Top 1% in Real Loss Insurance Claims Receive 20 Million Won Annually... Nearly 15% of Total

[Asia Economy Reporter Oh Hyung-gil] Among subscribers to indemnity medical insurance, the top 1% in claims for hospitalization receive an average annual insurance payout of about 20 million KRW. This accounts for 15% of the total insurance payouts.

On the 6th, Jeong Seong-hee, a research fellow at the Korea Insurance Research Institute, stated in the report "Characteristics of Indemnity Medical Insurance Claims" that "excessive and unnecessary medical use by a small number of people not only worsens the loss ratio of indemnity insurance but also contributes to the financial burden on the National Health Insurance."

The top 10% of indemnity insurance hospitalization claimants received an average of 6 million KRW annually, accounting for 48.5% of the total insurance payouts.

The report noted that in the case of outpatient treatment, there were claim cases where patients received outpatient care more than 800 times a year for minor illnesses such as gastritis, sprains, headaches, and lower back pain.

The report pointed out, "Due to excessive medical use by a small minority, the insurance premium burden is shifted to the majority of subscribers who either did not use medical services at all or used only necessary medical services." It also noted, "In the case of hospitalization, 95% of all subscribers are either non-claimants or receive small insurance payouts of less than 500,000 KRW annually, while those receiving more than 1 million KRW annually account for only 2-3% of all subscribers."

For outpatient treatment, more than 80% of all subscribers were either non-claimants or made small claims of less than 100,000 KRW annually, while those receiving more than 300,000 KRW annually accounted for about 9% of all subscribers.

Furthermore, "Diseases related to the musculoskeletal system and ophthalmology, which have a high proportion of non-reimbursed treatments, are concentrated among the top claim categories in indemnity insurance claims," the report explained. "Musculoskeletal diseases account for 41% of the total indemnity insurance claims, the highest proportion, and the proportion of non-reimbursed treatments in these claims is also very high at 81.2%."

Research fellow Jeong suggested, "To improve fairness in insurance premium burdens among indemnity insurance subscribers and to raise awareness of costs related to non-reimbursed treatments, it is necessary to introduce a differentiated premium system with discounts and surcharges linked to individual subscribers' non-reimbursed medical usage." He added, "Unlike injuries, the occurrence of diseases is somewhat inevitable, but since some control is possible depending on the subscriber's health management, applying discounts or surcharges on premiums based on medical usage volume can be considered."

He also emphasized, "To enhance the sustainability of the indemnity insurance system and increase the effectiveness of the government's policy to strengthen coverage, it is necessary to establish reasonable solutions for managing non-reimbursed treatments through public-private collaboration." He added, "Even if sustainability is pursued through product structure reform, if indemnity insurance payouts and non-reimbursed treatment management are not properly conducted, the effectiveness will significantly decline. Therefore, managing the total medical expenses through non-reimbursed treatment management is key for the National Health Insurance's coverage enhancement policy to achieve its intended goals."

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