"Doctor Wrote 'Hospitalization Appropriate'... Allegations of Distorted Medical Reviews in Private Health Insurance"

Professor Sanghyun Ahn: “Wording in Medical Review Was Delivered in the Exact Opposite Manner”

Structural Flaws Allow Insurers to Intervene and Control Medical Judgments

Pharmaceutical Sovereignty Solidarity Calls for Full Investigation of I

Allegations have emerged that, during the “medical advisory” process used to determine whether insurance benefits should be paid after varicose vein surgery, an advisory physician’s written opinion was altered to say the exact opposite of what it originally said. Patient and consumer groups described this as “evidence of fraud against the public” that betrayed the trust of 40 million indemnity health insurance policyholders, and called on financial authorities to conduct an immediate, comprehensive investigation.

On the 20th, at the Korea Consumer Federation Seoul Branch in Hannam-dong, Yongsan-gu, Seoul, Professor Sanghyun Ahn, a surgeon at Seoul National University Hospital, is speaking at the "Pharmaceutical Sovereignty Patient and Consumer Solidarity Press Conference". Photo by Jo Inkyung

The Pharmaceutical Sovereignty Patient and Consumer Solidarity and the Korean Society of Phlebology held a press conference on the 20th at the Seoul Branch of the Korea Consumer Federation in Hannam-dong, Yongsan-gu, Seoul, and presented specific cases and testimony showing that insurers’ medical advisory results had been altered from the original documents.

At the event, Sanghyun Ahn, a professor of surgery at Seoul National University Hospital, presented the medical advisory report he had written alongside the notice of medical advisory results received by a patient. He said, “In an advisory commissioned by an insurer, I stated that ‘one day of inpatient treatment is appropriate.’ But the notice delivered to the patient contained the exact opposite, saying that ‘hospitalization is merely an unnecessary administrative procedure.’”

Professor Ahn said, “In particular, the negative wording delivered to the patient appears to have been copied and inserted verbatim from language I used in a different case in the past. Experts’ medical judgments are being reworked to suit insurers’ preferences.”

The closed structure of “medical advisory brokerage firms,” which intervene between insurers and advisory physicians, was also cited as a factor that enables such distortions. Medical advisory reports are currently exchanged in formats that can be revised or edited, meaning there is no way to verify whether wording has been inserted or altered along the way.

Consumer A, a 56-year-old woman who says she was directly harmed in this case, said, “I suffered severe emotional distress after the insurer initially notified me that ‘the hospitalization was not medically appropriate.’ In the end, I had to seek a second opinion from another university hospital myself before I could receive the insurance benefits. It was only during this process that I learned the insurer had distorted the advisory report from the outset.”

The issue came to light when another doctor, who conducted a third-party medical review for A, checked the notice of her earlier medical advisory results and directly asked Professor Ahn to confirm its contents. The names of advisory physicians are not disclosed in medical advisory reports, so they cannot identify one another. However, because the pool of doctors is limited for certain hospitals or conditions, it can be possible to make an educated guess. Professor Ahn said he informed the Korean Society of Phlebology, which confirmed that there were other similar cases and brought the matter into the public arena.

Kim Taesik, chair of the Korean Society of Phlebology and a professor at Korea University Guro Hospital, criticized the practice, saying, “The continued statistical rise in insurance claims being denied or only partially paid following medical advisories is evidence that such advisories are being misused as a means of denying insurance benefits.” He added, “This is not simply an insurance benefits dispute; it has exposed a structural problem that allows insurers to intervene in and control medical judgments. It has undermined confidence in indemnity health insurance, a safety net for the public.”

The society and the solidarity group presented five key demands to financial authorities and the National Assembly: full disclosure of original medical advisory reports; introduction of a system requiring advisory physicians to disclose their identities; establishment of an independent third-party medical review and deliberation body; a ban on revisions and edits to advisory reports, along with revision history tracking; and an immediate, comprehensive Financial Supervisory Service investigation into cases in which claims were denied. They also characterized the core issue as “who is responsible for changing the advisory opinion” and called on insurers to provide a clear explanation.

Kwon Yongjin, policy committee chair of the Pharmaceutical Sovereignty Patient and Consumer Solidarity and a professor at Seoul National University Hospital, said, “It is unlikely that an insurer or medical advisory brokerage firm changed the contents without having any vested interest.” He stressed, “The Financial Supervisory Service must immediately launch an on-site investigation and clearly establish who changed the advisory and why.” Professor Kwon added that “it is important to put in place a system that prevents advisory opinions from being altered in the first place and to ensure transparency so patients can identify who conducted the advisory,” and also called for the introduction of an independent third-party review body.

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