A Breach Of Contract And Legal Liability In Fictitious Claims Within The Cooperation Between BPJS Health And Referral Hospitals: Case Study Of Hospital In Tegal

Abstract

This study examines a case of alleged fictitious claim submissions by a referral hospital to BPJS Health under a Cooperation Agreement within the National Health Insurance system. The case emerged following verification findings indicating inconsistencies between submitted claim documents and actual medical services provided, resulting in financial losses and temporary contractual suspension. The research analyzes whether such conduct constitutes a breach of contract under Indonesian civil law rather than an unlawful act. Employing normative legal research supported by limited interviews and applying statutory, conceptual, and case approaches, the study finds that the submission of fictitious claim documents represents a material breach of contractual obligations under Articles 1234 and 1243 of the Civil Law, violates the principle of good faith under Article 1338, and justifies contractual sanctions as agreed by the parties. The hospital, as a legal entity, bears civil liability grounded in contractual responsibility.