<![CDATA[Pending claims under Indonesia’s National Health Insurance programme (Jaminan Kesehatan Nasional, JKN) are commonly treated as a matter of documentary administration, so that their settlement is left to the correction of discharge summaries and the adjustment of coding. That framing conceals a more fundamental problem: when payment is withheld, an obligation remains unperformed across three interlocking legal relationships, while the law provides no clear map of how the resulting burden is to be distributed among the parties. This study pursues three aims: first, to map the structure of the legal relationships among BPJS Kesehatan, hospitals, and patients within the claims mechanism; second, to formulate the juridical qualification of pending-claim events; and third, to construct a model for allocating civil liability together with its settlement mechanisms. The study applies normative legal research using four approaches mapped directly onto the three research questions, namely the statutory, conceptual, case, and comparative approaches. The principal legal materials comprise the Indonesian Civil Code, Law No. 40 of 2004, Law No. 24 of 2011, Law No. 44 of 2009, Law No. 17 of 2023, Law No. 8 of 1999, and the implementing regulations governing health insurance. The findings show that the relationship among the three parties is not a single relationship but three relationships, each arising from a different source of obligation: an obligatory cooperation agreement between BPJS Kesehatan and hospitals, a therapeutic contract between hospitals and patients, and a statutory membership relationship between patients and BPJS Kesehatan. From this mapping, four juridical qualifications of pending claims are derived, together with a three-layer model comprising a test of procedural compliance, a test of causation and authority, and a test of proportionality and protection of the weakest party. The model makes it possible to distinguish what has hitherto been conflated: administrative negligence, default in payment, fraud, and risk arising from normative vagueness. It further establishes that patients cannot be made the ultimate bearers of pending-claim risk. In practical terms, the model offers an ordered basis for drafting clauses in cooperation agreements, for interim payment of undisputed portions of a claim, and for tiered dispute settlement.]]>
