"Refusal of Indemnity Insurance Payouts and Lawsuits... Severe Patients Must Be Guaranteed Coverage"

"Forum on Exploring Improvement Plans for the Indemnity Insurance System and Its Problems"

Insurers: "A Minimal Safeguard Against Excessive Treatment and Moral Hazard"

Medical Community: "Insurance Decisions Must Respect Medical Standards, N

There have been concerns raised that patients with severe illnesses are unable to receive indemnity insurance payouts after hospital treatments, or are being subjected to lawsuits demanding the return of insurance payments that were already made. On the other hand, insurance companies claim that excessive medical treatments by hospitals and moral hazard among indemnity insurance policyholders are causing annual insurance payout leakages amounting to several trillion won.

Participants are taking a commemorative photo at the forum titled "Exploring Issues and Improvement Measures of the Indemnity Insurance System through Cases of Damage to Patients with Severe Illnesses," held on the 24th at the National Assembly Members' Office Building. Office of Assemblyman Kim Sunmin.

At a National Assembly forum titled "Exploring Issues and Improvement Measures of the Indemnity Insurance System through Cases of Damage to Patients with Severe Illnesses," hosted on the 24th by Assemblywoman Kim Sunmin of the Health and Welfare Committee from the Innovation Party for the Fatherland, stakeholders expressed sharply contrasting views regarding indemnity health insurance issues.

Attorney Choi Taehyung, an adjunct professor at Yonsei Law School who gave the keynote presentation, explained that indemnity insurance was originally designed to serve as a private safety net supplementing non-reimbursed medical expenses and patient copayments, resulting in more than 40 million policyholders. However, he pointed out that unilateral denials of insurance payouts by insurers and a surge in lawsuits have threatened patients' rights to survival.

After analyzing 74 cases involving cancer patients, Attorney Choi found that in 30 cases, insurance terms were interpreted in favor of the insurer; in 16 cases, the insurer demanded evidence of metastasis or recurrence; and in 15 cases, policyholders were pressured to obtain opinions from third-party medical institutions. He emphasized, "There are cases where insurers refuse to pay insurance claims on the basis of clauses that do not even exist in the insurance policy," adding, "Unlike in the past, there is a growing trend of insurers filing lawsuits to recover payments that have already been made, claiming unjust enrichment."

Lee Taeyeon, Vice President of the Korean Medical Association, stated, "The essence of the indemnity insurance issue lies in the insurer's judgments infringing upon medical judgments." He stressed the need to reform the system to respect medical expertise, rather than maintaining a structure where payout criteria depend on whether the patient was hospitalized.

Regarding the medical advisory system, which has been criticized for being misused by insurers as a tool to deny insurance payouts, he stated, "We must establish a medical advisory committee independent of insurance company interests to ensure objectivity." He added, "Last month, the Korean Medical Association and the Financial Supervisory Service established a third-party medical advisory agreement framework. Going forward, we will pursue discussions to address the limitations of insurer-centric advisory structures and to ensure objectivity and transparency."

On the other hand, the insurance industry explained that 98.8% of all indemnity insurance claims are paid, and that payouts to cancer patients alone amounted to approximately 1.3 trillion won last year. The industry also called for stronger penalties against medical institutions involved in insurance fraud, such as promoting unnecessary treatments or issuing false medical certificates.

Lee Hyeonggeol, Head of the Long-term Insurance Division at the General Insurance Association of Korea, argued, "Currently, Korea's indemnity insurance payout rate is among the highest in the world, and it still serves as the final financial safeguard for patients." He further claimed, "On the contrary, losses of about 2 trillion won per year are occurring due to non-reimbursed treatments and false or excessive treatments by some medical institutions."

He added, "The medical advisory system is intended to verify medical justification before executing additional insurance payouts. This is not about stopping payments, but should be seen as a minimum safeguard to protect honest consumers from harm."

Jeon Hyunwook, Team Leader of the Insurance Product Dispute Division 2 at the Financial Supervisory Service, stated, "Medical advisory opinions should not be used solely as grounds for denying insurance payouts. Therefore, we are working to prevent bias among advisory committee members and to enhance fairness and expertise." He explained, "In terms of lawsuits, we are also strengthening internal controls by requiring insurance companies to operate litigation management committees that include external experts responsible for consumer protection."

This content was produced with the assistance of AI translation services.