"Statute of Limitations for Health Insurance Reimbursement Should Be Calculated from Refund Decision Date"

Three-Year Statute of Limitations Calculated from Date of Treatment
Commission: "It Should Be Changed to Refund Decision Date"

The Health Insurance Review and Assessment Service (HIRA) has been found to have acted unfairly by applying the starting point of the statute of limitations for claims for reimbursement of medical expenses in a way that disadvantages medical institutions, thereby refusing to pay medical fees.

The Anti-Corruption and Civil Rights Commission announced on the 13th that it had expressed an opinion for institutional improvement, stating that HIRA’s refusal to pay certain health insurance medical expenses—reclaimed during the processing of automobile insurance—on the grounds that the statute of limitations had expired, was unjust.

Anti-Corruption and Civil Rights Commission, Government Complex Sejong. Photo by Hyunmin Kim

Mr. A, who operates a hospital, treated a patient in October 2021 and received approximately 21 million won in medical fees through health insurance. Later, when the patient requested to switch to automobile insurance, Mr. A returned the previously received health insurance payment and re-billed the medical fees to the automobile insurance company.

However, the automobile insurance company raised an objection. The Automobile Insurance Medical Fee Dispute Mediation Committee decided that about 8 million won of the claimed amount could not be recognized as automobile insurance medical fees. To recover the 8 million won through health insurance, Mr. A contacted HIRA in October 2024, but HIRA refused payment, stating that the three-year legal period for claiming medical fees had passed. HIRA argued that once Mr. A canceled the health insurance claim and switched to automobile insurance, the original claim became invalid.

The Anti-Corruption and Civil Rights Commission found HIRA’s actions to be excessively harsh toward medical institutions. It pointed out that Mr. A had already interrupted the statute of limitations through the initial claim and had dutifully followed the settlement procedures, so it was unreasonable to nullify the effect of the statute of limitations interruption solely because a refund was requested.

The commission also proposed a new standard for determining the starting point of the statute of limitations that arises during the cross-settlement process between health insurance and automobile insurance. It concluded that the statute of limitations should be counted not from the date of treatment, but from the date of the refund decision that enables the claim to be refiled with health insurance after being denied by automobile insurance. Under this standard, Mr. A’s claim would be considered valid as it was made within three years from the refund decision date. The commission called on HIRA to re-examine Mr. A’s health insurance claim and to establish a work guideline stipulating that the refund decision date should serve as the starting point going forward.

Min Seongsim, Director of the Complaint Handling Bureau at the Anti-Corruption and Civil Rights Commission, stated, "It is excessively harsh for medical institutions to be disadvantaged despite faithfully following the necessary administrative procedures for the patient’s convenience. We hope that this institutional improvement will remove administrative uncertainties and provide more robust protection of citizens’ rights."

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