertension Primer illness showing enlargement of right ventricle
erected based on clinical examination, cardiac catheterization, causing permanent
physical disorders and based on Classification Cardiac Impairment The New York Heart
Association (NYHA) included minimal class IV (Unable to conduct any physical activities
while the symptoms may emerge at the time of taking a rest).
22.
Bacterial Meningitis
permanently neurological inability and occurs minimal for 6 (six) weeks.
While the diagnosis shall be confirmed by neurologist, and there should be found
bacterial infection in the brain fluid obtained from punksi lumbal.
23.
Benign Brain Tumor

Life threatening due to brain tumor not cancer causing brain defects and special
symptoms of increasing pressure in the skull as papilloedema, mental disorder, insane,
and sense disorders confirmed by neurologist. The existence of tumor as the basic shall
be confirmed by CT Scan or MRI.
Cyst, granuloma, form deviation on or of brain artery or vena (AVM), hematoma, and
pituitary gland tumor or that of spinal cord shall be excluded from this illness.
24.
Inflamed Brain
Inflammation diagnosis of brain (cerebral hemisphere, brainstem or cerebellum) due to
virus infection, causing meaningful complication occurring minimal for 6 (six) weeks,
including
permanent
nerve
deficit
- 28 -
and
been
confirmed
by
neurologist.
Permanent/localized neurological deficit can be in form of mental retardation, unstable

emotion, vision disorders, hearing disorder, speaking disorder, weaknesses or paralysis.
25.
Burn
Burn level three (All Skin Layers) minimal 20% (twenty percent) of total wide surface
area of the Insureds body.
26.
Poliomyelitis
Muscle paralysis on moving muscle components or breathing muscles causing

the Insured unable to make 3 (three) out of 5 (five) Daily Activities continuously
minimal for 3 (three) months.
27.
Serious Head Trauma

Any accidents causing head injury that causing permanently neurological deficit not less
than 6 (six) weeks since the accident occurred that the Insured cannot carry out his/her 3
(three) out of 5 (five) Daily Activities for minimal 6 (six) months. This diagnosis shall be
erected by neurologist and supported by Magnetic Resonance Imaging technique,
Computerized Tomography, or other acknowledged techniques. The accident shall occur
directly from outside body parts, visible, and shall not depend on other cause(s).
28.
Apallic Syndrome
Total brain cortex damages while the brain stem is still normal. This diagnosis shall be
erected by neurologist and condition of this syndrome shall constantly occur minimal for
1 (one) month.
29
Other Serious Coronary Cardiac Disorders
- 29 -
Constriction occurred on one of coronary arteries with minimal 75% (seventy five
percent) and 2 (two) other coronary arteries minimal 60% (sixty percent) proved by
coronary arteriography, without viewing whether the surgery has been conducted or not.
30
Angioplasty and other invasive procedure for Coronary Cardiac Disorder

Limit for this benefit payment shall be 10% (ten persen) of Total Critical Illness Insurance
or maximal not more than Rp. 200,000,000 (two hundred millions rupiah) after the
Insured follows ballooning angioplasty or intra arterial catheter procedure for treating the
constriction minimal for coronary vessel 60% of one or more coronary arterial blood
vessel in which majority is proved by angiographic. Revascularization shall be in
accordance with indication and consultant cardiologist or cardiac specialist.
The aforementioned benefit payment for this illness shall only be paid once and
remained benefit for additional Insurance of this critical illness (Critical Illness
Accelerated) shall be continued by the remaining 90% (ninety percent) of Total
Insurance Coverage for Critical Illness Accelerated.
Diagnostic action by angioplasty shall be excluded from this illness.
31.
Systemic Lupus Erythematosus

It is a kind of multi-systemically and multifactor autoimmune disorders signed with
increasing auto-antibody attacking various body antigen. Type of System Lupus
Erythematosus to insure by this Additional Insurance shall be limited to types of
Systemic Lupus Erythematosus involving kidney (Class III to Class IV of Lupus Nephritis,
defined by kidney biopsy, and in accordance with WHO classification). Those excluded
from critical illness claim on Systemic Lupus Erythematosus shall be other kinds of lupus,
namely discoid lupus and other types involving joints and hematology systems.
- 30 -
Erection of Systemic Lupus Erythematosus diagnosis shall be carried out by Specialist

on Rheumatology and Immunology.
32.
Class I :
Minimal Change Lupus Glomerulonephritis
Class II :
Messangial Lupus Glomerulonephritis
Class III :
Focal Segmental Proliverative Lupus Glomerulonephritis
Class IV :
Diffuse Proliferative Lupus Glomerulonephritis
Class V :
Membranous Lupus Glomerulonephritis
HIV obtained through Blood Transfusion and Work

A.
The Insured is infected by Human Immunodeficiency Virus (HIV) through blood
transfusion of the following conditions:

1.
Blood transfusion that medically required and given as a part of medication

process.
2.
Blood transfusion shall be conducted in Indonesia after the Policy Date effective,
Date of Insurance Change, whenever occurs earlier.
3.
Infection source shall be from any institutions holding blood transfusion and the
institutions can track the source of HIV-infected blood, and
4.
B.
Human Immunodeficiency Virus (HIV) infection shall be obtained from an
accident in workplace after effective date of the Policy or the date of Insurance change,
whichever occurs later, as long as the Insured perform his or her normally professional
obligations of his or her jobs in Indonesia, by following any evidences and stipulations
existing of the company as follows:
1.
HIV infection obtained due to accident in workplace shall be within 30 (thirty)

days commenced on the accidence, and
2.
Any evidences that the accident due to his or her work shall be the cause of HIV
infection, and
3.
Any evidences that cero-conversion of negative HIV to positive HIV shall occur
within 180 (one hundred and eighty) days after the accident happens. This
- 31 -
evidence shall be completed by testing negative HIV antibody within 5 (five)

days commenced on the date of accident due to his or her works.
4.
HIV infection due to other causes including sexual activities and drugs uses in
intra-vena shall be excluded from this illness.
This benefit shall be valid if the Insured works as Medical Worker, Medical worker
student, certified nurse, laboratory technician, dentist, paramedic, works in health center
and clinic (in Indonesia).
This benefit shall not be valid if point A and B has received medical treatment for treating
AIDS and for treating any impacts due to HIV virus infection, or managing for preventing
AIDS. The treatment intended shall be any treatments to make HIV inactive and noninfectious.
33.
Deaf (Loss of Audio Senses Function)

Unable to heal and total loss on audio senses functions in both ears due to illness or
accident. The diagnosis shall be supported with audiometry and audio testing provided
and certified by Ear, Nose and Throat Specialist physician.
34.
Mute (Loss of Vocal Ability)

Unable to heal and total loss on vocal function due to accident or disorders on vocal cord.
Vocal inability shall continuously occur for 12 months. Diagnosis of this disorder shall be
supported by evidences made by Ear, Nose and Throat specialist physician.
35
Blindness
Loss of total visual ability and unable to heal due to illness or accident. The blindness
shall be diagnosed by ophthalmologist.
36.
Progressive Schleroderma
It is a kind of collagen blood vessel disorder that systematically causes total fibrosis
progressively within the skin, blood vessel and other body organs. Diagnosis of this
disorder shall be supported by biopsy and other supporting evidences as results of
- 32 -
serology and this illness shall be in accordance with systemic proportion related to heart,
lungs and kidney.
37.
CREST syndrome
Medullary Cyst Illness

It is a kidney disorder that progressively hereditary characterized with cyst and medulla,
tubular atrophy and intestitial fibrosis with clinical anemia manifestation, polyuria and
loss of sodium through kidney, developing to chronic kidney failure. This diagnosis shall
be supported by kidney biopsy.
38.
Cardiomyopathy
Diagnosis erected by cardiologist that cardiomyopathy shall be caused by functional
disorder of cardiac ventricle chamber, showed by abnormal ECG results and confirmed
by echocardiography and causing physical inability permanently with minimal degree on
Class III in accordance with New York Association Classification of Cardiac Impairment.
Class III Meaningful inability signed with Patient in comfortable position of resting
position but ability in conducting very limited daily activities of normal condition and
shows any symptoms of congestive cardiac failure.
Class IV Inability to perform any activities. Congestive cardiac failure symptoms
emerges though in resting condition. Anytime physical activities increase, uncomfortable
condition occurs.
Cardiomyopathy directly relates to alcohol abuse shall be excluded.
39.
Celebral Anaeurysm Requiring Brain Surgery

The actual undergoing of brain surgery to correct an abnormal widening of the cerebral
artery involving all three layers of the cerebral arterial wall. The diagnosis must be made
- 33 -
by a licensed neurosurgeon, using standard cerebral angiography which indicates the

need for open surgery.
Exclusions:
40.
Multiple Root Avulsions of Brachial Plexus

The complete and permanent loss of use and sensory functions of an upper extremity
caused by avulsion of 2 or more nerve roots of the brachial plexus through accident or
injury. Complete injury of 2 or more nerve roots should be confirmed by electrodiagnostic
study done by a physiatrist or neurologist.
41.
Stroke Requiring Carotic Endarterectomy Surgery

Stroke Requiring Carotid Endarterectomy Surgery means the undergoing of carotid
Endarterectomy by expert and licensed surgeon, based on current standard medical
indications, to prevent recurrent ischemic cerebrovascular events.
42.
Surgery for Idiopathic Scoliosis

Surgery for idiopathic scoliosis means the undergoing of spinal surgery to correct an
abnormal curvature of the spine from it's normal straight line viewed from the back. The
condition must be present without an identifiable underlying cause and the curve of the
spine must be more than cobb angle 40 degree. Spinal deformity associated with
congenital defects and neuromuscular diseases are excluded
43.
Chronic Relapsing Pancreatitis

Chronic Relapsing Pancreatitis as a result of progressive severe destruction of pancreas,
this condition must be a result of recurrent acute pancreatitis and characterized by:
chronic continuous pancreatic function impairment resulting in mal-absorption of

intestine (high fat in stool) or diabetes.
- 34 -
Chronic Relapsing Pancreatitis directly cause by alcohol consumption is excluded.
44.
Elephantiasis
severe and permanent edema of arm and leg or other part of body from lymphatic
obstruction; and
Lymphatic obstruction caused by sexual transmitted disease, cancer, wound, surgery
scar, radiation, heart failure or congenital anomaly is excluded.
45.
Loss of Independent Living

Confirmation by a Consultant Physician of the loss of independent existence lasting for a
minimum period of 6 months and resulting in a permanent inability to perform at least
three (3) of the following Activities of Daily Living either with or without the use of
mechanical equipment, special devices or other aids and adaptations in use for disabled
persons. For the purpose of this benefit, the word "permanent", shall mean beyond the
hope of recovery with current medical knowledge and technology.

46.
Taking a bath
Dressing
Feeding
Relieving
Moving
Necrotising Fasciitis or Gangrene

clinical symptoms complied with diagnostic criteria of Necrotising Fasciitis;
- 35 -
extensive muscular destruction resulting in total permanent loss of involved body
part.
47.
Severe Rheumatoid Arthritis

Chronic rheumatoid arthritis is a result of an autoimmune disorder confirmed by a
physician
who specialized in rheumatology and immunology. It is characterized by all of the
following:
destruction and deformity of at least 3 of the following joints: interphalangeal
hand joint, wrist, elbow, knee, hip, ankle, cervical spine or interphalangeal foot joint.
Clinical findings and imaging study must evidence these changes, and
physical impairment resulting in inability to perform at least 3 of the 6 Activities
of Daily Living without the continual physical assistant of another person for a
continuous period of at least 180 days.

48.
Taking a bath
Dressing
Feeding
Relieving
Moving
Severe Ulcerative Colitis or Cronhs disease

Severe Ulcerative Colitis or Cronhs Disease characterized by at least 2 of the following:
- 36 -
autoimmune chronic active hepatitis and cirrhosis confirmed by pathological

study;
49.
Kawasaki Disease with Heart Complications

The diagnosis of Kawasaki disease by a consultant paediatrician or other appropriate
medical specialist. There must be echocardiographic evidence of cardiac involvement
manifesred by dilatation or neurysm formation in the coronary arteries which must persist
for at least 6 consecutive months.
Article 4
Maximum insurance coverage of total additional insurance for Critical Illness insured by Us for
the
same
Insured
shall
be
Insurance
Coverage
stated
on
the
Policy
data
or
Endorsement/Addendum by following stipulations:

a.
For Insured of 1 (one) year old through to 17 (seventeen) years old shall not exceed Rp.
500,000,000 (five hundred millions rupiah) for Rupiah currency or US$ 100,000 (one
hundred thousand United States Dollars) for US Dollar currency.
b.
For Insured of 18 (eighteen) years old through to 85 (eighty five) years old shall not
exceed Rp. 2,000,000,000 (two billions rupiah) for Rupiah currency or US$ 250,000 (two
hundred and fifty thousand United States Dollars) for US Dollar currency.
c.
By means of this paid Additional Insurance Benefit, then Insurance Coverage for Basic
Policy SmartLink shall be automatically decreased as the amount of Additional Insurance
Coverage for Critical Illness.
d.
In case Additional Insurance for Permanently Disabled Total Accelerated in 1 (one)

Policy exists, in which total amount of Additional Insurance Coverage for Critical Illness
Accelerated and Additional Insurance Coverage for Permanently Disabled of Total
Accelerated shall be more than Basic Insurance Coverage, then:
by means of this paid Additional Insurance Benefit for Critical Illness Accelerated,
then Additional Insurance Benefit for Total Accelerated Permanently Disabled
- 37 -
shall automatically change to the amount of Insurance Coverage for Basic Policy
as referred to in Article 4 item c above.
in case claim on Additional Insurance for Critical Illness Accelerated occurs and
Additional Insurance for Total Accelerated Permanently Disabled collectively,
then Benefit to pay for both Additional Insurances stated above shall not exceed
Insurance Coverage for Basic Policy.
e.
Insurance Coverage more than the above term a & b, effective if only agreed by the
Company.
Article 5
ELIMINATION PERIOD
Within 90 (ninety) days commenced on the effective date of this Additional Insurance for CI
Accelerated or commenced on the date of policy recovery, there shall not be benefit to pay from
this Additional Insurance for CI Accelerated.
Article 6
1.
You shall be obliged to deliver to Us claim notification in writing and evidence of related
illness at the time of claim not later than 30 (thirty) days commenced on the date of
diagnosis erected for related Critical Illness.
2.
Aforementioned notification shall be completed with original evidences at the time of

claim filing, among others:
3.
a.
Original policy;
b.
Original confirmation issued by the physician firstly diagnosing;
c.
Effective Your and Insureds personal identity;
d.
Other required evidences.
In case above evidences could not be delivered to Us at the determined time, We shall
reserve the right not to pay related claim.
Article 7
- 38 -
HEALTH EXAMINATION
We shall reserve the right to ask for health examination on the Insured by Consultant Doctor We
assign, if necessary.
Article 8
EXCEPTION
This Additional Insurance for CI Accelerated shall not be valid if the Insured suffers Critical
Illness, both directly or indirectly, caused by:
1.
All kinds of illness emerging from any injuries intentionally made both directly and
indirectly, suicide or suicide trial either in health physical and mental condition or not, or
2.
Any kinds of illness caused directly or indirectly by AIDS (Acquired Immune Deficiency
Syndrome) or AIDS Related Complex (ARC), or
3.
4.
Critical Illness firstly diagnosed before the Policy Date or Date of Additional Insurance for
CI Accelerated valid, or firstly diagnosed within Elimination period.
Article 9
This CI Accelerated Additional Insurance shall be terminated at the time of, whichever occurs
earlier:
1.
Lapse or Surrender Basic Policy, or
2.
Insured reaches 85 (eighty five) years old at the time of Basic Policy Anniversary, or
3.
After full payment of Additional Insurance Benefit for CI Accelerated in the form Critical
Illness Compensation.
ADDENDUM
- 39 -
ACCIDENTAL DEATH AND DISABLEMENT RIDER
We shall provide insurance to the person whose name written as the Insured on the page of
Policy Data of Basic Policy where this Additional Insurance enclosed, by following any provisions
in this Additional Insurance. We shall deliver this Additional Insurance due to Your application
relating Basic Policy You own, and it shall be merely if this Additional Insurance been registered
on page of Policy Data of Basic Policy or on Endorsement/Addendum and its paid Premium.
Article 1
DEFINITION
1.
Accident shall mean an incident occurring due to hardness outside body, immediately,
unintentionally, unpredictable, while its impacts can be proved and independent from other
causes.
2.
Injury shall mean body injury directly due to any accidents able to prove with bruise or
wound visible on outside body, except in case of being sank or inside injury found in
autopsy.
3.
Disablement shall mean any physical defects due to Injury caused by Accident causing the
Insured losing bodys functions, in which it constantly occurs exceeding 180 (one hundred
and eighty) days commenced on the date of Accident and unable to recover.
Article 2
ADDITIONAL INSURANCE BENEFIT
As long as the Policy and Additional Insurance effective, as long as We have received and
approved evidences on claim You apply, We shall play benefit for any risks as follows:
1.
In case the Insured experiences any Accidents and within 90 (ninety) days commenced on
the date of Accident occurred the Insured dies, then We shall pay the Death compensation
in the form of 100% (one hundred percent) of Insurance Coverage as written on the Policy
Data page.
2.
In case the Insured experiences Accident and suffers:

a.
Total Disablement, namely losing organs functions as follows:

-
both arms on or above metacarpophalangeal joint, or
- 40 -
both legs on or above metatarsophalangeal joint, or
both eyes (losing total functions of both eyes and unable to heal), or
one arm on or above metacarpophalageal joint and one leg on or above

metatarsophalangeal joint, or
one arm on or above metacarphophalangeal joint and one eye.
We shall therefore 100% (one hundred percent) of Insurance Coverage as stated on

the Policy Data page.
b.
Partial Disablement, namely losing one of organs functions as described below, then
We shall pay Insurance Coverage based on the following percentage:
-
right arm from shoulder 70% UP
left arm from shoulder 50% UP
right arm from elbow 60% UP
left arm from elbow 50% UP
right arm from wrist 60% UP
left arm from wrist 50% UP
one-half visual function 50% UP
audio functions of both ears 50% UP
audio function of one ear 15% UP
one leg from narrow part above ankle 50% UP
thumb of the right hand 25% UP
thumb of the left hand 20% UP
index finger of the right hand 15% UP
index finger of the left hand 10% UP
right middle finger or ring finger 6% UP
left middle finger or ring finger 6% UP
little finger of the right hand 10% UP
little finger of the left hand 7% UP
Four fingers of the right hand 40% UP
Four fingers of the left hand 35% UP
Right four fingers and thumb 60% UP
- 41 -
3.
Left four fingers and thumb 50% UP
All toes of one foot 10% UP
Thumb toe 4% UP
Each and every toe 1% UP
Additional Insurance Benefit as intended in article (1), item 3 can be paid by following
provisions:
a.
For them who are left-handed, word right shall mean left and vice versa.
b.
Special for right fingers and toes and thumb or thumb toe, We will pay this Additional
Insurance Benefit in proportion in accordance with number of loss of finger/thumb
joints due to Accident.
c.
For each and every Policy Year during this Policy and Additional Insurance effective,
total benefit of Additional Insurance shall be in proportional in accordance with
number of loss of each finger/thumb joints due to Accident.
d.
In case the Insured loses functions of more than 1 (one) body organ within 1 (one)
Policy Year, both for Total Disablement risk and Partial Disablement, then We shall
pay the Additional Insurance Benefit on each of aforementioned risks, as long as total
Additional Insurance Benefit We able to pay for all the risks shall be maximal 100%
(one hundred percent) of Insurance Coverage as stated in Policy Data page herein.
e.
You can only file 1 (one) claim on this Additional Insurance Benefit for each organ as
referred to in article (2) above.
f.
We will not bear on Total Disablement and Partial Disablement risks occurring before
or on the effective date of Basic Policy or Additional Insurance herein.
Article 3
MAXIMUM INSURANCE
In case the Insured is protected by more than 1 (one) Policy We issue for protection type of
Accidental Death and Disablement, then maximum insurance coverage We can pay on the risk
of Accidental Death and Disablement in all Policies shall be totally as follows:
- 42 -
a.
Rp. 500,000,000.- (five hundred million rupiahs) for Policy in Rupiah currency or
US$100,000 (one hundred thousand Dollar United States) for Policy in US Dollar, for the
Insured under 1 (one) year old through 17 (seventeen) years old; or
b.
Rp. 2,000,000,000.- (two billion Rupiahs) for Policy in Rupiah currency or US$500,000 (five
hundred thousand Dollar United States) for Policy stated in US Dollar, for the Insured under
18 (eighteen) years old through 65 (sixty five) years old.
Article 4
EVIDENCE ON DISABLEMENT
1.
Disablement shall be proved by Physicians Certificate made by Physician treating the

Insured. The certificate shall include confirmation that the Insured suffered Total
Disablement or Total Disablement and impossible to recovered.
2.
Without reducing factual power upon Physicians Certificate as intended in article (1) above,
We shall fully reserve the right to ask the Insured conduct health examination to Consultant
Physician We assign.
Article 5
ADDITIONAL BENEFIT CLAIM
1.
Claim Notification
Notification on the occurrence of any risks insured in this Additional Insurance shall
immediately be informed to Us in written form at the latest 60 (sixty) days commenced on
the date of Accident.
2.
Claim Evidence
For the claim filed, We will immediately send the claim form suitable for reporting and claim
evidence to the Benefit. Completed claim form and claim evidences shall be delivered to Us
within 210 (two hundred and ten) days commenced on the date of Accident.
Any claim documents required for Total and Partial Disablement shall be as follows:
a.
Photo copy of valid personal identity of the Policyholder and the Insured.
b.
Completed claim form on Disablement due to Accident.
c.
X-ray photo of the defected organ.
- 43 -
d.
Minutes/Official Letter issued by the Police for rider accident.
e.
Other Evidences We regard important for You to deliver to support the claim.
Claim document for death risk shall follow the rules as determined in General Terms of
Policy.
3.
Physicians Examination
We shall fully reserve the right to obligate the Insured to conduct medical examination to a
Consultant Physician We appoint, and request that autopsy shall be conducted to obtain
required evidences on the death cause(s) (if required).
4.
Claim Payment
We will pay Additional Benefit to the Beneficiaries based on those written on the Application
Letter for Individual Life Insurance or its amendment form, if available. In case there is only
one Beneficiary and it turns out that he/she dies and no change of Beneficiary, then We
shall pay Additional Benefit to legal heirs of the aforementioned Beneficiary.
Article 6
EXCEPTION
This additional Insurance shall not be valid if, directly or indirectly, the Insured dies due to:
1.
His/her involvement in dueling, except that it is an action for self-defense, self-injured or

efforts for self-injured, or suicide both in healthy- physical and mental condition or not,
2.
Any crimes conducted for certain intentions by Policyholder, Insured or someone assigned
as Beneficiary, or
3.
Airplane accident in which the Insurer is a passenger within or crewman of the airplane with
definite scheduled, or
4.
Risky work or profession of the Insured, for example, as military, police, fireman, miner or
other works/professions with high risks but if the risk premium has been paid, or
5.
Any risky sports or hobbies conducted by the Insured, i.e. car racing, motor racing, hors
spurring, glider flying, mount climbing, boxing, wrestling, including any sports and hobbies
containing risks and dangers, but if the risk premium has been paid, or
6.
Any accidents occurred due to insane, any illness attacking neurological system, drunk (the
Insured is under alcoholic influence), narcotics use and or drugs abuses.
- 44 -
Article 7
This Additional Insurance shall be terminated in case:
1.
Lapse and Surrender Basic Policy, or
2.
Insured reaches 65 (sixty five) years old, in which this Additional Insurance shall be
terminated on the next Policy Anniversary, or
3.
After full payment of Additional Insurance Benefit for Accidental Death and Disablement
Rider, both for this Additional Insurance and other Additional Insurances protecting the
Insurance.
Termination of this Insurance shall not impede procedure of any claims that may be previously
filed, namely during the insurance effective period.
- 45 -
ADDENDUM POLICY TERMS FOR PERIODIC PREMIUM LINK UNIT

Total Permanent Disability (TPD)
We shall provide insurance to the person(s) whose name(s) written as the Insured on the page of
Policy Data of Basic Policy where this Additional Insurance for Total Permanently Disability
enclosed, by following any provisions in this Addendum Policy Terms for Periodic Premium Link
Unit of PT Asuransi Allianz Life Indonesia on Total Permanent Disability (hereinafter called TPD
Additional Insurance). We shall deliver this TPD Additional Insurance due to Your application
relating Policy You own, and it shall be valid only if this TPD Additional Insurance been
registered on page of Policy Data of the Policy.
Article 1
DEFINITION
1.
unintentionally, unpredictably, while its impacts can be proved and independent from
other causes.
2.
Illness shall mean a physical condition indicated by pathological deviation/disorder

compared to normally healthy condition.
3.
Total Permanent Disability shall mean a physical condition where the Insured, due to a
kind of Illness or Accident, has loss his or her body parts functions or unable to work
normally for obtaining income, and such things continue to occur more than 180 (one
hundred and eighty) days as of the date of Accident/Illness and can not be recovered.
Special for the unemployed Insured for 6 (six) months before disability or the Insured has
been retired before disabled, then definition of Total Permanent Disability shall mean a
condition where the Insured, due to an Illness or Accident, can not work for minimal 3
(three) out of 5 (five) Daily Activities.
4.
Total Permanent Disability shall mean losing organs functions as follows:

a.
Both arms on or above metacarpophalangeal joint, or
b.
Both legs on or above metarsophalangeal joint, or
- 46 -
c.
Both eyes (losing total functions of both eyes and unable to recover), or
d.
One arm on or above metacarpophalageal joint and one leg on or above

metarsophalangeal joint, or
5.
e.
One arm on or above metacarphophalangeal joint and one eye, or
f.
One leg on or above metatarsophalangeal joint and one eye.

a.
Taking a bath shall refer to self-ability to clean own body when taking a bath or
using shower or cleaning own body using other good manners.
b.
Dressing shall refer to self-ability to wear, put off, tighten, and loosen all kinds of
dresses.
c.
Feeding shall refer to self-ability to put the food into own mouth in which the food
has been prepared and served.
d.
Relieving shall refer to self-ability to defecate and urinate in toilet or water closet,
or at least able to retain defecate or urinate to keep good self-health condition.
e.
support or to move from one place to another on flat floor without using a
wheelchair.
Article 2
INSURANCE BENEFIT
1.
As long as the Policy and Additional Insurance effective, as long as We have received
and approved evidences on claim You apply, We shall pay benefit for Additional
Insurance Benefit as stated on the page of Policy Data in case the Insured suffers Total
Permanent Disability.
2.
Aforementioned benefit payment above will be calculated with total loans and other
obligations included in the basic insurance, if any.
3.
After above Additional Benefit being paid, this Additional Insurance and Additional
Insurance for Accidental Death Disablement Rider shall be automatically terminated.
Article 3
MAXIMUM INSURANCE
- 47 -
In case the Insured is protected by more than 1 (one) Policy We issue for protection type of Total
Permanent Disability, then maximum insurance coverage We can pay on the risk of Total
Permanent Disability for those all policies shall be Rp. 1,000,000,000.- (one billions rupiah) for
Policies in Rupiah currency or USD 250,000 (two hundred and fifty thousand Dollar the United
States) for Policy in US Dollar currency.
Article 4
EVIDENCE AND DECISION FOR TOTAL PERMANENT DISABILITY
1.
Total Permanent Disability shall be proved by Physicians Certificate made by Physician

treating the Insured. The certificate shall include confirmation that the Insured suffered
Total Permanent Disability or impossible to recover.
2.
Without reducing factual power upon Physicians Certificate as intended in article (1)
above, We shall fully reserve the right to ask the Insured performing health examination
to Consultant Physician We assign, and this may be performed periodically as long as
the Insured suffers Total Permanent Disability.
Article 5
1.
The claim filing to obtain this Additional Benefit shall be attached with complete
evidences and shall be delivered to Us not later than 210 (two hundred and ten) days
commenced on the date of Accident/Illness onset.
2.
Aforementioned claim shall be equipped with original evidences, among others, as

follows:
3.
a.
Photocopy of valid personal identity of the Policyholder and the Insured;
b.
Completed claim form on Disability due to Accident;
c.
Original certificate issued by the treating physician;
d.
X-ray photo of the defected organ;
e.
Minutes/Official Letter issued by the Police for rider accident;
f.
In case you can not deliver us aforementioned evidences, then We reserve the right not
to pay the related claim.
- 48 -
Article 6
HEALTH EXAMINATION
Consultant Physician We assign, if required.
Article 7
EXCEPTION
This Additional Insurance shall not be valid if, directly or indirectly, the Insured suffers Total
Permanent Disability due to:
1.

2.
Any crimes conducted for certain intentions by Policyholder, Insured or someone

assigned as Beneficiary, or
3.
Airplane accident in which the Insured is a passenger within or crewman of the airplane
with indefinite scheduled, or
4.
Risky work or profession of the Insured, for example, as military, police, miner or other
works/professions with high risks but if the risk premium has been paid, or
5.
Any risky sports or hobbies conducted by the Insured, i.e. car racing, motor racing, horse
spurring, glider flying, mount climbing, boxing, wrestling, including any sports and
hobbies containing risks and dangers, but if the risk premium has been paid, or
6.
Any accidents occurred due to insane, any illness attacking neurological system, drunk
(the Insured is under alcoholic influence), narcotics use and or drugs abuses.
7.
Any illnesses suffered by the Insured prior to the effective date of this Additional
Insurance that may cause Total Permanent Disability, proven by treatment, diagnosis,
consultation and/or medication for the illness prior to the effective date of this Additional
Insurance.
- 49 -
Article 8
This Additional Insurance shall be terminated in the following cases, whichever occurs earlier:
1.
Lapse and Surrender, or
2.
The Insured reaches 65 (sixty five) years old, or
3.
After full payment of Additional Insurance Benefit in the form of compensation for Total
- 50 -

Total Permanent Disability Accelerated (TPD Acc)
Policy Data where this Additional Insurance for Total Permanently Disability Accelerated
enclosed, by following any provisions in this Addendum Policy Terms for Periodic Premium Link
Unit of PT Asuransi Allianz Life Indonesia on Total Permanent Disability Accelerated (hereinafter
called TPD Accelerated Additional Insurance). We shall deliver this TPD Accelerated
Additional Insurance due to Your application relating Policy You own, and it shall be valid only if
this TPD Accelerated Additional Insurance been registered on page of Policy Data of the Policy.
Article 1
DEFINITION
1.
other causes.
2.
Illness shall mean a physical condition indicated by pathological deviation/disorder

3.
condition where the Insured, due to an Illness or Accident, can not perform for minimal 3
4.

a.
- 51 -
b.
c.
d.
One arm on or above metacarpophalangeal joint and one leg on or above

5.
e.
One arm on or above metacarpophalangeal joint and one eye, or
f.

a.
b.
dresses.
c.
d.
e.
wheelchair.
Article 2
INSURANCE BENEFIT
1.
As long as the Policy and Additional Insurance effective, as long as We have received
and approved evidences on claim You apply, We shall pay benefit for Additional
Insurance Benefit as stated on the page of Policy Data in case the Insured suffers Total
Permanent Disability. By the payment of this Additional Insurance Benefit, then
Insurance Coverage for SmartLink Basic Policy shall automatically decrease in amount
of Additional Insurance Coverage for Total Permanent Disability.
2.
Aforementioned Additional Benefit payment above will be calculated with total loans and
other obligations included in the basic insurance, if any.
- 52 -
3.
After above Additional Benefit being paid, this Additional Insurance and Additional
Insurance for Accidental Death Disablement Rider, if any, shall be automatically
terminated.
Article 3
a.
In case the Insured is protected by more than 1 (one) Policy We issue for protection type
of Total Permanent Disability, then maximum insurance coverage We can pay on the risk
of Total Permanent Disability for those all policies shall be Rp. 1,000,000,000.- (one
billions rupiah) for Policies in Rupiah currency or USD 250,000 (two hundred and fifty
thousand Dollar the United States) for Policy in US Dollar currency.
b.
By the payment of this Additional Insurance Benefit, then the Insurance Coverage for
SmartLink Basic Policy shall automatically decrease in amount of Additional Insurance
Benefit for Accelerated Total Permanent Disability being paid.
c.
In case Additional Insurance for Critical Illness Accelerated in 1 (one) Policy exists, in
which total amount of Additional Insurance Coverage for Total Permanent Disability and
Insurance Coverage for Critical Illness Accelerated of Basic Policy shall be more than
Basic Insurance Coverage, then:
by means of this paid Additional Insurance Benefit for Total Permanent Disability
Accelerated, then Additional Insurance Benefit for Critical Illness Accelerated
shall automatically change to the amount of Insurance Coverage for Basic Policy
as referred to in Article 3 item b above.
in case claim on Additional Insurance for Total Permanent Disability Accelerated

occurs and Additional Insurance for Critical Illness Accelerated occurs
simultaneously, then Benefit to pay for both Additional Insurances stated above
shall not exceed Insurance Coverage for Basic Policy.
- 53 -
Article 4
EVIDENCE AND DECISION FOR TOTAL PERMANENT DISABILITY
1.
Total Permanent Disability shall be proved by Physicians Certificate made by Physician

treating the Insured. The certificate shall include confirmation that the Insured suffered
Total Permanent Disability or impossible to recover.
2.
Without reducing factual power upon Physicians Certificate as intended in article (1)
above, We shall fully reserve the right to ask the Insured performing health examination
to Consultant Physician We assign, and this may be performed periodically as long as
the Insured suffers Total Permanent Disability.
Article 5
1.
The claim filing to obtain this Additional Benefit shall be attached with complete
evidences and shall be delivered to Us not later than 210 (two hundred and ten) days
commenced on the date of Accident/Illness onset.
2.
Aforementioned claim shall be equipped with original evidences, among others, as

follows:
3.
a.
Photocopies of valid personal identity of the Policyholder and the Insured.
b.
Completed claim form on Disability due to Accident.
c.
Original certificate made by treating physician.
d.
X-ray photo of the defected organ.
e.
Minutes/Official Letter issued by the Police for rider accident.
f.
In case you can not deliver us aforementioned evidences, then We reserve the right not
to pay the related claim.
Article 6
HEALTH EXAMINATION
Consultant Physician We assign, if required.
- 54 -
Article 7
EXCEPTION
This Additional Insurance shall not be valid if, directly or indirectly, the Insured suffers Total
Permanent Disability due to:
1.

2.

3.
Airplane accident in which the Insured is a passenger within or crewman of the airplane
with indefinite scheduled, or
4.
Risky work or profession of the Insured, for example, as military, police, miner or other
works/professions with high risks but if the risk premium has been paid, or
5.
Any risky sports or hobbies conducted by the Insured, i.e. car racing, motor racing, horse
spurring, glider flying, mount climbing, boxing, wrestling, including any sports and
hobbies containing risks and dangers, but if the risk premium has been paid, or
6.
Any accidents occurred due to insane, any illness attacking neurological system, drunk
(the Insured is under alcoholic influence), narcotics use and or drugs abuses.
7.
Insurance that may cause Total Permanent Disability, proven by treatment, diagnosis,
consultation and/or medication for the illness prior to the effective date of this Additional
Insurance.
Article 8
This Additional Insurance shall be terminated in the following cases, whichever occurs earlier:
1.
2.
The Insured reaches 65 (sixty five) years old, or
3.
After full payment of Additional Insurance Benefit in the form of compensation for Total
- 55 -
- 56 -

Payor Benefit
Policy Data where this Payor Benefit Additional Insurance enclosed, by following any provisions
in this Addendum Policy Terms for Periodic Premium Link Unit of PT Asuransi Allianz Life
Indonesia on Payor Benefit (hereinafter called Payor Benefit Additional Insurance). We shall
deliver this Payor Benefit Additional Insurance due to Your application relating Policy You own,
and it shall be valid only if this Payor Benefit Additional Insurance been registered on page of
Policy Data of the Policy.
Article 1
TERMS
1.
other causes.
2.
Illness shall mean a physical condition signed by pathological deviation/disorder

3.
4.

a.
b.
- 57 -
c.
d.

5.
e.
One arm on or above metacarpophalangeal joint and one eye, or
f.

a.
b.
dresses.
c.
d.
e.
wheelchair.
6.
Critical illness shall mean 38 (thirty eight) illnesses by following definition:

1.

Infarct of parts of heart muscles caused by lack of blood supply to heart.
Diagnostic criteria to meet at the time of heart attack shall be to meet 3 (three)
criteria out of 5 (five) criteria as follows whichever conforms the first heart attack:
a.
b.
Change of electrocardiogram description specifically showing Infarct

Myocardial of early stadium and;
c.
d.
e.
Left Ventricular Ejection fraction less than 50% (fifty percent) that occurs
for 3 (three) or more months after the onset.
- 58 -
2.
Stroke
symptoms, in which it occurs more than 24 (twenty four) hours including brain
tissue infarct, brain bleeding, thrombosis and embolism. This diagnosis should
be supported by some conditions as follows:
a.
Evidence on permanently neurological deficit shall be erected by a

neurologist doctor and the symptoms occurred at least during 6 months
after the onset.
b.
The
discovery
is
derived
from
Magnetic
Resonance
Imaging,
Computerized Tomography, or other examinations using Imaging

technique according to the diagnose of new stroke.
Excepted illnesses:
a.
b.
Brain damage due to accident or injury, infection, vasculity, and inflamed

illness;
3.
c.
d.

It shall mean surgery operation by opening the cardiac wall, to conduct surgery
on one or more artery vessels due to constriction or obstruction on the artery
vessel. Diagnose shall be erected based on Angiography showing meaningful
coronary arterial obstruction and the procedure shall be based on a
4.

It shall mean surgery operation by opening the cardiac to change or repair any
valves due to defective cardiac valves. Abnormal cardiac valves diagnose shall
- 59 -
be erected on the basis of cardiac catheterization or echocardiogram and the

examining procedure shall be based on any consideration made by cardiologist.
5.
Cancer
It is a kind of illness signed with malignant tumor due to uncontrolled cell growth
and spreading malignant tumor cell and invasion to tissue. Diagnose shall be
erected on the basis of tissue examination and diagnosed by Oncologist or
Pathologist. Excepted illnesses are as follow:
Carcinoma In situ and any tumors histologically describing pre-cancer or

not invasive, including Breast Carcinoma In Situ, Cervical Dysplasia CIN
1, CIN 2 and CIN 3.
Hyperkeratosis, basal cell and squamous skin cancer, and melanoma

with thickness less than 1.5 mm Breslow, or less than Clark Level 3
except there is other evidence showing any spreads;
Prostate Gland Cancer based on tissue examination and also TNM

classification T1a or T1b or prostate gland cancer based on same
classification
or
Lesser
Classification,
T1N0M0
Papillary
micro
carcinoma of thyroid gland with diameter less than 1 cm, Papillary micro
carcinoma of urinary bladder, and Chronic Lymphocytic Leukemia less
It shall be included all kinds of leukemia (except for lymphatic leukemia),

malignant tumor on all body organs but all kinds of skin tumor (except for
melanoma malignum) and benign tumor and cancer stadium in situ shall not be
insured under this Insurance coverage.
6.
Kidney Failure
Final stage of kidney failure described as functioning failure of both chronic
kidneys and can not be recovered, that it requires ordered kidney dialysis or
kidney transplantation.
- 60 -
7.
Paralysis
Loss of joint functions at least those of arms and both legs, or one arm and one
leg, totally and constantly, and continuously occurs at least for 6 (six) weeks.
Such a condition shall be erected by neurologist. Any injuries caused by
intentional actions by oneself shall be excluded from this illness.
8.
Multiple Sclerosis
It is a kind of illness causing defects on central neurological system
progressively that causing brain and brain stem defects. Fixed diagnose without
hesitancies shall be made by neurologist confirming combination of the
following: any symptoms leading to fibers (white substance) including optical
nerves, brain stem, spinal cord, that causing neurological deficit; and has
developed minimal for 6 (six) months in which it causes disturbance on
coordination and functions of motor censor. Data supporting reoccurrence and
symptoms appearance or neurological deficit.
Neurological system defect due to other illnesses as SLE and HIV shall be
excluded from this kind of illness.
9.

Haematopoitic stem cells preceded by total ablasion of haematopoitic

stem cells; or
One of human organs as follows: kidney, heart, liver, and lungs,

pancreas due to final failure of such organs functions.
10.

condition and questionnaire or acceptable standard test regarding Alzheimer
Illness or any problems on degenerative organic brain that cannot be recovered,
- 61 -
in case it causes real decrease in mental and social functions that that requires
continuous
monitoring
towards
the
Insured.
Progressive
degeneration
occurrence of kornu anterior medulla spinalis (lesion lower motor neuron),

traktus kortiko spinalis (lesion upper motor neuron) and nucleic motor brain stem.
Diagnose shall clinically be confirmed by specialist doctor accordingly appointed
by the Insurer. Excluded illnesses shall be as follows:
11.
Coma
Unconsciousness condition without any reactions or responses to external
stimuli or internal needs that continuously occur with the result that requires lifesupporting tools including a need to use respirator at least during 96 (ninety six)
hours. Permanently neurological deficit must occur and continuously be suffered
for 42 days. Coma due to direct alcohol abuse or drugs shall be excluded.
12.
Parkinson Illness
neurologist and recommended by any doctors appointed by the Insurer where
the Insureds condition cannot be controlled using drugs; showing progressive
defects. This Insurance shall be for Parkinson Idiopathic only. All other kinds of
Parkinson shall be excluded from this Insurance.
Inability to conduct Daily Activities with or without supporting device minimal 3
(three) out of 5 (five) Daily Activities and such inability has occurred continuously
for minimal 6 (six) months.
Daily Activities (in accordance with Article 1 : 5):
Taking a bath
Dressing
Feeding
Relieving
- 62 -
Moving
13.
Terminal Illness
In condition the illness or final stadium suffered by the Insured based on
diagnosis made by examining doctor while it has been approved by the Insureds
doctor predicting that life expectancy of the Insured shall be less than 12
(twelve) months.
14.

Final stage illness shall included intersisial lungs due to chronic respiration
failure.
Diagnosis shall be erected by lungs specialist doctor and shall meet symptoms
and evidences as follows:
Analysis on arterial blood gas using partial oxygen pressures 55 mmHg

or less (PaO2<55 mmHg)
15.
Chronic Hepatitis
a.
Permanent yellow
b.
Ascites
c.
Chronic hepatitis due to alcohol and drugs consumption shall be excluded from
this insurance.
16.
- 63 -
Undoubtedly-definite diagnosis regarding Neuron Motor Illness due to

progressive degeneration on brain stem and Anterior horn cells or neuron bulbar
efferent including atrophy spinal muscle, progressive bulbar palsy, amyotrophic
lateral sclerosis and primary lateral sclerosis. And it is supported by definite
evidences from the signs and deficit neurological symptoms and approved by
Insurers doctor. And the diagnosis shall be erected by neurologist.
17.
Muscular Dystrophy
It is combination of hereditary muscle degeneration illnesses causing
weaknesses or muscle atrophy. Diagnosis shall be erected definitely by
neurologist, and the evidence shall be based on daily activities examination that
confirms the Insureds inability for conducting daily activities with or without helps,
minimal 3 (three) out of 5 (five) Daily Activities taking place minimal 6 (six)
months.
18.
Taking a bath
Dressing
Feeding
Relieving
Moving
Aplastis Anemia
The chronic and persistent failure of spinal cord functions causing anemia,
neutropenia and thrombocytopenia requiring minimal one of the following
treatments:
a.
Blood transfusion
b.
c.
d.
- 64 -
19

aneurism, constriction, obstruction requiring excision and surgery to change
disordered aorta by opening stomach and chest cavities. Aorta intended in this
definition shall be thorax and abdominal aorta excluding those Aorta branches.
Surgery in nature of invasive minimal or intra-arterial technique shall be
excluded from this stipulation.
20.
Hepatitis Fulminant
Liver failure due to sub massive or massive liver parenchyma death caused by
Hepatitis virus. Hepatitis fulminant due to suicide trial, poisoned, drugs
overdoses and over-alcohol shall be excluded from this Insurance.
Liver parenchyma death including almost all liver lobus. And causes
reticular damages and its functions.
21.
Obvious icterus.

Pulmonary Arterial Hypertension Primer illness showing enlargement of right
ventricle erected based on clinical examination, cardiac catheterization, causing
permanent physical disorders and based on Classification Cardiac Impairment
The New York Heart Association (NYHA) included minimal class IV (Unable to
conduct any physical activities while the symptoms may emerge at the time of
taking a rest).
- 65 -
22.
permanently neurological inability and occurs minimal for 6 (six) weeks.
23.
Benign Brain Tumor

symptoms of increasing pressure in the skull as papilloedema, mental disorder,
insane, and sense disorders confirmed by neurologist. The existence of tumor as
the basic shall be confirmed by CT Scan or MRI.
Cyst, granuloma, form deviation on or of brain artery or vena (AVM), hematoma,
and pituitary gland tumor or that of spinal cord shall be excluded from this illness.
24.
Inflamed Brain
Inflammation diagnosis of brain (cerebral hemisphere, brain stem or cerebellum)
due to virus infection, causing meaningful complication occurring minimal for 6
(six) weeks, including permanent nerve deficit and been confirmed by
neurologist. Permanent/localized neurological deficit can be in form of mental
retardation, unstable emotion, vision disorders, hearing disorder deficit, speaking
disorder, weaknesses or paralysis.
25.
Burn
Burn level three (All Skin Layers) minimal 20% (twenty percent) of total wide
surface area of the Insureds body.
26.
Poliomyelitis
- 66 -
Muscle paralysis on moving muscle components or breathing muscles

causing the Insured unable to make 3 (three) out of 5 (five) Daily
Activities continuously minimal for 3 (three) months.
27.
Serious Head Trauma

Any accidents causing head injury that causing permanently neurological deficit
not less than 6 (six) weeks since the accident occurred that the Insured cannot
carry out his/her 3 (three) out of 5 (five) Daily Activities for minimal 6 (six)
months. This diagnosis shall be erected by neurologist and supported by
Magnetic Resonance Imaging technique, Computerized Tomography, or other
acknowledged techniques. The accident shall occur directly from outside body
parts, visible, and shall not depend on other cause(s).
28.
Apallic Syndrome
Total brain cortex damages while the brain stem is still normal. This diagnosis
shall be erected by neurologist and condition of this syndrome shall constantly
occur minimal for 1 (one) month.
29.

percent) and 2 (two) other coronary arteries minimal 60% (sixty percent) proved
by coronary arteriography, without viewing whether the surgery has been
conducted or not.
The intended coronary artery shall be Left Main Coronary Artery (LC), Left
Anterior Descending Artery (LAD), Circumflex Artery and Right Coronary Artery
(RC).
- 67 -
30.

Limit for this benefit payment shall be 10% of Total Critical Illness Insurance or
maximal not more than Rp. 200,000,000 (two hundred millions rupiah) after the
Insured follows ballooning angioplasty or intra arterial catheter procedure for
treating the constriction minimal for coronary vessel 60% of one or more
coronary arterial blood vessel in which majority is proved by angiographic.
Revascularization shall be in accordance with indication and consultant
cardiologist or cardiac specialist.
(RC).
Plus) shall be continued by the remaining 90% (ninety percent) of Total
Insurance Coverage for Critical Illness Accelerated (Critical Illness Plus).
31.

It is a kind of multi-systemically and multifactor autoimmune disorders signed
with increasing auto-antibody attacking various body antigen. Type of System
Lupus Erythematosus to insure by this Additional Insurance shall be limited to
types of Systemic Lupus Erythematosus involving kidney (Class III to Class IV of
Lupus Nephritis, defined by kidney biopsy, and in accordance with WHO
classification). Those excluded from Critical Illness claim on Systemic Lupus
Erythematosus shall be other kinds of lupus, namely discoid lupus and other
types involving joints and hematology systems.
Erection of Systemic Lupus Erythematosus diagnosis shall be carried out by
Specialist on Rheumatology and Immunology.
- 68 -
32.
Class I
Class II
Class III
Class IV
Class V

A.
The Insured is infected by Human Immunodeficiency Virus (HIV) through
blood transfusion of the following conditions:

1.
Blood transfusion that medically required and given as a part of

medication process.
2.
Blood transfusion shall be conducted in Indonesia after the Policy Date

effective, Date of Insurance Change, whenever occurs earlier.
3.
Infection source shall be from any institutions holding blood transfusion

and the institutions can track the source of HIV-infected blood, and
4.
B. Human Immunodeficiency Virus (HIV) infection shall be obtained from an

accident in workplace after effective date of the Policy or the date of Insurance
change, whichever occurs later, as long as the Insured perform his or her
1.
HIV infection obtained due to accident in workplace shall be within 30

(thirty) days commenced on the accidence, and
2.
Any evidences that the accident due to his or her work shall be the
cause of HIV infection, and
3.
Any evidences that cero-conversion of negative HIV to positive HIV shall

occur within 180 (one hundred and eighty) days after the accident
happens. This evidence shall be completed by testing negative HIV
antibody within 5 (five) days commenced on the date of accident due to
his or her works.
- 69 -
4.
HIV infection due to other causes including sexual activities and drugs
uses in intra-vena shall be excluded from this illness.
This benefit shall be valid if the Insured works as Medical Worker, Medical
worker student, certified nurse, laboratory technician, dentist, paramedic, works
in health center and clinic (in Indonesia).
This benefit shall not be valid if point A and B has received medical treatment for
treating AIDS and for treating any impacts due to HIV virus infection, or
managing for preventing AIDS. The treatment intended shall be any treatments
to make HIV inactive and non-infectious.
33.

Unable to heal and total loss on audio senses functions in both ears due to
illness or accident. The diagnosis shall be supported with audiometry and audio
testing provided and certified by Ear, Nose and Throat Specialist physician.
34.

Unable to heal and total loss on vocal function due to accident or disorders on
vocal cord. Vocal inability shall continuously occur for 12 (twelve) months.
Diagnosis of this disorder shall be supported by evidences made by Ear, Nose
and Throat specialist physician.
35.
Blindness
Loss of total visual ability and unable to heal due to illness or accident. The
blindness shall be diagnosed by ophthalmologist.
36.
It is a kind of collagen blood vessel disorder that systematically causes total
fibrosis progressively within the skin, blood vessel and other body organs.
Diagnosis of this disorder shall be supported by biopsy and other supporting
- 70 -
evidences as results of serology and this illness shall be in accordance with

systemic proportion related to heart, lungs and kidney.
37.
CREST syndrome

It is a kidney disorder that progressively hereditary characterized with cyst and
medulla, tubular atrophy and intestitial fibrosis with clinical anemia manifestation,
polyuria and loss of sodium through kidney, developing to chronic kidney failure.
This diagnosis shall be supported by kidney biopsy.
38.
Cardiomyopathy
Diagnosis erected by cardiologist that cardiomyopathy shall be caused by
functional disorder of cardiac ventricle chamber, showed by abnormal ECG
results and confirmed by echocardiography and causing physical inability
permanently with minimal degree on Class III in accordance with New York
Association Classification of Cardiac Impairment.
Class III Meaningful inability signed with Patient in comfortable position of
resting position but ability in conducting very limited daily activities of normal
condition and shows any symptoms of congestive cardiac failure.
Class IV Inability to perform any activities. Congestive cardiac failure
symptoms emerges though in resting condition. Anytime physical activities
increase, uncomfortable condition occurs.
- 71 -
39.

The actual undergoing of brain surgery to correct an abnormal widening of the
cerebral artery involving all three layers of the cerebral arterial wall. The
diagnosis must be made by a licensed neurosurgeon, using standard cerebral
angiography which indicates the need for open surgery.
Exclusions:
40.

The complete and permanent loss of use and sensory functions of an upper
extremity caused by avulsion of 2 or more nerve roots of the brachial plexus
through accident or injury. Complete injury of 2 or more nerve roots should be
confirmed by electrodiagnostic study done by a physiatrist or neurologist.
41.

Stroke Requiring Carotid Endarterectomy Surgery means the undergoing of
carotid Endarterectomy by expert and licensed surgeon, based on current
standard medical indications, to prevent recurrent ischemic cerebrovascular
events.
42.

Surgery for idiopathic scoliosis means the undergoing of spinal surgery to
correct an abnormal curvature of the spine from it's normal straight line viewed
from the back. The condition must be present without an identifiable underlying
cause and the curve of the spine must be more than cobb angle 40 degree.
Spinal deformity associated with congenital defects and neuromuscular diseases
are excluded
43.
- 72 -
Chronic Relapsing Pancreatitis as a result of progressive severe destruction of

pancreas, this condition must be a result of recurrent acute pancreatitis and
characterized by:
chronic continuous pancreatic function impairment resulting in malabsorption of intestine (high fat in stool) or diabetes.
Chronic Relapsing Pancreatitis directly cause by alcohol consumption is

excluded.
44.
Elephantiasis
severe and permanent edema of arm and leg or other part of body from
lymphatic obstruction; and

Lymphatic obstruction caused by sexual transmitted disease, cancer,
wound, surgery scar, radiation, heart failure or congenital anomaly is
excluded.
45.

Confirmation by a Consultant Physician of the loss of independent existence
lasting for a minimum period of 6 months and resulting in a permanent inability to
perform at least three (3) of the following Activities of Daily Living either with or
without the use of mechanical equipment, special devices or other aids and
adaptations in use for disabled persons. For the purpose of this benefit, the word
"permanent", shall mean beyond the hope of recovery with current medical
knowledge and technology.

Necrotising fasc Daily Activities (in accordance with Article 1 : 5):
- 73 -
46.
Taking a bath
Dressing
Feeding
Relieving
Moving

clinical symptoms complied with diagnostic criteria of Necrotising

Fasciitis;
extensive muscular destruction resulting in total permanent loss of

involved body part.
47.

Chronic rheumatoid arthritis is a result of an autoimmune disorder confirmed by
a physician
who specialized in rheumatology and immunology. It is characterized by all of
the following:
destruction and deformity of at least 3 of the following joints:

interphalangeal hand joint, wrist, elbow, knee, hip, ankle, cervical spine
or interphalangeal foot joint. Clinical findings and imaging study must
evidence these changes, and
physical impairment resulting in inability to perform at least 3 of the 6

Activities of Daily Living without the continual physical assistant of
another person for a continuous period of at least 180 days.

- 74 -
48.
Taking a bath
Dressing
Feeding
Relieving
Moving

Severe Ulcerative Colitis or Cronhs Disease characterized by at least 2 of the
following:
autoimmune chronic active hepatitis and cirrhosis confirmed by

pathological study;
49.

The diagnosis of Kawasaki disease by a consultant paediatrician or other
appropriate medical specialist. There must be echocardiographic evidence of
cardiac involvement manifesred by dilatation or neurysm formation in the
coronary arteries which must persist for at least 6 consecutive months.
7.
Waiting period shall mean the period starting from the date of Insured stated to medically
suffer Total Permanent Disability or commenced on the Insured firstly diagnosed to
suffer one of aforementioned Critical Illnesses, through to the date of acceptance and
approval of claim for this Payor Benefit Additional Insurance.
Article 2
THE INSURED
Special for this Payor Benefit Insurance Coverage, the Insured shall be the Policyholder.
- 75 -
Article 3
INSURANCE BENEFIT
As long as the Policy and Payor Benefit Additional Insurance is effective and the Insured of this
Payor Benefit Additional Insurance has not reached 64 (sixty four) years old, in case the Insured
suffered Total Permanent Disability and firstly diagnosed to suffer one of the aforementioned
Critical Illnesses as referred to in Article 1 of this Payor Benefit Additional Insurance herein, then
after We have received and approved the claim evidences proposed, We will release the Insured
from his or her obligation to pay Periodic Premium (and Periodic Top-Up Premium, optional) as
of the date of expiration after We receive and approve the claim. Furthermore, We will pay the
Periodic Premium (and Periodic Top-Up Premium, optional) directly used to purchase Unit.
Premium allocation shall be based on the next premium allocation from the last premium You
pay.
We shall deliver premium release benefit as follows:
1.
Periodic Premium (and Top-Up Periodic Premium, optional), that We release shall be as
stated on the page of Policy Data/Endorsement/Addendum.
2.
Premium period payment released shall be the next expiration date after we receive and
approve the claim, until the Insured reaches 65 (sixty five) years old, or in case the
Insured dies before such time, until a time as if the Insurer reaches 65 (sixty five) years
old if he or she was alive.
3.
In case Periodic Premium (and Top-Up Periodic Premium, if available) having maturity
date exists within Waiting Period, then the Insured within this Payor Benefit Additional
Insurance must remain to perform his or her obligation to pay Periodic Premium (Top-Up
Periodic Premium, if available) as in normal condition. In case We finally accept and
approve the claim for benefit of this Payor Benefit Additional Insurance, then We will
return it to the Insured covered by this Payor Benefit Additional Insurance total Periodic
Premium (Top-Up Periodic Premium, if available) being paid during the Waiting Period.
Article 4
ELIMINATION PERIOD
- 76 -
We will not pay any benefit for this Payor Benefit Additional Insurance for risks of Critical Illness
firstly diagnosed upon the Insured under this Payor Benefit Additional Insurance within 90
(ninety) days commenced on the effective date of this Payor Benefit Additional Insurance or
commenced on the date of policy recovery.
Article 5
1.
Total Permanent Disability Claim

a.
Notification of Total Permanent Disability claim shall be enclosed with complete

evidences and shall be transferred to us not later than 210 (two hundred and
ten) days as of the date of Total Permanent Disability occurrence.
b.
Aforementioned notification shall be completed with original evidences at the

time of claim filing, among others, as follows:
1.
Fully-completed form of Total Permanent Disability claim;
2.
Certificate from treating Physician stating that the Insured under this
Payor Benefit Additional Insurance suffers Total Permanent Disability
and it is possible unrecovered;
3.
X-ray photograph on the disabled organ(s);
4.
Photocopy of valid the Insured under this Payor Benefit Additional

Insurances identity card;
5.
Minutes/certificate issued from the Policy for rider accidents;
6.
Other evidences we deem necessary to make available by You for

supporting the claim.
c.
In case above evidences could not be delivered to Us at the determined time,

We shall reserve the right not to pay related claim.
2.
Critical Illness Claim

a.
Notification of Critical Illness shall be enclosed with complete evidences and

shall be transferred to Us not later than 30 (thirty) days as of the Insured firstly
diagnosed to suffer such Critical Illness.
- 77 -
b.
Aforementioned notification shall be enclosed with original evidences at the time

of claim filing, among others:
1.
Fully-completed form of Critical Illness claim by physician firstly

diagnosing;
2.
Payor Benefit Additional Insurance suffers Critical illness and it is
possible unrecovered;
3.
Photocopy of valid the Insured under this Payor Benefit Additional

Insurances identity card;
4.

c.

Article 6
HEALTH EXAMINATION
Without prejudice to decrease power of Certificate issued by the Physician as referred to in

above article herein, We shall fully reserve the right to obligate the Insured to conduct medical
examination to a Consultant Physician We assign, as long as the Insured still suffers Total
Permanent Disability or Critical Illness.
Article 7
EXCEPTION
1.
This additional Payor Benefit Insurance shall not be valid if, directly or indirectly, the
Insured suffers Total Permanent Disability due to:
a.
His/her involvement in dueling, except that it is an action for self-defense, selfinjured or efforts for self-injured, or suicide both in healthy- physical and mental
condition or not,
b.

- 78 -
c.
Airplane accident in which the Insured is a passenger within or crewman of the

airplane with indefinite scheduled, or
d.
Risky work or profession of the Insured, for example, as military, police, flight, or
e.
Any risky sports or hobbies conducted by the Insured, i.e. car racing, motor
racing, horse spurring, glider flying, mount climbing, boxing, wrestling, including
any sports and hobbies containing risks and dangers, but if the risk premium has
been paid, or
f.
Any accidents occurred due to insane, any illness attacking neurological system,
drunk (the Insured is under alcoholic influence), narcotics use and or drugs
abuses.
g.
Insurance that may cause Total Permanent Disability, proven by treatment,
diagnosis, consultation and/or medication for the illness prior to the effective
date of this Additional Insurance.
2.
h.
Abnormality, Illness and/or congenital disability, or
i.
HIV/AIDS infection and/or contaminating venereal diseases.
This Payor Benefit Additional Insurance shall not valid in case, both directly and
indirectly, the Insured suffers any Critical Illnesses as follows:
a.
All kinds of illness emerging from any injuries intentionally made both directly
and indirectly, suicide or suicide trial either in health physical and mental
condition or not, or
b.
Any kinds of illness caused directly or indirectly by AIDS (Acquired Immune

Deficiency Syndrome) or AIDS Related Complex (ARC), or
c.
d.
Critical Illness firstly diagnosed before the Policy Date or Date of Payor Benefit
Additional Insurance, or firstly diagnosed within Elimination period.
Article 8
- 79 -
This Payor Benefit Additional Insurance shall be terminated in the following cases, whichever
occurs earlier:
1.
2.
The Insured of this Policy dies; or
3.
The Insured under this Payor Benefit Additional Insurance reaches 65 (sixty five) years
old at the time of basic Policy anniversary, or
4.
We have accepted and approved and paid the claim on additional insurance of Spouse
Payor Benefit or Spouse Payor Protection or Payor Protection that also attached to this
Policy (if available).
- 80 -

Payor Protection
Policy Data where this Payor Protection Additional Insurance enclosed, by following any
provisions in this Addendum Policy Terms for Periodic Premium Link Unit of PT Asuransi Allianz
Life Indonesia on Payor protection (hereinafter called Payor Protection Additional Insurance).
We shall deliver this Payor Protection Additional Insurance due to Your application relating Policy
You own, and it shall be valid only if this Payor Protection Additional Insurance been registered
on page of Policy Data of the Policy.
Article 1
THE INSURED
Special for this Payor Protection Insurance Coverage, the Insured shall be the Policyholder.
Article 2
INSURANCE BENEFIT
As long as the Policy and Additional Insurance is effective and the Insured of this Additional
Insurance has not reached 64 (sixty four) years old, in case the Insured dies then after We
accept and approve the claim evidence being filed, We will release the Insured from his or her
obligation to pay Periodic Premium (and Periodic Top-Up Premium, optional) as of the maturity
date after We receive and approve the claim. Furthermore, We will pay the Periodic Premium
(and Periodic Top-Up Premium, optional) directly used to purchase Unit. Premium allocation
shall be based on the next premium allocation from the last premium You pay.
(1)
Periodic Premium (and Top-Up Periodic Premium, optional), that WE release shall be as
(2)
approve the claim, until a time as if the Insurer reached 65 (sixty five) years old if he or
she was alive.
- 81 -
Article 3
CLAIM
Application to obtain Additional Insurance benefit as referred to in this Additional Insurance
Addendum shall be filed by you to us not later than 60 (sixty) days as of the date of Insureds
death, by completing required claim documents.
Article 4
EXCEPTION
This Additional Insurance shall be invalid in case the Insured dies due to:
1.
Within 2 (two) years as of the approval date of this Additional Insurance, the Insured dies
due to:
a.
Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex or

Human Immunodeficiency Virus (HIV) infection; or
b.
2.
Suicide; or
The Insured dies within Insurance Period due to death sentence by the court, or due to
intentional perform or participate in a crime or a crime trial, both active and not, or in
case the Insured dies due to criminal act insured by the party having or participating to
have interest on this insurance coverage.
Article 5
This Insurance shall be terminated due to the following cases, whichever occurs earlier:
1.
2.
The Insured under this Additional Insurance has reached 65 (sixty five) years old at the
time of Basic Policy Anniversary, or
3.
We have accepted and approved and paid the claim on additional insurance of Spouse
Payor protection or Spouse Payor Protection or Payor Benefit that also attached to this
Policy (if available).
- 82 -

Spouse Payor Benefit

Policy Data where this Spouse Payor Benefit Additional Insurance enclosed, by following any
Life Indonesia on Payor Benefit (hereinafter called Spouse Payor Benefit Additional
Insurance). We shall deliver this Spouse Payor Benefit Additional Insurance due to Your
application relating Policy You own, and it shall be valid only if this Spouse Payor Benefit
Additional Insurance been registered on page of Policy Data of the Policy.
Article 1
TERMS
1.
other causes.
2.
Illness shall mean a physical condition signed by pathological deviation/disorder

3.
4.

a.
b.
c.
- 83 -
d.

5.
e.
One arm on or above metacarphophalangeal joint and one eye, or
f.

f.
g.
dresses.
h.
i.
j.
wheelchair.
6.
Critical Illness shall mean 38 (thirty eight) illnesses by following definition:

1.

Infarct of parts of heart muscles caused by lack of blood supply to heart.
Diagnostic criteria to meet at the time of heart attack shall be to meet 3 (three)
criteria out of 5 (five) criteria as follows whichever conforms the first heart attack:
a.
b.
Change of electrocardiogram description specifically showing Infarct

Myocardial of early stadium and;
c.
d.
e.
Left Ventricular Ejection fraction less than 50% (fifty percent) that occurs
for 3 (three) or more months after the onset.
2.
Stroke
- 84 -

symptoms, in which it occurs more than 24 (twenty four) hours including brain
tissue infarct, brain bleeding, thrombosis and embolism. This diagnosis should
be supported by some conditions as follows:
a.
Evidence on permanently neurological deficit shall be erected by a

neurologist doctor and the symptoms occurred at least during 6 months
after the onset.
b.
The
discovery
is
derived
from
Magnetic
Resonance
Imaging,
Computerized Tomography, or other examinations using Imaging

technique according to the diagnose of new stroke.
Excepted illnesses:
a.
b.
Brain damage due to accident or injury, infection, vasculity, and inflamed

illness;
c.
c.

It shall mean surgery operation by opening the cardiac wall, to conduct surgery
on one or more artery vessels due to constriction or obstruction on the artery
vessel. Diagnose shall be erected based on Angiography showing meaningful
coronary arterial obstruction and the procedure shall be based on a
4.

It shall mean surgery operation by opening the cardiac to change or repair any
valves due to defective cardiac valves. Abnormal cardiac valves diagnose shall
be erected on the basis of cardiac catheterization or echocardiogram and the
examining procedure shall be based on any consideration made by cardiologist.
- 85 -
5.
Cancer
It is a kind of illness signed with malignant tumor due to uncontrolled cell growth
and spreading malignant tumor cell and invasion to tissue. Diagnose shall be
erected on the basis of tissue examination and diagnosed by Oncologist or
Pathologist. Excepted illnesses are as follow:
-
Carcinoma In situ and any tumors histologically describing pre-cancer or

not invasive, including Breast Carcinoma In Situ, Cervical Dysplasia CIN
1, CIN 2 and CIN 3.
Hyperkeratosis, basal cell and squamous skin cancer, and melanoma

with thickness less than 1.5 mm Breslow, or less than Clark Level 3
except there is other evidence showing any spreads;
Prostate Gland Cancer based on tissue examination and also TNM

classification T1a or T1b or prostate gland cancer based on same
classification
or
Lesser
Classification,
T1N0M0
Papillary
micro
carcinoma of thyroid gland with diameter less than 1 cm, Papillary micro
carcinoma of urinary bladder, and Chronic Lymphocytic Leukemia less
-
It shall be included all kinds of leukemia (except for lymphatic leukemia),

malignant tumor on all body organs but all kinds of skin tumor (except for
melanoma malignum) and benign tumor and cancer stadium in situ shall not be
insured under this Insurance coverage.
6.
Kidney Failure
Final stage of kidney failure described as functioning failure of both chronic
kidneys and can not be recovered, that it requires ordered kidney dialysis or
kidney transplantation.
- 86 -
7.
Paralysis
Loss of joint functions at least those of arms and both legs, or one arm and one
leg, totally and constantly, and continuously occurs at least for 6 (six) weeks.
Such a condition shall be erected by neurologist. Any injuries caused by
intentional actions by oneself shall be excluded from this illness.
8.
Multiple Sclerosis
It is a kind of illness causing defects on central neurological system
progressively that causing brain and brain stem defects. Fixed diagnose without
hesitancies shall be made by neurologist confirming combination of the
following: any symptoms leading to fibers (white substance) including optical
nerves, brain stem, spinal cord, that causing neurological deficit; and has
developed minimal for 6 (six) months in which it causes disturbance on
coordination and functions of motor censor. Data supporting reoccurrence and
symptoms appearance or neurological deficit.
Neurological system defect due to other illnesses as SLE and HIV shall be
excluded from this kind of illness.
9.

-
Haematopoitic stem cells preceded by Total ablasion of haematopoitic

stem cells; or
One of human organs as follows: kidney, heart, liver, and lungs,

pancreas due to final failure of such organs functions.
10

condition and questionnaire or acceptable standard test regarding Alzheimer
Illness or any problems on degenerative organic brain that cannot be recovered,
- 87 -
in case it causes real decrease in mental and social functions that that requires
continuous
monitoring
towards
the
Insured.
Progressive
degeneration
occurrence of kornu anterior medulla spinalis (lesion lower motor neuron),

traktus kortiko spinalis (lesion upper motor neuron) and nucleic motor brain stem.
Diagnose shall clinically be confirmed by specialist doctor accordingly appointed
by the Insurer. Excluded illnesses shall be as follows:
11.
Coma
Unconsciousness condition without any reactions or responses to external
stimuli or internal needs that continuously occur with the result that requires lifesupporting tools including a need to use respirator at least during 96 (ninety six)
hours. Permanently neurological deficit must occur and continuously be suffered
for 42 days. Coma due to direct alcohol abuse or drugs shall be excluded.
12.
Parkinson Illness
neurologist and recommended by any doctors appointed by the Insurer where
the Insureds condition cannot be controlled using drugs; showing progressive
defects. This Insurance shall be for Parkinson Idiopathic only. All other kinds of
Parkinson shall be excluded from this Insurance.
Inability to conduct Daily Activities with or without supporting device minimal 3
(three) out of 5 (five) Daily Activities and such inability has occurred continuously
for minimal 6 (six) months.
Taking a bath
Dressing
Feeding
Relieving
- 88 -
Moving
13.
Terminal Illness
In condition the illness or final stadium suffered by the Insured based on
diagnosis made by examining doctor while it has been approved by the Insureds
doctor predicting that life expectancy of the Insured shall be less than 12 months.
14.

Final stage illness shall included intersisial lungs due to chronic respiration
failure.
Diagnosis shall be erected by lungs specialist doctor and shall meet symptoms
and evidences as follows:
-
Analysis on arterial blood gas using partial oxygen pressures 55 mmHg

or less (PaO2<55 mmHg)
15.
Chronic Hepatitis
a.
Permanent yellow
b.
Ascites
c.
Chronic hepatitis due to alcohol and drugs consumption shall be excluded from
this insurance.
16.
- 89 -
Undoubtedly-definite diagnosis regarding Neuron Motor Illness due to

progressive degeneration on brain stem and Anterior horn cells neuron bulbar
efferent including atrophy spinal muscle, progressive bulbar palsy, amyotrophic
lateral sclerosis and primary lateral sclerosis. And it is supported by definite
evidences from the signs and deficit neurological symptoms and approved by
Insurers doctor. And the diagnosis shall be erected by neurologist.
17.
Muscular Dystrophy
It is combination of hereditary muscle degeneration illnesses causing
weaknesses or muscle atrophy. Diagnosis shall be erected definitely by
neurologist, and the evidence shall be based on daily activities examination that
confirms the Insureds inability for conducting daily activities with or without helps,
minimal 3 (three) out of 5 (five) Daily Activities taking place minimal 6 (six)
months.
18.
Taking a bath
Dressing
Feeding
Relieving
Moving
Aplastis Anemia
The chronic and persistent failure of spinal cord functions causing anemia,
neutropenia and thrombocytopenia requiring minimal one of the following
treatments:
a.
Blood transfusion
b.
c.
d.
- 90 -
19

aneurism, constriction, obstruction requiring excision and surgery to change
disordered aorta by opening stomach and chest cavities. Aorta intended in this
definition shall be thorax and abdominal aorta excluding those Aorta branches.
Surgery in nature of invasive minimal or intra-arterial technique shall be
excluded from this stipulation.
20.
Hepatitis Fulminant
Liver failure due to sub massive or massive liver parenchyma death caused by
Hepatitis virus. Hepatitis fulminant due to suicide trial, poisoned, drugs
overdoses and over-alcohol shall be excluded from this Insurance.
Liver parenchyma death including almost all liver lobus. And causes
reticular damages and its functions.
21.
Obvious icterus.

Pulmonary Arterial Hypertension Primer illness showing enlargement of right
ventricle erected based on clinical examination, cardiac catheterization, causing
permanent physical disorders and based on Classification Cardiac Impairment
The New York Heart Association (NYHA) included minimal class IV (Unable to
conduct any physical activities while the symptoms may emerge at the time of
taking a rest).
22.
- 91 -
permanently neurological inability and occurs minimal for 6 weeks.
23.
Benign Brain Tumor

symptoms of increasing pressure in the skull as papilloedema, mental disorder,
insane, and sense disorders confirmed by neurologist. The existence of tumor as
the basic shall be confirmed by CT Scan or MRI.
Cyst, granuloma, form deviation on or of brain artery or vena (AVM), hematoma,
and pituitary gland tumor or that of spinal cord shall be excluded from this illness.
24.
Inflamed Brain
Inflammation diagnosis of brain (cerebral hemisphere, brain stem or cerebellum)
due to virus infection, causing meaningful complication occurring minimal for 6
(six) weeks, including permanent nerve deficit and been confirmed by
neurologist. Permanent/localized neurological deficit can be in form of mental
retardation, unstable emotion, vision disorders, hearing disorder deficit, speaking
disorder, weaknesses or paralysis.
25.
Burn
Burn level three (All Skin Layers) minimal 20% (twenty percent) of total wide
surface area of the Insureds body.
26.
Poliomyelitis
-
- 92 -
Muscle paralysis on moving muscle components or breathing muscles

causing the Insured unable to make 3 (three) out of 5 (five) Daily
Activities continuously minimal for 3 (three) months.
27.
Serious Head Trauma

Any accidents causing head injury that causing permanently neurological deficit
not less than 6 (six) weeks since the accident occurred that the Insured cannot
carry out his/her 3 (three) out of 5 (five) Daily Activities for minimal 6 (six)
months. This diagnosis shall be erected by neurologist and supported by
Magnetic Resonance Imaging technique, Computerized Tomography, or other
acknowledged techniques. The accident shall occur directly from outside body
parts, visible, and shall not depend on other cause(s).
28.
Apallic Syndrome
Total brain cortex damages while the brain stem is still normal. This diagnosis
shall be erected by neurologist and condition of this syndrome shall constantly
occur minimal for 1 (one) month.
29.

percent) and 2 (two) other coronary arteries minimal 60% (sixty percent) proved
by coronary arteriography, without viewing whether the surgery has been
conducted or not.
(RC).
- 93 -
30.

Limit for this benefit payment shall be 10% of Total Critical Illness Insurance or
maximal not more than Rp. 200,000,000 (two hundred millions rupiah) after the
Insured follows ballooning angioplasty or intra arterial catheter procedure for
treating the constriction minimal for coronary vessel 60% (sixty percent) of one
or more coronary arterial blood vessel in which majority is proved by
angiographic. Revascularization shall be in accordance with indication and
consultant cardiologist or cardiac specialist.
(RC).
Plus) shall be continued by the remaining 90% (ninety percent) of Total
Insurance Coverage for Critical Illness Accelerated (Critical Illness Plus).
31.

It is a kind of multi-systemically and multifactor autoimmune disorders signed
with increasing auto-antibody attacking various body antigen. Type of System
Lupus Erythematosus to insure by this Additional Insurance shall be limited to
types of Systemic Lupus Erythematosus involving kidney (Class III to Class IV of
Lupus Nephritis, defined by kidney biopsy, and in accordance with WHO
classification). Those excluded from Critical Illness (Critical Illness Plus) claim on
Systemic Lupus Erythematosus shall be other kinds of lupus, namely discoid
lupus and other types involving joints and hematology systems.
Erection of Systemic Lupus Erythematosus diagnosis shall be carried out by
Specialist on Rheumatology and Immunology.
- 94 -
32.
Class I
Class II
Class III
Class IV
Class V

A. The Insured is infected by Human Immunodeficiency Virus (HIV) through
blood transfusion of the following conditions:
1.
Blood transfusion that medically required and given as a part of

medication process.
2.
Blood transfusion shall be conducted in Indonesia after the Policy Date

effective, Date of Insurance Change, whenever occurs earlier.
3.
Infection source shall be from any institutions holding blood transfusion

and the institutions can track the source of HIV-infected blood, and
4.
B. Human Immunodeficiency Virus (HIV) infection shall be obtained from an

accident in workplace after effective date of the Policy or the date of Insurance
change, whichever occurs later, as long as the Insured perform his or her
1.
HIV infection obtained due to accident in workplace shall be within 30

(thirty) days commenced on the accidence, and
2.
Any evidences that the accident due to his or her work shall be the
cause of HIV infection, and
Any evidences that cero-conversion of negative HIV to positive HIV shall

occur within 180 (one hundred and eighty) days after the accident
- 95 -
happens. This evidence shall be completed by testing negative HIV

antibody within 5 (five) days commenced on the date of accident due to
his or her works.
4.
HIV infection due to other causes including sexual activities and drugs
uses in intra-vena shall be excluded from this illness.
This benefit shall be valid if the Insured works as Medical Worker, Medical
worker student, certified nurse, laboratory technician, dentist, paramedic, works
in health center and clinic (in Indonesia).
This benefit shall not be valid if point A and B has received medical treatment for
treating AIDS and for treating any impacts due to HIV virus infection, or
managing for preventing AIDS. The treatment intended shall be any treatments
to make HIV inactive and non-infectious.
33.

Unable to heal and total loss on audio senses functions in both ears due to
illness or accident. The diagnosis shall be supported with audiometry and audio
testing provided and certified by Ear, Nose and Throat Specialist physician.
34.

Unable to heal and total loss on vocal function due to accident or disorders on
vocal cord. Vocal inability shall continuously occur for 12 months. Diagnosis of
this disorder shall be supported by evidences made by Ear, Nose and Throat
specialist physician.
35.
Blindness
Loss of total visual ability and unable to heal due to illness or accident. The
blindness shall be diagnosed by ophthalmologist.
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36.
It is a kind of collagen blood vessel disorder that systematically causes total
fibrosis progressively within the skin, blood vessel and other body organs.
Diagnosis of this disorder shall be supported by biopsy and other supporting
evidences as results of serology and this illness shall be in accordance with
systemic proportion related to heart, lungs and kidney.
37.
CREST syndrome

It is a kidney disorder that progressively hereditary characterized with cyst and
medulla, tubular atrophy and intestitial fibrosis with clinical anemia manifestation,
polyuria and loss of sodium through kidney, developing to chronic kidney failure.
This diagnosis shall be supported by kidney biopsy.
38.
Cardiomyopathy
Diagnosis erected by cardiologist that cardiomyopathy shall be caused by
functional disorder of cardiac ventricle chamber, showed by abnormal ECG
results and confirmed by echocardiography and causing physical inability
permanently with minimal degree on Class III in accordance with New York
Association Classification of Cardiac Impairment.
Class III Meaningful inability signed with Patient in comfortable position of
resting position but ability in conducting very limited daily activities of normal
condition and shows any symptoms of congestive cardiac failure.
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Class IV Inability to perform any activities. Congestive cardiac failure

symptoms emerges though in resting condition. Anytime physical activities
increase, uncomfortable condition occurs.
39.

The actual undergoing of brain surgery to correct an abnormal widening of the
cerebral artery involving all three layers of the cerebral arterial wall. The
diagnosis must be made by a licensed neurosurgeon, using standard cerebral
angiography which indicates the need for open surgery.
Exclusions:
40.

The complete and permanent loss of use and sensory functions of an upper
extremity caused by avulsion of 2 or more nerve roots of the brachial plexus
through accident or injury. Complete injury of 2 or more nerve roots should be
confirmed by electrodiagnostic study done by a physiatrist or neurologist.
41.

Stroke Requiring Carotid Endarterectomy Surgery means the undergoing of
carotid Endarterectomy by expert and licensed surgeon, based on current
standard medical indications, to prevent recurrent ischemic cerebrovascular
events.
42.

Surgery for idiopathic scoliosis means the undergoing of spinal surgery to
correct an abnormal curvature of the spine from it's normal straight line viewed
from the back. The condition must be present without an identifiable underlying
cause and the curve of the spine must be more than cobb angle 40 degree.
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Spinal deformity associated with congenital defects and neuromuscular diseases

are excluded
43.

Chronic Relapsing Pancreatitis as a result of progressive severe destruction of
pancreas, this condition must be a result of recurrent acute pancreatitis and
characterized by:
chronic continuous pancreatic function impairment resulting in malabsorption of intestine (high fat in stool) or diabetes.
Chronic Relapsing Pancreatitis directly cause by alcohol consumption is

excluded.
44.
Elephantiasis
severe and permanent edema of arm and leg or other part of body from
lymphatic obstruction; and

Lymphatic obstruction caused by sexual transmitted disease, cancer,
wound, surgery scar, radiation, heart failure or congenital anomaly is
excluded.
45.

Confirmation by a Consultant Physician of the loss of independent existence
lasting for a minimum period of 6 months and resulting in a permanent inability to
perform at least three (3) of the following Activities of Daily Living either with or
without the use of mechanical equipment, special devices or other aids and
adaptations in use for disabled persons. For the purpose of this benefit, the word
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"permanent", shall mean beyond the hope of recovery with current medical
knowledge and technology.

46.
Taking a bath
Dressing
Feeding
Relieving
Moving

clinical symptoms complied with diagnostic criteria of Necrotising

Fasciitis;
extensive muscular destruction resulting in total permanent loss of

involved body part.
47.

Chronic rheumatoid arthritis is a result of an autoimmune disorder confirmed by
a physician
who specialized in rheumatology and immunology. It is characterized by all of
the following:
destruction and deformity of at least 3 of the following joints:

interphalangeal hand joint, wrist, elbow, knee, hip, ankle, cervical spine
or interphalangeal foot joint. Clinical findings and imaging study must
evidence these changes, and
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physical impairment resulting in inability to perform at least 3 of the 6

Activities of Daily Living without the continual physical assistant of
another person for a continuous period of at least 180 days.

48.
Taking a bath
Dressing
Feeding
Relieving
Moving

Severe Ulcerative Colitis or Cronhs Disease characterized by at least 2 of the
following:
autoimmune chronic active hepatitis and cirrhosis confirmed by

pathological study;
49.

The diagnosis of Kawasaki disease by a consultant paediatrician or other
appropriate medical specialist. There must be echocardiographic evidence of
cardiac involvement manifesred by dilatation or neurysm formation in the
coronary arteries which must persist for at least 6 consecutive months.
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7.
Waiting period shall mean the period starting from the date of Insured stated to medically
suffer Total Permanent Disability or commenced on the Insured firstly diagnosed to
suffer one of aforementioned Critical Illnesses, through to the date of acceptance and
approval of claim for this Spouse Payor Benefit Additional Insurance.
Article 2
THE INSURED
Special for this Spouse Payor Benefit Insurance Coverage, the Insured shall be the
Policyholders legal spouse.
Article 3
INSURANCE BENEFIT
As long as the Policy and this Spouse Payor Benefit Additional Insurance is effective and the
Insured of this Spouse Payor Benefit Additional Insurance has not reached 64 (sixty four) years
old, in case the Insured suffered Total Permanent Disability and firstly diagnosed to suffer one of
the aforementioned Critical Illnesses as referred to in Article 1 of this Spouse Payor Benefit
Additional Insurance herein, then after We have received and approved the claim evidences
proposed, We will release the Insured from his or her obligation to pay Periodic Premium (and
Periodic Top-Up Premium, optional) as of the maturity date after We receive and approve the
claim. Furthermore, We will pay the Periodic Premium (and Periodic Top-Up Premium, optional)
directly used to purchase Unit. Premium allocation shall be based on the next premium allocation
from the last premium You pay.
1.
2.
approve the claim, until the Insured reaches 65 (sixty five) years old, or in case the
Insured dies before such time, until a time as if the Insurer reaches 65 (sixty five) years
old if he or she was alive.
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3.
In case Periodic Premium (and Top-Up Periodic Premium, if available) having maturity
date exists within Waiting Period, then the Insured under this Spouse Payor Benefit
Additional Insurance must remain to perform his or her obligation to pay Periodic
Premium (Top-Up Periodic Premium, if available) as in normal condition. In case We
finally accept and approve the claim for benefit of this Spouse Payor Benefit Additional
Insurance, then We will return it to the Insured covered by this Spouse Payor Benefit
Additional Insurance total Periodic Premium (Top-Up Periodic Premium, if available)
being paid during the Waiting Period.
Article 4
ELIMINATION PERIOD
We will not pay any benefit for this Spouse Payor Benefit Additional Insurance for risks of Critical
Illness firstly diagnosed upon the Insured under this Spouse Payor Benefit Additional Insurance
within 90 (ninety) days commenced on the effective date of this Spouse Payor Benefit Additional
Insurance or commenced on the date of policy recovery.
Article 5
1.
Total Permanent Disability Claim

a.
Notification of Total Permanent Disability claim shall be enclosed with complete

evidences and shall be transferred to Us not later than 210 (two hundred and
ten) days as of the date of Total Permanent Disability occurrence.
b.
Aforementioned notification shall be completed with original evidences at the

time of claim filing, among others, as follows:
1.
Fully-completed form of Total Permanent Disability claim;
2.
Spouse Payor Benefit Additional Insurance suffers Total Permanent
Disability and it is possible unrecovered;
3.
X-ray photograph on the disabled organ(s);
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4.
Photocopy of valid the Insured under this Spouse Payor Benefit

Additional Insurances identity card;
5.
Minutes/certificate issued from the Policy for rider accidents;
6.

c.

2.
Critical Illness Claim

a.
Notification of Critical Illness shall be enclosed with complete evidences and

shall be transferred to Us not later than 30 (thirty) days as of the Insured firstly
diagnosed to suffer such Critical Illness.
b.
Aforementioned notification shall be enclosed with original evidences at the time

of claim filing, among others, as follows:
1.
Fully-completed form of Critical Illness claim by physician firstly

diagnosing;
2.
Spouse Payor Benefit Additional Insurance suffers Critical illness and it
is possible unrecovered;
3.
Photocopy of valid the Insured under this Spouse Payor Benefit

Additional Insurances identity card;
4.

c.

Article 6
HEALTH EXAMINATION
Without prejudice to decrease power of Certificate issued by the Physician as referred to in
above article herein, We shall fully reserve the right to obligate the Insured to conduct medical
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examination to a Consultant Physician We assign, as long as the Insured still suffers Total
Permanent Disability or Critical Illness.
Article 7
EXCEPTION
1.
This additional Spouse Payor Benefit Insurance shall not be valid if, directly or indirectly,
the Insured suffers Total Permanent Disability due to:
a.
His/her involvement in dueling, except that it is an action for self-defense, selfinjured or efforts for self-injured, or suicide both in healthy- physical and mental
condition or not,
b.

c.
Airplane accident in which the Insured is a passenger within or crewman of the

airplane with indefinite scheduled, or
d.
Risky work or profession of the Insured, for example, as military, police, flight, or
e.
Any risky sports or hobbies conducted by the Insured, i.e. car racing, motor
racing, horse spurring, glider flying, mount climbing, boxing, wrestling, including
any sports and hobbies containing risks and dangers, but if the risk premium has
been paid, or
f.
Any accidents occurred due to insane, any illness attacking neurological system,
drunk (the Insured is under alcoholic influence), narcotics use and or drugs
abuses, or
g.
Insurance that may cause Total Permanent Disability, proven by treatment,
diagnosis, consultation and/or medication for the illness prior to the effective
date of this Additional Insurance, or
h.
Abnormality, Illness and/or congenital disability, or
i.
HIV/AIDS infection and/or contaminating venereal diseases.
- 105 -
2.
This Spouse Payor Benefit Additional Insurance shall not be valid in case, both directly
and indirectly, the Insured suffers any Critical Illnesses as follows:
a.
All kinds of illness emerging from any injuries intentionally made both directly
and indirectly, suicide or suicide trial either in health physical and mental
condition or not, or
b.
Any kinds of illness caused directly or indirectly by AIDS (Acquired Immune

Deficiency Syndrome) or AIDS Related Complex (ARC), or
c.
d.
Critical Illness firstly diagnosed before the Policy Date or Date of Spouse Payor
Benefit Additional Insurance, or firstly diagnosed within Elimination period.
Article 8
This Spouse Payor Benefit Additional Insurance shall be terminated in the following cases,
whichever occurs earlier:
1.
2.
The Insured of this Policy dies; or
3.
The Insured under this Payor Benefit Additional Insurance reaches 65 (sixty five) years
old at the time of basic Policy anniversary, or
4.
We have accepted and approved and paid the claim on additional insurance of Payor
Benefit or Payor Protection or Spouse Payor Protection that also attached to this Policy
(if available).
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Spouse Payor Protection
Policy Data where this Spouse Payor Protection Additional Insurance enclosed, by following any
Life Indonesia on Spouse Payor Protection (hereinafter called Spouse Payor Protection
Additional Insurance). We shall deliver this Spouse Payor Protection Additional Insurance due
to Your application relating Policy You own, and it shall be valid only if this Spouse Payor
Protection Additional Insurance been registered on page of Policy Data of the Policy.
Article 1
THE INSURED
Special for this Additional Insurance, the Insured shall be the Policyholders spouse.
Article 2
INSURANCE BENEFIT
As long as the Policy and Additional Insurance is effective and the Insured of this Additional
Insurance has not reached 64 (sixty four) years old, in case the Insured dies then after We
accept and approve the claim evidence being filed, We will release the Insured from his or her
obligation to pay Periodic Premium (and Periodic Top-Up Premium, optional) as of the maturity
date after We receive and approve the claim. Furthermore, We will pay the Periodic Premium
(and Periodic Top-Up Premium, optional) directly used to purchase Unit. Premium allocation
shall be based on the next premium allocation from the last premium You pay.

(1)
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(2)
approve the claim, until a time as if the Insurer reached 65 (sixty five) years old if he or
she/he was alive.
Article 3
CLAIM
Application to obtain Additional Insurance benefit as referred to in this Additional Insurance

Addendum shall be filed by you to us not later than 60 (sixty) days as of the date of Insureds
death, by completing required claim documents.
Article 4
EXCEPTION
This Additional Insurance shall be invalid in case the Insured dies due to:
1.
Within 2 (two) years as of the approval date of this Additional Insurance, the Insured dies
due to:
a.
Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex or

Human Immunodeficiency Virus (HIV) infection; or
b.
2.
Suicide; or
The Insured dies within Insurance Period due to death sentence by the court, or due to
intentional perform or participate in a crime or a crime trial, both active and not, or in
case the Insured dies due to criminal act insured by the party having or participating to
have interest on this insurance coverage.
Article 5
This Insurance shall be terminated due to the following cases, whichever occurs earlier:
1.
2.
The Insured of this Additional Insurance has reached 65 (sixty five) years old at the time
of Basic Policy Anniversary, or
3.
We have accepted and approved and paid the claim on Payor Protection or Payor
Benefit or Spouse Payor Benefit that also attached to this Policy (if available).
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ADDENDUM
ADDITIONAL INSURANCE FLEXICARE
the Policy Data page of Basic Policy where this Additional Insurance enclosed, by following any
stipulations existing in this Additional Insurance Coverage herein. We shall give this additional
insurance due to your request related to Basic Policy You own, and shall be valid only if this
Additional Insurance has been written on the Policy Data of the Basic Policy or on the
Endorsement/Addendum and its paid Premium.
Article 1
DEFINITION
1.
Surgery shall mean any surgeries/operations emerging upon Physicians recommendation

based on the classification to name in list of Benefit, i.e. Minor, Intermediate, Major and
Complex.
2.
One Day Surgery shall mean Surgery without staying in hospital.
3.
Proper Cost shall mean any costs really issued by the Insured to obtain Medical Treatment,
not an engineer or counterfeit and not any costs emerging upon treatments not Medically
Required.
4.
Medically Required shall be any health services or treatments fulfilling the following
provisions:
a.
Referred by Physician,
b.
Shall be needed and shall fulfill basic requirements of the Participants needs, safe
and effective in treating as ordered,
c.
Shall be part of treatments approved by Ministry of Health of the Republic of Indonesia,
d.
Shall be based on effective costs in natural location for conducting such treatment with
quality, quantity, frequency and period as ordered,
e.
Shall be based on any reasons :

i.
Habitual treatment (To help the patient for his or her daily activities);
ii.
Personal pleasure for Participant, his/her Familys or Physicians interest;
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iii.
Non-exaggerating if compared with other health services.
iv.
Not for experiment and screening.
v.
The main objective shall be to return or to recover his or her health and to
prolong his or her age.
Health service for cosmetic interest, or to remove/reduce pain, or to meet lifestyle

interest, cannot be categorized as Medically Required.
The fact that physician has given medical handling or the treatment is the only way to
heal the injury, illness or mental treatment, it shall not mean to be Medically Required.
We reserve the right to determine whether the treatment is Medically Required based
on considerations of:
5.
Ministry of Health of the Republic of Indonesia
Indonesian Specialist Physician Association
Indonesian Physician Association
Our Medical Staff, Staff of Law Department or Consultant
Our Medical Counselor Board
Medical Workers shall be physician (doctor), specialist physician, dentist or specialist

dentist, medical or dentistry school graduate both from domestic or overseas acknowledged
by local Government and having practical license but may not double up as
Policyholder/the Insured, and not a relative of Policyholder/Insured, insurance agency, work
colleague or company/employee or member of Policyholder family/Insured, except with Our
approval.
6.
Endorsement shall be any amendments made to the Policy and has been approved by Us
and You.
7.
Hospital Treatment Day shall be each and every day when the Insured treated as InHospital Patient for minimal 24 (twenty four) hours.
8.
Accident shall be an incident occurred due to hardness element outside self-body,

accidentally, unintentionally, unpredictably, and the impacts can be proved and
independent of other causes.
9.
Injury shall mean abnormal condition of human body due to pathological changes caused
by accident.
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10.
Insurance Benefit shall mean any payment We make based on Addendum upon Insureds
Treatment according to this Addendum.
11.
Effective Period shall be effective period of Additional Insurance namely for 1 (one) year,
commenced on the effective date and shall be terminated one year later.
12.
Grace Period shall be 30 (thirty) days commenced on the effective date of Additional
Insurance.
13.
In-Hospital Patient shall be an Insured treated in Hospital as patient that should stay and
some treatments are required for medical interest, diagnosis, and treatment for Illness and
Injury insured by this Additional Insurance, and excluding old people, rehabilitation, place
for vacation or prolonged treatment.
14.
Illness shall mean any abnormal conditions of human body due to pathological changes.
15.
Pre-Existing Diseases or Injuries shall mean all diseases, injuries or health condition of
the Insured before the effective date of this Additional Insurance, in which:
a)
He/she has obtained diagnosis; or
b)
Some one will normally try to obtain a diagnosis, treatment, therapy, or
c)
She/he has been recommended by the Physician to obtain medical treatment,

independent of any treatments actually conducted or not.
16.
Special Diseases shall mean any diseases stated hereinbelow, and all of their
complications:
a.
Stone in kidney, urinary duct, bile duct.
b.
Liver and blood vessels (including hypertension and stroke)
c.
Cataract
d.
All kinds of cysts, benign and/or malignant tumor (including uterus myoma)
e.
Nose cavity disorder requiring surgical operations due to sinus condition
f.
Diabetes mellitus
g.
Complicated tuberculosis
h.
Thyroid gland disorder
i.
Fat disorder in blood (including cholesterol)
j.
Hernia Nucleus Pulposus requiring surgical operation
k.
All hematological cases
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17.
Hospital Treatment shall mean any treatments within this Additional Insurance Period as
In-House Patient upon recommendation and under routine control and treatment by a
physician merely and independently due to or partially due to Injury or Illness suffered by
the Insured within this Additional Insurance term.
18.
Nurse shall mean a nurse fulfilling requirements or in process of training or general nurse
registered according to effective regulations where he/she works.
19.
Hospital/Clinic shall mean health treatment institution providing Health Treatment facilities
both for In-Patient and Out-Patient in which diseases or accident has obtained license from
the authority. But for mental Hospital/Clinic, treatment for drug addictive, senior citizens
home and traditional treatment institution shall be excluded from this Hospital/Clinic
category.
20.
Daily Principal Benefit shall mean any compensations paid based on number of InHospital Treatment Days upon the Insured in which this compensation is charged by the
Hospital to the Insured as In-Hospital Patient for any diseases or injuries insured under this
Additional Insurance as stated in the List of Benefits.
21.
List of Benefits shall mean appendix regulating amount of Insurance Benefit as a part of
this Additional Insurance.
Article 2
As long as the Policy and Additional Insurance is effective, We will provide insurance coverage
as follows:
1.
Daily Principal Benefit for Hospital Treatment due to Non-Accident

In case a kind of Disease causing the Insured to take to the Hospital, in which the Hospital
Treatment occurs within Additional Insurance Period, then We shall pay Daily Principal
Benefit as included in List of Benefits for each and every day the Insured treated in
Hospital, maximum 180 (one hundred and eight) days in an Effective period.
2.
Daily Principal Benefit for Hospital Treatment due to Accident

In case a kind of Injury causing the Insured to take to the Hospital, in which the Hospital
Treatment occurs within Additional Insurance Period, then We shall pay the Daily Principal
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Benefit as included in the List of Benefits for each and every day the Insured treated in
Hospital, maximum 180 (one hundred and eight) days in an Effective period.
3.
Surgical Benefit for Hospital Treatment due to Non-Accident

In case a kind of disease causing the Insured to follow Surgery Operation of Hospital
Treatment, then in addition to Daily Principal Benefit, We shall give other benefit for
surgical operation according to type of surgery included in the List of Benefit for one period
of In-Hospital Treatment.
In case in one session of Surgery there are two actions with different classification, then
Insurance Benefit shall be calculated on the basis of classification type of Surgery giving
most benefit as included in the List of Benefit.
In case the Insured experiences One Day Surgery, Insurance Benefit will be calculated on
the basis of type of Surgical Operation included in the List of Benefits, except for Daily
Principal Benefit stated on item 1 and 2 above shall not be paid.
4.
Surgical Benefit for Hospital Treatment due to Accident

In case a kind of Injury causing the Insured to follow Surgery Operation of Hospital
Treatment, then in addition to Daily Principal Benefit, We shall give other benefit for
surgical operation according to type of surgery included in the List of Benefit for one period
of In-Hospital Treatment.
In case in one session of Surgery there are two actions with different classification, then
Insurance Benefit shall be calculated on the basis of classification type of Surgery giving
most benefit as included in the List of Benefit.
In case the Insured experiences One Day Surgery, Insurance Benefit will be calculated on
the basis of type of Surgical Operation included in the List of Benefits, except for Daily
Principal Benefit stated on item 1 and 2 above shall not be paid.
5.
Healing Benefit for Hospital Treatment due to other than Accident

In case a kind of Disease causing the Insured to take to the Hospital for more than 30
(thirty) days successively, in which the Hospital Treatment occurs within Additional
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Insurance Effective Period, then We shall pay the healing benefit all at once as included in
the List of Benefits for one period of In-Hospital Treatment.
6.
Healing Benefit for Hospital Treatment due to Accident

In case a kind of Injury causing the Insured to take to the Hospital for more than 30 (thirty)
days successively, in which the Hospital Treatment occurs within Additional Insurance
Effective Period, then We shall pay the healing benefit all at once as included in the List of
Benefits for one period of In-Hospital Treatment.
This Additional Insurance Benefit shall be given by following provisions:
a.
Based on Proper Cost proved by legal payment receipt and that Medically Required.
b.
That the Treatment is caused by non-excepted Diseases or Injuries according to

Article 6.
c.
That the Insured has exceeded the Grace Period, but for Treatment due to Injury.
d.
In case the Treatment is caused by Diseases and Injuries simultaneously, then

amount of Insurance Benefit to pay shall be categorized as Treatment due to Injury.
e.
In case the Participant experiences In-Hospital Treatment occurs before the

termination of Additional Insurance, We shall bear the Treatment for maximum 30
(thirty) days after the date of termination of Additional Insurance, under provision not
exceeding maximum benefit included on the List of Benefit.
f.
In case In-Hospital Treatment is conducted before exceeding 30 (thirty) days

commenced on the date of Insured leaving the Hospital due to previous In-Hospital
Treatment and that still requires advanced treatment, then shall be regarded as one
period of In-Hospital Treatment.
Article 3
TERM AND EXTENSION
1.
Term for this Additional Insurance shall be as stated in Additional Insurance Data, and can
be extended by calculating total Premiums of Additional Insurance to pay by You based on
the entry age at the time of extension and follow the provisions We determine.
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2.
In case We approve extension for this Additional Insurance Term, then the approval upon
this Additional Insurance and amount of the Premium to pay will be stated in Endorsement.
3.
In case We have approved the Term Extension then, automatically, the determined
Premium relates to term extension of this Additional Insurance coverage shall be cut
through this Unit commenced on the date We approve the extension on term for this
Additional Insurance.
Article 4
ENTRY AGE AND PREMIUM PAYMENT
1.
Limit of Entry Age to be Insured in this Additional Insurance shall be 1 (one) year old
through maximum 55 (fifty five) years old, and can be extended until 64 (sixty four) years
old by written approval by Us.
2.
Premium for this Additional Insurance shall be annual premium, but procedure of the
payment shall be conducted monthly and shall be charged on the Unit formed in this Policy
till the Insured attains the age of 65 (sixty five) years old or till the Policy maturity,
whichever occurs earlier. This Additional Insurance Premium shall be depended on the age
of Insured, amount of Additional Insurance Benefit being taken and other conditions We
determine from time to time.
3.
Payment procedure for this Additional Insurance Premium shall be conducted through Unit
cutting each month. Special for Additional Insurance approved at the time of Policy issue,
the Premiums for the first through the twelfth months shall be cut from Unit on the thirteenth
month until twenty fourth months together with cut of units for the second year and
furthermore shall be conducted on each and every month during the term of this Additional
Insurance. Additional Insurance approved after the Policy issue, Unit cutting shall directly
be performed on each and every month commenced on the date of approval during its
Term for this Additional Insurance.
4.
At the time of this Additional Insurance extended, We reserve the right to make some
amendments on annual premium for next insurance term.
5.
In case some errors occurred on the calculation of entry age causing data inaccuracy
included on the Application of Life Insurance or supporting documents delivered, causing
- 115 -
errors on determination on amount of Additional Insurance Premium You should pay, then
We will immediately make recalculation to determine amount of Additional Insurance
Premium should to pay based on real data and We will immediately inform You the result
after all required data accepted by Us. Surplus or minus of Additional Insurance Premium
will be fully added/charged to the Unit to form in this Policy.
6.
In case there is insufficiency in Additional Insurance Premium payment due to any reasons
as aforementioned above and the formed Unit is not enough to cover the insufficiency, then
We will give You more time to Top-Up the fund for 14 (fourteen) days commenced on the
date of notification issue. In case it exceeds the time range as stated above You has not/do
not perform Top-Up, then this Policy shall be automatically cancelled.
Article 5
POLICY EFFECTIVENESS AND MATURITY
Effective Date of Additional Insurance:
This Additional Insurance shall be effective and valid commences on 00.01 of West Indonesian
Time Zone (WIB) on the date determined as Effective Date of Additional Insurance as included in
the Policy Data.
Maturity Date of Additional Insurance:
1.
Cancellation by You
In Case you deliver written notification to US to end this Additional Insurance or to terminate
this Additional Insurance relating the Insured person in this Additional Insurance, this
termination shall be effective on the date of letter acceptance or on the date stated on the
notification, whichever occurs earlier. In this case there shall be no premium return and shall
not release Your obligation to pay the premium for insurance period passed.
2.
Cancellation by Us
From time to time, We reserve the right to amend any terms and conditions in the Additional
Insurance, including but not limited to Protections and Benefits stated in Additional
Insurance, or to cancel this Insurance Benefit on the date of Additional Insurance
Anniversary by delivering notification at the latest in previously 30 (thirty) days, that directly
given to you or delivered by registered mail to You at your last address informed Us. The
- 116 -
amendments made to terms and conditions or cancellation of this Additional Insurance shall
be valid commences on the date of Additional Insurance anniversary.
3.
Automatic Cancellation
This Additional Insurance shall be immediately ended due to the following incidents in view
of items 1 and 2 of this Article, whichever occurs earlier:
a.
Maturity of Basic Insurance Policy, or
b.
Additional Insurance Premium is not paid, since the Unit is not sufficient to pay the
premium, or
4.
c.
The Insured dies, or
d.
At the time Insured attains 65 (sixty five) years old.
Maturity of Additional Insurance

This Additional Insurance shall be terminated on 00.01 of West Indonesian Time Zone (WIB)
on the date as stated in Additional Insurance Data.
5.
Claim at the Time of Additional Insurances Maturity
Article 6
EXCEPTION
Diseases/illness and/or Treatment and/or costs excluded from this Additional Insurance shall be
as follows:
1.
Special Diseases and Pre-Existing Diseases/Injuries, except the Insured has obtained
insurance coverage for 12 (twelve) months constantly in this Additional Insurance.
2.
Organ transplantation, including all treatments and/or healings related with organ
transplantation.
3.
All supporting device and/or artificial auxiliaries.
4.
Dialysis, including all treatments and/or healings related to Dialysis.
5.
Treatment and/or healings not yet approved by Ministry of Health/Food and Drugs Agency
(POM)/Medical Professions Organization.
6.
Treatment and/or healings related to mental health, speaking therapy, treatment for drugs
and/or alcohol addiction, psychological therapy and any healings related to Psychologist.
7.
All treatments and/or healings related to:
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8.
a.
Infertility, including all artificial inseminations, test-tube baby, and fertility returns.
b.
Endometriosis.
c.
Impotence.
d.
All hormonal therapies related to pre-menopause syndrome.
Treatment and/or healings for obesity, body-weight reducing, or any efforts to increase
body weight.
9.
Treatment and/or healings related to cosmetic as plastic surgery except for reconstructing
plastic surgery due to accident occurred 30 (thirty) days after the incident.
10.
Medical Check Up and health selection including TORCH.
11.
Treatment and/or healings related to:
12.
a.
Hernia under 10 years old
b.
Congenital abnormal, offspring and/or growth abnormal.
Eye refracting disorders, including treatment and/or healings related to eye refracting
disorders.
13.
Circumcision, including phimosis for those above 2 years old.
14.
Treatment and/or healings related to:

a.
HIV/AIDS, including any diseases or conditions related to HIV/AIDS.
b.
Sexually transmitted diseases.
15.
Abortion.
16.
Non-Medical Cost, but excluding administrative cost.
17.
Food Supplement.
18.
Any vitamins without physicians recommendation and medical indication.
19.
Any treatments and/or healings due to:
20.
a.
Active involvement in war, riot, fights or crimes,
b.
Any injuries intentionally made and suicide trails.
Any treatments and/or healings due to his or her participation in dangerous activities or
sports as follow:
a.
Mount climbing, rock climbing, building climbing
b.
Bungee jumping
c.
White-water rafting
- 118 -
21.
d.
Boxing
e.
All aero-flying activities (parachute jumping, glider flying, sky diving, Ultralite, etc.)
f.
All diving activities using breathing auxiliaries (diving, etc.)
g.
All activities of speed contest on machine vehicles (motor, car, boat racings, etc.)
Any caused treatments and/or healings since the Participant perform flying activities by
using chartered airplane, military/police, or helicopter.
22.
Out-Hospital Treatment.
23.
Tooth Treatment.
24.
Pregnancy and Giving Birth Treatment including all treatments and/or healings related to
Pregnancy and Giving Birth activities.
25.
Other things to arrange specially based on any Endorsements agreed by Us and You.
Article 7
OTHER INSURANCE
Insurance Benefit under this Additional Insurance shall be paid as extra amount to other
insurance owned by the Insured, or on the name of the Insured.
Article 8
CLAIM PROCEDURE
In case the Insured follows any treatments as stated in Article 2 of this Addendum herein, then:
1.
You shall submit evidences:

a.
Original receipt on treatment payment with stamp on it or legalized copy of receipt

issued by the Hospital
b.
Completed Claim Form from Us in which it has been signed by the Physician treating
and sealed with the Hospitals seal.
c.
2.
Claim shall be filed at the latest 30 (thirty) days after the treatment finished.
In case You shall file the claim document incompletely as stated in paragraph 1 of this
article, it shall be regarded that the claim has not been filed.
3.
We reserve the right to request the Insured to examine his or her health condition in
Hospital or physician We assign upon Our expenses to process the claim.
- 119 -
4.
We reserve the right to investigate claim documents You file.
5.
In case the claim is approved by Us, then the payment for Insurance Benefit according to
Our approval shall be performed at the latest 14 (fourteen) days after the approval.
6.
In case You do not file any claim documents accordingly till the limit of time as stipulated by
paragraph 1 of this article herein, then We shall not be obliged to process the claim
according to the period of time as stated in article 5 herein.
Article 9
CURRENCY FOR ADDITIONAL INSURANCE
This Additional Insurance shall be issued in certain currency as stated in the Policy Data. In case
claim on currency other than that used for Additional Insurance and the claim is approved by Us,
then the claim payment by Us shall be performed in accordance with currency that stated in the
Additional Insurance.
- 120 -
LIST OF BENEFITS
INDIVIDUAL INSURANCE PROGRAM FLEXICARE (Per Unit)
(Rp)
HEALTH ALLIANZ LIFE INDONESIA
NO
1.
BENEFITS
AMOUNT
Daily Principal Benefit
per day
for Hospital Treatment
(maximum 180 days per
due to Non-Accident
2.
year)
Daily Principal Benefit
per day
for Hospital Treatment
(maximum 180 days per
due to Accident
3.
Surgery
Benefit
for
Surgery benefit able to
Hospital Treatment due
pay in one period of In-
Surgery
Benefit
for
Surgery benefit able to
Healing
Benefit
Special
Rp. 2,000,000.-
Great
Rp. 1,300,000.-
Medium
Rp. 900,000.-
Little
RP. 500,000.-
Special
Rp. 4,000,000.-
Great
Rp. 2,600,000.-
Medium
Rp. 1,800,000.-
Little
RP. 1,000,000.-
Hospital Treatment
to Accident
5.
Rp. 200,000.-
year)
to Non-Accident
4.
Rp. 100,000.-
Hospital Treatment
for
Healing benefit able to
to Non-Accident
Rp. 1,000,000.-
Hospital Treatment in
case the treatment
requires more than 30
days
6.
Healing
Benefit
for
Healing benefit able to
to Accident
Hospital Treatment in
case the treatment
requires more than 30
days
- 121 -
Rp. 2,000,000.-

Policy - Riders English (04062012)

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ENGLISH TRANSLATION

Daily Activity shall mean 5 (five) things as follows:

The First Heart Attack

Specific painful on chess at the time of attack;

Change of electrocardiogram description specifically showing Infarct Myocardial of

Increasing heart enzyme content CK-MB;

Increasing Troponin (T or I);

Evidence on permanently neurological deficit shall be erected by a neurologist doctor

The discovery is derived from Magnetic Resonance Imaging, Computerized

Transient Ischaemic Attacks;

Blood vessel illness influencing eyes and optical nerves.

Ischaemic attacks from vestibulary system.

Coronary Cardiac Surgery

Surgery Operation on to Change Cardiac Valves

Paopillary microcarcinoma of urinary bladder, and Chronic Lymphocytic Leukemia less

All kinds of tumor caused by HIV infection.

Transplantation of Body Vital Organ

Haematopoitic stem cells preceded by total ablasion of haematopoitic stem cells; or

Other Stem Cell transplantation shall be excluded from this illness.

10. Alzheimer/Degenerative Organic Brain Illness that cannot be recovered.

Non-Organic Illnesses as neurosis and psychosis, mental illness.

Brain damage due to alcohol consumption.

Parkinson due to drugs use shall be excluded from this illness.

Requiring extensive and permanent oxygen therapy.

FEV1 test result shall be less than 1 liter.

Short of breath when taking a rest

15. Chronic Hepatitis

18. Aplastis Anemia

Stimulating medicine for spinal cord

Spinal cord transplantation

Diagnosis shall be erected by Haematologist.

20. Hepatitis Fulminant

Rapid size reducing of the liver.

Liver function testing showing massive liver parenchyma damages.

21. Pulmonary Arterial Hypertension Primer

23. Benign Brain Tumor

24. Inflamed Brain

Polio virus shall be the cause, and

Muscle paralysis on moving muscle components or breathing muscles causing the

27. Serious Head Trauma

Spinal cord Injury/Trauma, and

Head injury due to other causes

28. Apallic Syndrome

29. Other Serious Coronary Cardiac Disorders

WHO Classification on Lupus Nephritis:

: Minimal Change Lupus Glomerulonephritis

: Messangial Lupus Glomerulonephritis

: Focal Segmental Proliverative Lupus Glomerulonephritis

: Diffuse Proliferative Lupus Glomerulonephritis

: Membranous Lupus Glomerulonephritis

32. HIV obtained through Blood Transfusion and Work

The Insured is infected by Human Immunodeficiency Virus (HIV) through blood

Blood transfusion that medically required and given as a part of treatment

The Insured shall not either Thalassaemia major or Hemophilia sufferer.

Human Immunodeficiency Virus (HIV) infection shall be obtained from an accident in

HIV infection obtained due to accident in workplace shall be within 30 (thirty)

Local schleroderma (linier or morphea schleroderma)

Eosinophilic Fascitis; and

37. Medullary Cyst Illness

39. Celebral Anaeurysm Requiring Brain Surgery

infection and mycotic aneurysm; and

limited craniectomy and burr hole procedures.