Claims Procedure Research Articles

Examining the Role of Alternative Dispute Resolution (ADR) and Small Claim Procedure in the Settlement of Civil Disputes in Uganda

Over the past several decades, there has been growing interest amongst advocates worldwide in the use of alternative dispute resolution (ADR) techniques to resolve their clients' disputes more economically and efficiently. In the face of bottlenecks and backlogs in the court systems, as well as spiraling costs and fees, courts and members of the legal fraternity have been part of the movement seeking means other than litigation for resolving disputes. As a result, the development of more flexible means of resolving disputes in the form of ADR techniques has gained popularity, and the Ugandan legal system is no exception. Undoubtedly, the benefits of incorporating ADR into the Ugandan legal system offer significant potential, leading to its widespread recognition in Uganda. The legal system has undergone tremendous reforms in recent years, making a study on ADR particularly timely in this context. This paper aims to introduce to the reader the concept of ADR and its implications in the Ugandan context, particularly in dealing with the rampant problem of case backlog in Uganda's judiciary. We conducted this study using the doctrinal method of research, which relies on secondary information from highly qualified state publicists as clearly outlined in textbooks, novels, law journals, articles, websites, and other literature, including class notices. The researcher also utilized court rulings from various states' judges, parliamentary acts on Alternative Dispute Resolution (ADR), and international agreements in which Uganda participates to determine the pace at which Uganda's legal system has integrated ADR to settle civil disputes. Keywords: Alternative dispute resolution, Arbitration, Civil dispute settlement, Mediation, Small claim procedure

PROSEDUR KLAIM BPJS KESEHATAN PASIEN RAWAT JALAN GUNA MENUNJANG PELAYANAN KESEHATAN DI RUMAH SAKIT

The Social Security Administering Body (BPJS) is a program as a follow-up to the National Health Insurance (JKN). The BPJS claim process requires files that are used as a condition for accepting the claim. The files will be processed by Casemix staff after the patient has finished receiving services. Bina Kasih Hospital indicated that there were incomplete files for hospital billing costs and filling in the patient's way of going home when entering the identity of the outpatient BPJS Health patient. If the proof of service is not completed and supporting sheets such as hospital billing costs are not yet available, then the case-mix officer will not be able to process the outpatient BPJS Health claim. This research aims to determine the BPJS Health claim procedure for outpatients to support health services. This type of research is a qualitative descriptive study with 2 informants (1 Casemix head, and 1 Casemix officer). The research location was at Bina Kasih Hospital Pekanbaru in June – August 2023 using observation guidelines and interview guidelines. The results of the research are that the BPJS will only verify outpatient files if all the files are complete, the procedure flow for submitting an outpatient BPJS Health claim at Bina Kasih Hospital in writing does not yet exist, the BPJS Health Claim SPO for outpatients already exists in writing, but it is still there is no separation between outpatient and inpatient SPO. It is hoped that the BPJS Health files for outpatients must be complete before a claim is made and the SPO for BPJS Health claims files at Bina Kasih Hospital is made separately between the SPO for outpatient claims files and the SPO for inpatient claims files

Workshop on s-claim application system for BPJS claim officers at Grandmed Lubuk Pakam Hospital

BPJS Health is a public legal entity that is directly responsible to the President and functions to organize health insurance programs for all Indonesian residents, including foreigners who work for a minimum of six months in Indonesia. The BPJS Health claim procedure can be quite complicated and requires a lot of supporting documents. Unclearness in the guidance or instructions provided can make participants confused and not prepare the complete documents required, one of which is incomplete data files. This is a problem that slows down the claim process. This activity aims to provide health education on the application of the S-National Health Insurance (JKN) system, namely health protection program in Indonesia designed to provide basic health care and protection benefits for all Indonesian citizens. The main goal of JKN is to ensure that everyone in Indonesia has access to adequate basic health services, either through contributions paid by participants themselves or contributions paid by the government for certain groups. With the existence of JKN, it is hoped that the entire population of Indonesia can feel the benefits of equitable and quality health services, thereby improving the health status of the community as a whole. Claims to BPJS officers. The method of implementing activities is using observation sheets and questionnaires regarding the application of the S-Claim system to BPJS officers. Through this activity, it is hoped that the knowledge of BPJS claims officers can increase and change attitudes so that they can apply the BPJS E-Claim system correctly. Socialization to BPJS claims officers can be concluded that the knowledge of BPJS claims officers at Grandmed Lubuk Pakam Hospital has increased by 60% after conducting socialization using discussion, lecture and question and answer methods as well as holding quizzes or tests to evaluate participants' understanding of the S application.

Tinjauan Penyebab Klaim Pending Pasien Badan Penyelenggara Jaminan Sosial (BPJS) Rawat Inap di RSUD Kembangan Jakarta Barat

Financing activities at Kembangan Regional Hospital are dominated by BPJS Health Participants, when submitting claim from patients participating in BPJS Health, there are still delays in submitting claim which will have an impact on hospital operational activities. The aim of this research was to determine the causes of Pending Claims that accurred at Kembangan Regional Hospital. This study used a descriptive method with a mix method approach. The BPJS Health claim procedure for inpatient services at Kembangan Hospital is in accordance with the exiting Standar Operating Procedures. The data used are pending claim files originating from inpatient treatment in November 2022- Jaunary 2023. The research result found 941 inpatient claim files and 84 pending claim files. The cause of pending claim were classified into 7, Conformity between surgical procedures was 22 (26%), inaccuracy in administrative verification and SEP suitability in inputting data into INA-CBGs was 19 (23%), coding determined by the coder was not unbundled by 17 (20%), INA-CBG codes was 9 (!1%), DPJP daognostic code matching 6 (7%), Hospital code conformity 6 (7%), and finally redmissions for the same disease coding 5 (6%). Based on the 5M identification, there are factors, namely the man factor: because the claim file was not accepted by BPJS Health due to coding. The coding given by the hospital to the hospital to the BPJS was not appropriate. Material: supporting files which arrived late on the specified day. Meanwhille, the 3 other factors, namely the money machine and methid, were not obstacles or causes fot the return of the claim files. It is recommended to reevaluate and socialize the reasoms fpr returning BPJS Health claims so that the BPJS Health claim submission process is carried out well and accepted.

Pre-trial procedures in disputes on the protection of intellectual rights

Pre-trial conflict resolution procedures do not cease to be in demand, and the development of their legal regulation does not lose its relevance. Disputes on protecting intellectual rights are no exception, and most countries have established special pre-trial procedures. However, specific difficulties emerge when applying the legal norms related to pre-trial conflict resolution procedures in disputes on the protection of intellectual rights, which can be clearly demonstrated while studying the Russian experience using the mentioned pre-trial procedures. The paper aims to analyze and define the peculiarities of pre-trial procedures in disputes on protecting intellectual rights in Russia. Using systemic approach, as well as comparative legal and formal legal analysis allowed author to define the peculiarities of pre-trial procedures in disputes on the protection of intellectual rights in the Russian Federation: special requirement on the mandatory pre-trial claim procedure is a departure from the general approach, according to which such procedure is required for disputes arising from transactions or unjust enrichment, and is probably due to the complexity of these disputes; in the administrative pre-trial procedure of dispute examination in the Chamber of Patent Disputes the parties have a wide enough set of procedural rights and opportunities, and the procedure is quite close to the judicial procedure, and in some respects even exceeds it.

Analysis of the Implementation of Changes in Old Age Security (JHT) Claim Procedures during the COVID 19 Pandemic (Case Study at the BPJS Employment Company)

Analysis of the Implementation of Changes in Old Age Security (JHT) Claim Procedures during the COVID 19 Pandemic (Case Study at the BPJS Employment Company)

Research on Claim Clause of New FIDIC Contract Condition based on Industry Status

The global economy has begun to recover after the coronavirus epidemic has basically ended, and Chinese and international construction projects have gradually resumed work. Due to the impact of the novel coronavirus epidemic, engineering projects in China and internationally have been extremely difficult to carry out in the past few years, and many projects are facing the dilemma of missing deadlines. In this case, the contractor should actively carry out salvage measures such as claim for construction period to ensure the continued implementation of the project, and should take the initiative to submit claims and carry out normal claim procedures according to the contract. By analyzing the claim conditions of the new version of FIDIC contract, this paper analyzes the relevant problems faced by contractors, puts forward corresponding countermeasures, and provides a new idea of FIDIC claim for Chinese contractors going to the world.

Perlindungan Hukum terhadap Penyewa Mobil yang di Asuransikan dalam Perjanjian Sewa-Menyewa Mengalami Kecelakaan di Kota Medan: Studi Kasus PT Berkah Travel dan Tour Medan

This research aims to analyze legal protection for car renters in rental agreements who experience accidents in Medan City, by taking the case study of PT Berkah Travel and Tour. The research method used is an empirical legal method with a case approach, with data collection techniques, literature studies, interviews with related parties. In answering the problem, a case approach and a statue approach were used. Based on research, it can be seen that PT Berkah Travel and Tour insures each car unit, and provides protection for the driver. However, there are several limitations and requirements that need to be met by renters to be able to take advantage of this insurance. Apart from that, several obstacles were found in implementing this legal protection, such as complex claim procedures and quite long claim settlement times. This research discusses legal protection for insured car renters.

Automation Within a Novel Platform for the European Small Claims Procedure

Abstract Contemporary technology and artificial intelligence increasingly facilitate the delivery of justice by automating, accelerating, and supporting judicial procedures with digitisation and automation tools. This article analyses options for the automatisation of the European Small Claims Procedure. The authors propose the digitisation of the procedure to a greater extent by additional features, such as AI-powered translation and text-to-speech tools, as well as creation of a trustworthy system for submission and storing of procedural documents based on the Estonian e-File example within the framework of the ongoing EU-funded SCAN II-project.

Assessment of Intelligent Vehicle Damage and Cost Estimator for Insurance Companies

Now a day’s many accidents are taking place, Suppose if an accident had taken place and they want to claim with the respective car insurer they need to likely go through the process of having a person inspect the car's damage at your home or a repair centre and then needing to wait for an official estimate and approval to go ahead with getting the necessary repair work done. While this traditional process can be lengthy and keep your car off the road longer than you'd like, artificial intelligence can now play a role in speeding up the process by taking over the appraiser's work. Vehicle damage detection is used to reduce claims leakage during insurance processing. Visual inception and validation are usually done. As it takes a long time because a person needs to come and inspect the damage. Here we are trying to automate the procedure. Using this automation, we can avoid time conception for the insurance claim procedure. In this we are using the VGG16 model to predict the damage of vehicle. We get the accuracy of 94.56% of VGG16.

실손의료보험 청구절차 개선을 위한 법적 과제

실손의료보험 청구절차 개선을 위한 법적 과제

Conditions for Referring Claims to Summarily Triable Cases not Limited to the Amount of the Claim

The paper examines the procedural rules establishing conditions for assigning claims to summarily triable cases that are not limited by the amount of claims, as well as the practice of arbitrazh courts and courts of general jurisdiction on their application, which indicates the lack of uniformity in the interpretation of these conditions. The author concludes that such claims should, according to the documents submitted by the plaintiff, meet the criteria of indisputability. However, indisputability of the claims identified after referring the case for consideration in a summary procedure does not in itself prevent their consideration in the procedure mentioned above. The author points out the need to distinguish between the conditions for the confirmation of debt by the defendant and the conditions for the recognition of monetary obligations by the defendant; the author justifies the guidelines in understanding and evaluating the latter. The paper also highlights inconsistency in the legal regulation of the balance between writ cases and cases of summary proceedings in civil proceedings. If in the arbitrazh procedure all cases of writ proceedings for which a writ has not been issued fall under the category of summary proceedings that do not require the absence of a dispute concerning the issue of law. In civil proceedings this does not occur and the relevant claims are considered in the general claim procedure, since they cannot be attributed to the category of summary proceedings due to the lack of the criterion of indisputability. In conclusion, the author suggests additional explanations be provided to the courts regarding the formal features of this category of summary proceedings and indicate the need in civil proceedings for summary proceedings to set a limit not of 100,000 rubles, but 500,000 rubles.

Legal Protection Bumi Putera Joint Life Insurance Policyholders

This study aims to examine the legal protection provided to customers of life insurance policyholders in Bumi Putera, focusing on product transparency, fair and fast claim procedures, as well as appeal and lawsuit procedures. The method used field research with a qualitative approach through in-depth interviews with customers and related parties in Bumi Putera. The data collection techniques used were document studies and in-depth interviews. The collected data were analyzed by qualitative analysis methods, namely data reduction, data presentation, and conclusions. This research is expected to provide useful recommendations for Bumi Putera in improving legal protection for life insurance policyholder customers.

Досудебный порядок урегулирования спора по групповому иску: в поисках оптимальной модели

The article discusses some differences between the Code of Arbitrazh Procedure and the Code of Civil Procedure as regards the compliance with the pre-trial procedure for settling claims in a class action. The author comes to the conclusion that the observance of such a procedure should not be a necessary condition for the consideration of a class action or returning the claim or leaving it without consideration. The absence in the Code of Civil Procedure of a requirement to observe pre-trial procedure for class actions calls for changes and its unification in this regard with the provisions of the Code of Arbitrazh Procedure. The author draws attention to the lack of grounds for recovering a fine from the defendant in accordance with the Consumer Right Protection Law in case of non-compliance by the consumers with the claim procedure before filing a class action.

Implementation Model of Timeliness of BPJS Claims Based on Penomenology Study

The purpose of this study was to explore the factors of delay in BPJS claims for inpatients at the Yukum Medical Center Hospital. The type of research in this study using qualitative research using a qualitative approach is expected to produce a basic model in providing the most appropriate recommendations in solving the problem of the timeliness of submitting BPJS claims at the Yukum Medical Center hospital. This subject is the accuracy of BPJS claims. The object of this research is the Yukum Medical Center casemix team. The results of the analysis conclude that the claim procedure already has an SPO/regulation that regulates the procedure for submitting a BPJS claim but has not run according to the SPO/regulation. The delay in BPJS claims in 2021 is around 80%. delays in BPJS claims as a result of the lack of quality of the casemix team's human resources and inaccurate and incomplete medical resumes. Factors causing delays in BPJS claims from aspects of Man, Method, Machine, Material, and Money. Expected recommendations so that recommendations/solutions are proposed again. The claim procedure is in accordance with the implementation flow, but the SPO/regulation has not been running well. BPJS RS claim. Yukum Medical Center 80% of 2021 claims are late. Factors causing delays in BPJS claims there is no evaluation of the competency of the casemix team (man), late and incomplete medical resumes (material), lack of printers when there is an increase in the number of patients (mechine), lack of budget for HR training (money). The BPJS claim recommendations at the Yukum Medical Center Hospital have been running but the results of the implementation have not been in line with expectations, so recommendations are needed.

Legal Regulations of Enforcement Procedure in Selected Foreign Jurisdictions

This article provides a brief comparative analysis of the peculiarities of the enforcement procedures in selected foreign countries and jurisdictions with various legal systems, including France, the United Kingdom, Belarus, Kazakhstan, the Baltic countries, as well as research into the organizational structure of their enforcement agencies. The article also provides an analysis of the diverse procedures applied in EU countries for enforcement of decisions of courts and other authorities in civil and commercial cases, including the European Enforcement Order, European Order for Payment, European Small Claims Procedure, as well as the procedure under the Recast Brussels I Regulation. The author’s objective is to consider the procedures of enforcement of Ukrainian court decisions in these countries, as well as to raise the issue of the possible application of these procedures in the relevant legislation of Ukraine and to provide material for further research and analysis of these options.

실손의료보험 보험금청구 간소화에 관한 법적 연구

The problem has been raised that the traditional claim method, called claim for medical insurance, does not correspond to the development of Korean IT technology. In this paper, the author critically considers that the existing insurance claim procedure is not valid, and reviews the contents of the main legislation (proposal) proposed to the National Assembly. Currently, our society is rapidly changing from the analog era to the digital era. We are living in an era where various financial payments are made with just one smartphone. Nevertheless, the procedure for claiming insurance does not reflect the new era. In the insurance industry, consumer-oriented digital methods from designing or developing insurance products to contract management and insurance payment management are very important. Among these, one of the most important factors is the simplification of the claim process for medical insurance claims of policyholders. The simplification plan for indemnity insurance is based on the content that the insurance claim is made electronically when a patient makes a request to the hospital without paper documents. While focusing on literature research, this study adopts an analytical method that accommodates difficulties encountered in the working world and a review method of major legislation (proposal) proposed by the National Assembly. We favored the simplification of medical insurance claims through insurance intermediaries, but pointed out the problems that may arise when operating this method. The simplification of insurance claims is expected to dramatically improve the efficiency of insurance companies and the convenience of consumers, but the medical community opposes this because of side effects such as restrictions on the use of patient medical information and insurance subscriptions, and leakage of patient personal medical information. This appears to be the biggest obstacle to simplifying insurance claims. A few ways to solve this problem are suggested. The method of claiming insurance by issuing a paper receipt is not suitable for the future. In order to solve the waste of human resources or administrative costs, a plan for simplifying insurance claims must be implemented.

Efektivitas Penyelenggaraan Klaim Jaminan Kematian BPJS Ketenagakerjan Atas Kematian Pekerja Migran Indonesia Di Jawa Timur

Work is the primary need of every human being. By working, they will get a salary or wages that becomes the exchange rate to buy various necessities for life. But unfortunately, the fact is that getting a job in Indonesia is not an easy thing. This encourages people, especially those with education from elementary school to high school, to look for job opportunities abroad. From an economic perspective, the rapidly growing world market and the influence of globalization have opened up demand for workers in foreign economic sectors. Migrant workers act as accomplices and agents of economic and social progress in their country of origin and their country of placement. However, they are also very vulnerable to risks that can result in death. In this regard, the state is responsible for providing proper welfare for its citizens by providing services to Indonesian Migrant Workers through the BPJS Ketenagakerjaan Death Security. The heirs will receive cash benefits if Indonesian migrant worker dies. However, in practice, each BPJS Ketenagakerjaan branch office has its own regulations regarding the procedure for claiming death benefits. In this case, the BPJS Ketenagakerjaan Branch of Karimun Jawa in East Java provides file requirements that differ from the Regulation of the Minister of Manpower and Transmigration Number 18 of 2018 concerning Social Security for Indonesian Migrant Workers, which impedes the heirs. Furthermore, the level of education and family members of the Indonesian migrant workers from small towns prevent them from learning about the Death Insurance Claim procedure at BPJS Ketenagakerjaan Karimun Jawa.

Pre-judicial (claims) work of the hotel organization with consumers

Based on the analysis of legislation, the results of scientific research, materials of judicial and entrepreneurial practice, the content and features of pre-trial (claim) work of hotel organizations with consumers are analyzed. Particular attention is paid to the need to comply with both procedural (regulatory) and procedural rules for the implementation of the pre-trial procedure for resolving disputes. Conclusions are drawn about the significance of the claim procedure for resolving disputes for consumers and hotel organizations, directions for further pre-trial (claim) work of hotel organizations with consumer claims.

Pending BPJS claim to support the quality of outstanding hospital in Muhammadiyah Hospital Bandung

The purpose of the study was to determine the efforts made in handling outpatient pending claims. The method used is descriptive research with a quantitative approach. The population is all BPJS pending claims for outpatients. The sample was calculated using the solvent formulation and obtained 83 pending outpatient BPJS claim files. Research time in February – April 2022 on the Casemix unit. The results show that the outpatient BPJS claim procedure has been running following the Standard Operating Procedures. The causes of pending BPJS outpatient claims, medical administration as much as 86%, inaccurate diagnosis 8%, and incomplete medical resume 4%. Evaluation of pending BPJS Outpatient claims problems, coordinating each section, and improving section performance.