Policy- Riders English (04062012)

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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:

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.

3. 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 organ‟s 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 Insured‟s 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 Insured‟s 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 Insurer‟s 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 Insured‟s 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 Insured‟s body.

26. Poliomyelitis

- 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. The Insured shall not either Thalassaemia major or Hemophilia sufferer.

B. 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 Sense’s Function)

Unable to heal and total loss on audio sense‟s 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 Cronh’s disease

Severe Ulcerative Colitis or Cronh‟s 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 Insured‟s personal identity;

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d. Other required evidences.

3. 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

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, 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:

Insured‟s Age at the Time of Diagnosed with Critical

Illness

Insurance Coverage to

Receive

<=1 20%

2 40%

3 60%

4 80%

>=5 100%

2. 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:


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:


b. Change of electrocardiogram description specifically showing Infarct Myocardial

of early stadium and;



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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:


b. Brain damage due to accident or injury, infection, vasculity, and inflamed illness;




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.

- 23 -

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

All kinds of tumor caused by HIV infection.

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

- 24 -

shall be erected by neurologist. Any injuries caused by intentional actions by oneself

shall be excluded from this illness.


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.


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 organ‟s functions.



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:

- 25 -

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.


Undoubtedly-definite diagnosis regarding Parkinson Idiopathic illness given by

neurologist and recommended by any doctors appointed by the Insurer where the

Insured‟s 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



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 Insured‟s doctor predicting that

life expectancy of the Insured shall be less than 12 months.

- 26 -


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:

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



a. Permanent yellow

b. Ascites

c. Hepatic enchephalopathy

Chronic hepatitis due to alcohol and drugs consumption shall be excluded from this

insurance.


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 Insurer‟s doctor. And the diagnosis shall

be erected by neurologist.


It is combination of hereditary muscle degeneration illnesses causing weaknesses or

muscle atrophy. Diagnosis shall be erected definitely by neurologist, and the evidence

- 27 -

shall be based on daily activities examination that confirms the Insured‟s inability for

conducting daily activities with or without helps, minimal 3 (three) out of 5 (five) 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 thrombocytopenia requiring minimal one of the following treatments:






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.


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.


- 28 -

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.


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).



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.


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 and been confirmed by neurologist.

- 29 -

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 Insured‟s body.

26. Poliomyelitis

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.


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).


Spinal cord Injury/Trauma, and

Head injury due to other causes


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

- 30 -

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.


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.

- 31 -

Erection of Systemic Lupus Erythematosus diagnosis shall be carried out by Specialist

on Rheumatology and Immunology.








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


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

- 32 -

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.


Unable to heal and total loss on audio sense‟s 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.


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.


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

- 33 -

serology and this illness shall be in accordance with systemic proportion related to heart,

lungs and kidney.


Local schleroderma (linier or morphea schleroderma)

Eosinophilic Fascitis; and

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.

Cardiomyopathy directly relates to alcohol abuse shall be excluded.


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

- 34 -

by a licensed neurosurgeon, using standard cerebral angiography which indicates the

need for open surgery.

Exclusions:




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.


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.


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


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.

- 35 -

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.


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.



- Taking a bath

- Dressing

- Feeding

- Relieving

- Moving



clinical symptoms complied with diagnostic criteria of Necrotising Fasciitis;


- 36 -

extensive muscular destruction resulting in total permanent loss of involved body

part.


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.



- Taking a bath

- Dressing

- Feeding

- Relieving

- Moving


Severe Ulcerative Colitis or Cronh‟s Disease characterized by at least 2 of the following:




- 37 -

autoimmune chronic active hepatitis and cirrhosis confirmed by pathological

study;



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

- 38 -

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:

a. Original policy;

b. Original confirmation issued by the physician firstly diagnosing;

c. Effective Your and Insured‟s personal identity;

d. Other required evidences.

3. 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

- 39 -

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. Any congenital illnesses, or

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

- 40 -


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 body‟s 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 organ‟s functions as follows:

- both arms on or above metacarpophalangeal joint, or

- 41 -

- 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 organ‟s 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

- 42 -

- Left four fingers and thumb ················································· 50% UP

- All toes of one foot ···························································· 10% UP

- Thumb toe ······································································ 4% UP

- Each and every toe ··························································· 1% UP

3. 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:

- 43 -

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 Physician‟s 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 Physician‟s 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.

- 44 -

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. Physician‟s 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.

- 45 -

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.

- 46 -

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


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 part‟s 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 organ‟s functions as follows:

a. Both arms on or above metacarpophalangeal joint, or

b. Both legs on or above metarsophalangeal joint, or

- 47 -

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

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.


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

- 48 -

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 Physician‟s 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 Physician‟s 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:

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. Other Evidences We regard important for You to deliver to support the claim.

3. In case you can not deliver us aforementioned evidences, then We reserve the right not

to pay the related claim.

- 49 -

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:



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.

- 50 -

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




- 51 -



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



other causes.

2. Illness shall mean a physical condition indicated by pathological deviation/disorder








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




- 52 -



d. One arm on or above metacarpophalangeal joint and one leg on or above


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






dresses.







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.

- 53 -

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.

- 54 -

Article 4

EVIDENCE AND DECISION FOR TOTAL PERMANENT DISABILITY

1. Total Permanent Disability shall be proved by Physician‟s 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 Physician‟s 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:

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. Other Evidences We regard important for You to deliver to support the claim.

3. 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.

- 55 -

Article 7

EXCEPTION

This Additional Insurance shall not be valid if, directly or indirectly, the Insured suffers Total

Permanent Disability due to:



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


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.

Article 8


This Additional Insurance shall be terminated in the following cases, whichever occurs earlier:


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


- 56 -



- 57 -



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



other causes.

2. Illness shall mean a physical condition signed by pathological deviation/disorder













- 58 -




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






dresses.







wheelchair.

6. Critical illness shall mean 38 (thirty eight) illnesses by following definition:


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:


b. Change of electrocardiogram description specifically showing Infarct

Myocardial of early stadium and;



e. Left Ventricular Ejection fraction less than 50% (fifty percent) that occurs

for 3 (three) or more months after the onset.

- 59 -

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:


b. Brain damage due to accident or injury, infection, vasculity, and inflamed

illness;




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




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

- 60 -

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


All kinds of tumor caused by HIV infection.

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.

- 61 -

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.


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.



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 organ‟s functions.




condition and questionnaire or acceptable standard test regarding Alzheimer

Illness or any problems on degenerative organic brain that cannot be recovered,

- 62 -

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 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.



neurologist and recommended by any doctors appointed by the Insurer where

the Insured‟s 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

- 63 -

Moving



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 Insured‟s

doctor predicting that life expectancy of the Insured shall be less than 12

(twelve) months.



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



a. Permanent yellow

b. Ascites


Chronic hepatitis due to alcohol and drugs consumption shall be excluded from

this insurance.


- 64 -

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

Insurer‟s doctor. And the diagnosis shall be erected by neurologist.


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 Insured‟s inability for conducting daily activities with or without helps,

minimal 3 (three) out of 5 (five) Daily Activities taking place minimal 6 (six)

months.


Taking a bath

Dressing

Feeding

Relieving

Moving

18. Aplastis Anemia

The chronic and persistent failure of spinal cord functions causing anemia,

neutropenia and thrombocytopenia requiring minimal one of the following

treatments:





- 65 -


19 Aorta Vessel Surgery


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.


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.


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).

- 66 -



permanently neurological inability and occurs minimal for 6 (six) weeks.





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 Insured‟s body.

26. Poliomyelitis

Polio virus shall be the cause, and

- 67 -

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.


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).


Spinal cord Injury/Trauma, and

Head injury due to other causes


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.



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).

- 68 -


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).



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.


- 69 -







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



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.

- 70 -

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.


Unable to heal and total loss on audio sense‟s 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.


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.


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

- 71 -

evidences as results of serology and this illness shall be in accordance with

systemic proportion related to heart, lungs and kidney.




- 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.


- 72 -


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:




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.


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.


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


- 73 -

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.

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.


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):

- 74 -

- 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.


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.



- 75 -

- Taking a bath

- Dressing

- Feeding

- Relieving

- Moving


Severe Ulcerative Colitis or Cronh‟s Disease characterized by at least 2 of the

following:




autoimmune chronic active hepatitis and cirrhosis confirmed by

pathological study;



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.

- 76 -

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

- 77 -

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

Insurance‟s 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.

- 78 -

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;


Payor Benefit Additional Insurance suffers Critical illness and it is

possible unrecovered;

3. Photocopy of valid the Insured under this Payor Benefit Additional

Insurance‟s identity card;





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, self-

injured or efforts for self-injured, or suicide both in healthy- physical and mental

condition or not,

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


- 79 -

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. 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.

h. Abnormality, Illness and/or congenital disability, or

i. HIV/AIDS infection and/or contaminating venereal diseases.

2. 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. Any congenital illnesses, or

d. Critical Illness firstly diagnosed before the Policy Date or Date of Payor Benefit

Additional Insurance, or firstly diagnosed within Elimination period.

Article 8


- 80 -

This Payor Benefit Additional Insurance shall be terminated in the following cases, whichever

occurs earlier:


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).

- 81 -



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) Premium period payment released shall be the next expiration date after we receive and

approve the claim, until a time as if the Insurer reached 65 (sixty five) years old if he or

she was alive.

- 82 -

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 Insured‟s

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. Suicide; or

2. 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:


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).

- 83 -



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



other causes.

2. Illness shall mean a physical condition signed by pathological deviation/disorder














- 84 -



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



f. Taking a bath shall refer to self-ability to clean own body when taking a bath or


g. Dressing shall refer to self-ability to wear, put off, tighten, and loosen all kinds of

dresses.

h. Feeding shall refer to self-ability to put the food into own mouth in which the food


i. Relieving shall refer to self-ability to defecate and urinate in toilet or water closet,


j. Moving shall refer to self-ability to move own body from bed to chair with upright


wheelchair.

6. Critical Illness shall mean 38 (thirty eight) illnesses by following definition:


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:


b. Change of electrocardiogram description specifically showing Infarct

Myocardial of early stadium and;



e. Left Ventricular Ejection fraction less than 50% (fifty percent) that occurs

for 3 (three) or more months after the onset.

2. Stroke

- 85 -


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:


b. Brain damage due to accident or injury, infection, vasculity, and inflamed

illness;


c. Ischaemic attacks from vestibulary system.

3 Coronary Cardiac Surgery

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




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.

- 86 -

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


- All kinds of tumor caused by HIV infection.

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.

- 87 -

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.


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.



- 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 organ‟s functions.


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


condition and questionnaire or acceptable standard test regarding Alzheimer

Illness or any problems on degenerative organic brain that cannot be recovered,

- 88 -

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 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.



neurologist and recommended by any doctors appointed by the Insurer where

the Insured‟s 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

- 89 -

Moving



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 Insured‟s

doctor predicting that life expectancy of the Insured shall be less than 12 months.



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



a. Permanent yellow

b. Ascites


Chronic hepatitis due to alcohol and drugs consumption shall be excluded from

this insurance.


- 90 -

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

Insurer‟s doctor. And the diagnosis shall be erected by neurologist.


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 Insured‟s inability for conducting daily activities with or without helps,

minimal 3 (three) out of 5 (five) Daily Activities taking place minimal 6 (six)

months.


Taking a bath

Dressing

Feeding

Relieving

Moving

18. Aplastis Anemia

The chronic and persistent failure of spinal cord functions causing anemia,

neutropenia and thrombocytopenia requiring minimal one of the following

treatments:






- 91 -

19 Aorta Vessel Surgery


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.


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.


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).


- 92 -


permanently neurological inability and occurs minimal for 6 weeks.





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 Insured‟s body.

26. Poliomyelitis

- Polio virus shall be the cause, and

- 93 -

- 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.


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).


- Spinal cord Injury/Trauma, and

- Head injury due to other causes


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.



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).

- 94 -


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).



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.

- 95 -








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



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

- 96 -

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.


Unable to heal and total loss on audio sense‟s 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.


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.

- 97 -


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.




- 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.

- 98 -

Class IV – Inability to perform any activities. Congestive cardiac failure

symptoms emerges though in resting condition. Anytime physical activities

increase, uncomfortable condition occurs.



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:




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.


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.


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


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.

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.


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

- 100 -

"permanent", shall mean beyond the hope of recovery with current medical

knowledge and technology.



- 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.


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

- 101 -

• 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


Severe Ulcerative Colitis or Cronh‟s Disease characterized by at least 2 of the

following:




autoimmune chronic active hepatitis and cirrhosis confirmed by

pathological study;



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.

- 102 -

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

Policyholder‟s 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. Periodic Premium (and Top-Up Periodic Premium, optional), that We release shall be as


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.

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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;


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 Insurance‟s identity card;

5. Minutes/certificate issued from the Policy for rider accidents;





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;


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 Insurance‟s identity card;





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, self-

injured or efforts for self-injured, or suicide both in healthy- physical and mental

condition or not,

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


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. 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, or

h. Abnormality, Illness and/or congenital disability, or

i. HIV/AIDS infection and/or contaminating venereal diseases.

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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. Any congenital illnesses, or

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:


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 Policyholder‟s 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) Periodic Premium (and Top-Up Periodic Premium, optional), that We release shall be as


- 108 -

(2) Premium period payment released shall be the next expiration date after we receive and

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 Insured‟s

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. Suicide; or

2. 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:


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 Physician‟s 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 Participant‟s 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 Family‟s or Physician‟s 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:

- 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

5. 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 In-

Hospital 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.

- 111 -

10. Insurance Benefit shall mean any payment We make based on Addendum upon Insured‟s

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

- 112 -

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 In-

Hospital 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

- 114 -

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.

- 115 -

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

- 116 -

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

- 117 -

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

c. The Insured dies, or

d. At the time Insured attains 65 (sixty five) years old.

4. 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 Insurance‟s 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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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.

8. 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:

a. Hernia under 10 years old

b. Congenital abnormal, offspring and/or growth abnormal.

12. 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 physician‟s recommendation and medical indication.

19. Any treatments and/or healings due to:

a. Active involvement in war, riot, fights or crimes,

b. Any injuries intentionally made and suicide trails.

20. 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

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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.)

21. 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 Hospital‟s seal.

c. Claim shall be filed at the latest 30 (thirty) days after the treatment finished.

2. 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.

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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.

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LIST OF BENEFITS

INDIVIDUAL INSURANCE PROGRAM – FLEXICARE (Per Unit)

(Rp)

HEALTH ALLIANZ LIFE INDONESIA

NO BENEFITS AMOUNT

1. Daily Principal Benefit

for Hospital Treatment

due to Non-Accident

per day

(maximum 180 days per

year)

Rp. 100,000.-

2. Daily Principal Benefit

for Hospital Treatment

due to Accident

per day

(maximum 180 days per

year)

Rp. 200,000.-

3. Surgery Benefit for

Hospital Treatment due

to Non-Accident

Surgery benefit able to

pay in one period of In-

Hospital Treatment

Special Rp. 2,000,000.-

Great Rp. 1,300,000.-

Medium Rp. 900,000.-

Little RP. 500,000.-

4. Surgery Benefit for


to Accident

Surgery benefit able to


Hospital Treatment

Special Rp. 4,000,000.-

Great Rp. 2,600,000.-

Medium Rp. 1,800,000.-

Little RP. 1,000,000.-

5. Healing Benefit for


to Non-Accident

Healing benefit able to


Hospital Treatment in

case the treatment

requires more than 30

days

Rp. 1,000,000.-

6. Healing Benefit for


to Accident

Healing benefit able to


Hospital Treatment in

case the treatment

requires more than 30

days

Rp. 2,000,000.-

Documents

Policy- Riders English (04062012)