The Criminal Law Construction for Health Insurance Claim Payment Failure: A Synergy between Health Law and Financial Sector Regulation
Main Article Content
Abstract
This normative legal study aims to construct the criminal liability qualification for the failure to pay claims by health insurance companies, with primary reference to Law No. 17 of 2023 concerning Health. The research employs a qualitative doctrinal method through legislative and conceptual approaches. The analysis reveals that Law No. 17 of 2023 does not contain a specific criminal offense for claim payment failure. The primary legal basis for criminal sanctions is found in Law No. 4 of 2023 concerning the Development and Strengthening of the Financial Sector (P2SK Law). The Health Law functions as a philosophical and substantive foundation, establishing the right to health and obligations of transparency, thereby elevating the social gravity of violations in health financing. The criminal elements required are a synthesis of both frameworks, demanding proof of unlawful acts, fault, loss, causality, and the fulfillment of specific offense formulations in the P2SK Law. Corporate criminal liability is constructed through the identification doctrine and dual liability principles. This study concludes that criminal qualification requires a layered legal construction, integrating the substantive norms of the Health Law with the sanction instruments of the financial sector laws. This model provides a more precise analytical tool for prosecuting corporate misconduct in overlapping regulatory fields like health insurance.
Article Details
Section
How to Cite
References
Anggriheny, B. R., & Nababan, R. Y. (2022). Due to the Legal Failure to Pay by the Insurance of the Insurance Policy of the Insured. Lambung Mangkurat Law Journal, 7(1), 29–44.
Aswin, A., Suendro, S., Afrita, I. (2021). Settlement of Defaults in the Life Insurance Policy Between the Insurer and the Insured. Journal Indonesia Law & Policy Review, 2(2), 57-72.
Bashori, B., Hardyansah, R., & Darmawan, D. (2024). Legal Analysis of Big Data and Analytics in Preventing Discrimination and Protecting Insurance Customers. Journal of Social Science Studies, 4(1), 185-192.
Clarkson, C. M. V. (2005). Corporate Liability and Manslaughter: Should we be going Dutch? Criminal Law Review, 2005(Mar), 187–198.
Darmawan, D., F. Issalillah, R.K. Khayru, A.R.A. Herdiyana, A.R. Putra, R. Mardikaningsih & E.A. Sinambela. (2022). BPJS Patients Satisfaction Analysis Towards Service Quality of Public Health Center in Surabaya. Media Kesehatan Masyarakat Indonesia, 18(4), 124-131.
Firmansyah, Y., Haryanto, I., & Ernawati, E. (2022). Fraud Issues in the National Health Insurance (Causes, Legal Impacts, Dispute Settlement and Preventive Measures). Jurnal Multidisiplin Madani, 2(4), 1663–1680.
Fuchs, A. (2010). The Duty of Utmost Good Faith in Insurance Law: A Comparative Analysis of American and German Law. Penn State International Law Review, 28(3), 613–659.
Gobert, J., & Punch, M. (2003). Rethinking Corporate Crime. Cambridge University Press, Cambridge.
Hadjon, P. M. (2007). Perlindungan Hukum Bagi Rakyat di Indonesia. Peradaban, Surabaya.
Harianto, A. V., Vitrianingsih, Y., Issalillah, F., & Mardikaningsih, R. (2024). Challenges and Changes Concerning National Health Development in Indonesia: Legal Perspectives, Service Access, and Infectious Disease Management. International Journal of Service Science, Management, Engineering, and Technology, 5(2), 22-26.
Hartika, Y., Saputra, R., Pakpahan, N. H., Darmawan, D., & Putra, A. R. (2023). A Study on the Falsification of Health Certificates: Perspective of Criminal Law and Professional Ethics. Journal of Social Science Studies, 3(2), 175-180.
Hartono, R., Darmawan, D., & Saputra, R. (2024). Regulation and Pharmaceutical Corporate Responsibility: Generic Drug Distribution, Patent Rights, and Their Impact on Equity of Access in the National Health Insurance System. Journal of Social Science Studies, 4(2), 303-318.
Hutahaean, H. (2022). Application of Criminal Sanctions in Cases of Manipulation of Demand and Collection of Health Services Fees for Patients Participating in the National Health Insurance Program. Ratio Legis Journal, 1(1), 16–16.
Issalillah, F. (2021). Advancing Quality of Life Through Sustainability Policies That Prioritize Health and Equality. Studi Ilmu Sosial Indonesia, 1(2), 65-74.
Issalillah, F., & Khayru, R. K. (2022). The Effect of Insurance Premiums and Brand Image on Interest to Be an Insurance Customer. International Journal of Service Science, Management, Engineering, and Technology, 1(3), 31–35.
Issalillah, F., D. Darmawan & R. K. Khayru. (2021). Social Cultural, Demographic and Psychological Effects on Insurance Product Purchase Decisions, Journal of Science, Technology and Society, 2(1), 1-10.
Issalillah, F., Rachmawati, E., & Kemarauwana, M. (2021). The role of service quality on satisfaction of BPJS participants. JESS, 1(2), 41-48.
Jamiri, L., Mujito, & Waskito, S. (2023). Hospital Fraud in the National Health Insurance Program from a Legal and Governance Perspective. Journal of Social Science Studies, 3(2), 259-272.
Khayru, R. K. & F. Issalillah. (2022). Service Quality and Patient Satisfaction of Public Health Care. International Journal of Service Science, Management, Engineering, and Technology, 1(1), 20 – 23.
Krippendorff, K. (2004). Content Analysis: An Introduction to its Methodology (2nd ed.). Sage Publications, Thousand Oaks.
Lee, J., Howard, K. J., Leong, C., Grigsby, T. J., & Howard, J. T. (2023). Beyond Being Insured: Insurance Coverage Denial as a Major Barrier to Accessing Care During Pregnancy and Postpartum. Clinical Nursing Research, 32(8), 1092-1103.
Mangkat, V. (2021). Tindak Pidana Pemalsuan Dokumen Perasuransian Menurut Undang-Undang Nomor 40 Tahun 2014 Tentang Perasuransian. Lex Crimen, 10(1), 119-127.
Mardikaningsih, R. (2022). Patient Satisfaction Based on Quality of Service and Location. Journal of Islamic Economics Perspectives, 4(1), 31-37.
Marzuki, P. M. (2005). Penelitian Hukum. Prenada Media, Jakarta.
Mulhadi, M., & Harianto, D. (2022). Breach of Contract by Insurer as Insurance Fraud. In ICSST 2021: Proceedings of the 1st International Conference on Social, Science, and Technology, ICSST 2021, 25 November 2021, Tangerang, Indonesia.
Nolan, D. (2020). Reining in Vicarious Liability. Industrial Law Journal, 49(4), 609-625.
Noor, A., Herisasono, A., Hardyansah, R., Darmawan, D., & Saktiawan, P. (2023). Juridical Review of the Rights of Indigent Patients in Health Services in Indonesia. Journal of Social Science Studies, 3(2), 253-258.
Polontoh, H. M. (2024). Legal Responsibility of the Insurance Company for Unpaid Participant Claims. Journal of World Science, 3(1), 105–110.
Republik Indonesia. (1945). Undang-Undang Dasar Negara Republik Indonesia Tahun 1945. Lembaran Negara Republik Indonesia Tahun 1945. Jakarta.
Republik Indonesia. (1999). Undang-Undang Republik Indonesia Nomor 8 Tahun 1999 tentang Perlindungan Konsumen. Lembaran Negara Republik Indonesia Tahun 1999 Nomor 42. Jakarta.
Republik Indonesia. (2014). Undang-Undang Republik Indonesia Nomor 40 Tahun 2014 tentang Perasuransian. Lembaran Negara Republik Indonesia Tahun 2014 Nomor 337. Jakarta.
Republik Indonesia. (2023a). Undang-Undang Republik Indonesia Nomor 4 Tahun 2023 tentang Pengembangan dan Penguatan Sektor Keuangan. Lembaran Negara Republik Indonesia Tahun 2023 Nomor 6. Jakarta.
Republik Indonesia. (2023b). Undang-Undang Republik Indonesia Nomor 17 Tahun 2023 tentang Kesehatan. Lembaran Negara Republik Indonesia Tahun 2023 Nomor 157. Jakarta.
Republik Indonesia. Kitab Undang-Undang Hukum Pidana. Lembaran Negara Republik Indonesia. Jakarta.
Rusli, R., & Halawa, F. (2024). Corporate Criminal Liability as an Insurance Crime Perpetrator Based on Law Number 1 of 2023 on Criminal Law. International Journal of Humanities Education and Social Sciences, 3(4), 2111-2117.
Sahidu, S., Putra, A. R., & Darmawan, D. (2023). Medical Advertising Regulations and Patient Protection as Consumers of Healthcare Services. Journal of Social Science Studies, 3(1), 331-342.
Setiawan, R. A., Khayru, R. K., Mardikaningsih, R., Issalillah, F., & Halizah, S. N. (2023). Implementation of Indonesian Positive Law in Combating Fraud and Forgery in Health Insurance and Protection against Industrial Losses. Journal of Social Science Studies, 3(1), 271-280.
Sewu, P. L. S., Octora, R., & Lusiana, F. (2022). Analysis of the Existence of Insurance Fraud in the Case of Insurance Claim Payment Failure and the Legal Protection for Insurance Clients in the Insurance Company’s Failure to Pay Claims. European Journal of Law and Political Science, 1(5), 79–86.
Shavell, S. (2004). Foundations of Economic Analysis of Law. Harvard University Press, Harvard.
Subiakso, A., Juliarto, T. S., Darmawan, D., Sisminarnohadi, S., & Romli, R. I. A. (2023). Legal Rights in Access to Health Services for Persons with Disabilities. Bulletin of Science, Technology and Society, 2(3), 15-20.
Syaiful, S. (2023). Implications of Law Number 4 of 2023 on Microfinancial Institutions. Jurnal Perundang-Undangan, 11(2), 21-41.
Tamaka, R. S., Wuryani, A. I., Lethy, Y. N., Issalillah, F., & Hardyansah, R. (2023). Legal Review of Patients' Rights in the Health Insurance System. Studi Ilmu Sosial Indonesia, 3(2), 69-84.
Tampil, V. C., Mubasyiroh, A. A., Khayru, R. K., Darmawan, D., & Prasetyo, B. A. (2023). Legal Protection for Patients in Health Services at Community Health Centers. Studi Ilmu Sosial Indonesia, 3(2), 85-100.
Wahyusetiawan, R., Herisasono, A., Khayru, R. K., Vitrianingsih, Y., & Issalillah, F. (2024). Health Facility Accountability for Terminal Patient Palliative Care Services Under Health Law. International Journal of Service Science, Management, Engineering, and Technology, 6(2), 45-57.
Warin, A. K. (2023). Social Relationship Between Urban Living Characteristics and Social Determinants of Population Health, Studi Ilmu Sosial Indonesia, 2(2), 307-332.
Yatno, Y., Darmawan, D., & Khayru, R. K. (2023). Hospitals' Legal Responsibility for Service Disruptions due to Information System Failures. Journal of Social Science Studies, 3(1), 319-330.